At-Home Sleep Apnea Testing

Vol. 20 • Issue 5 • Page 16

Cover Story

When, early in 2008, the overlords of Medicare announced they would reimburse for unattended home sleep testing, there was jubilation in some quarters, angst in others. Advocates and critics alike seemed to agree on one thing, though: Now that it had Medicare’s blessing, HST use would intensify, possibly enough to pose a competitive threat to sleep facilities.

After all, some patients suspected of having obstructive sleep apnea would rather test themselves in the familiar confines of their bedrooms than trying to fall asleep while tethered to sensors and observed by strangers in a sleep center.

Plus, Medicare pays about $750 for an overnight in-lab test but only about $275 for an at-home test. Eventually, some private insurers followed Medicare’s lead and began paying for HST in limited circumstances.

So it seemed a slam-dunk certainty HST would become routine throughout the land. Three years after Medicare’s decision, though, it hasn’t – at least, not yet.

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Evolution, not revolution

Cultures change slowly, advocates point out. Give HST time, and it will thrive. “HST has not flourished yet,” said Charles Atwood, MD, a prominent HST practitioner. “I think it is coming. I don’t think it’s going to be a revolution. It’s an evolution. New models of care take a while to get into practice. HST requires a new way of doing the business of sleep medicine no one has yet articulated.”

At the sleep facility he manages through the Veteran’s Administration Hospital System in Pittsburgh, Dr. Atwood diagnoses up to 40 percent of his patients via HST.

However, at the private, fee-for-service sleep facility he manages at the University of Pittsburgh Medical Center, Dr. Atwood diagnoses only about 5 percent of patients in their homes. That’s a telling statistic.

“HST is cost-effective in the VA system or in large HMOs such as Kaiser Permanente,” he observed. “They are self-insured systems, using their own money. But in a for-profit system, there is probably not as much profit margin to be had. The economic case for HST is less clear.”

George Burton, MD, medical director of the sleep disorders center at Kettering Medical Center, Kettering, Ohio, sees no economic case for HST as currently practiced in the private sector. “Given the cost of the equipment, the cost of educating patients in its use, and the cost of interpreting the results, there is no profit to be had,” he said.

Reimbursement spotty

Some say HST will take hold only when insurers start offering incentives to push patients in that direction. That hasn’t happened yet, although some payers offer HST coverage.

Independence Blue Cross (IBC), the largest private insurer in the Philadelphia region, reimburses for home studies under certain conditions. “We do cover at-home sleep testing for obstructive sleep apnea for both our Medicare members and our commercial members when it’s considered medically necessary and when certain criteria are met,” said Lisa Yoon, of IBC’s External Affairs Department.

Nevertheless, the only hospital in Philadelphia doing HST is the Hospital of the University of Pennsylvania (HUP) – and only through the VA system. Beginning this summer, though, HUP plans to offer HST in all its practice locations.

Allan Pack, MD, PhD, chief of the division of sleep medicine at the University of Pennsylvania’s School of Medicine, remembers how the medical director of one large private insurer reacted to HST 10 years ago. Initially, he was supportive. By their third meeting, the director voiced concern about “opening the floodgates” of HST without knowing who would do the testing and how well. “I think they are frightened of a potential mushrooming of the number of studies,” Dr. Pack said.

Repeat testing

One factor making HST economically iffy is the need for repeat testing. Most providers use Type III monitoring devices, which record just four channels. Even so, the equipment is complex enough that patients use it incorrectly.

“To be sure, repeats are more of a problem in the home than in the sleep lab,” Dr. Atwood said. “Our rate is about 10 percent. Some people have as high as 30 percent.”

Medicare reimburses for repeats, but private insurers “are all over the map” about paying for them, Dr. Atwood said. “Some, I’ve heard, will give the sleep center a lump sum to manage the whole sleep medicine experience,” he said. “If you need to do a repeat, you lose out.”

To lower your repeat rate, have patients demonstrate they can use the equipment before they leave the sleep lab, Dr. Atwood advised. “Still,” he cautioned, “the rate will never be zero.”

As for treating OSA with positive airway pressure therapy, many patients take an auto-adjustable PAP device home and self-titrate it over the course of a month or so. Despite some recent research suggesting that self-titrating OSA patients may adhere to PAP therapy as well as in-lab patients, Medicare has shown no inclination to pay for auto-PAP in the home.

“In auto-PAP, patients are hit with the highest pressures first,” said Dr. Burton, who favors in-lab titration. “Thirty percent of them can’t tolerate it. So that’s a 30-percent treatment failure rate. In a sleep lab, a technician is there to adjust CPAP if the patient wakes up. That’s a lot different than sending a patient home with a blower.”

New accreditation

Recently, the American Academy of Sleep Medicine began offering separate accreditation for HST, a move some sleep physicians feel is unnecessary. Dr. Pack, however, sees a silver lining.

“I think insurers will be happy to see some criteria for what constitutes an indication for a home study,” he observed. “Otherwise, anyone who snores would be eligible, and the potential for abuse is major. By accrediting it, the AASM shows they are paying special attention to quality in home studies. It gives home testing some prominence.”

Dr. Atwood concurred. “I think the AASM is taking the long view that HST is here to stay, and they want to get their arms around it and have some ability to define what quality care means in this context.”

Dr. Burton, however, remains skeptical. “HST is a good idea if we could get the technology streamlined so we had no disconnects,” he said. “If there was some profit margin, this would take off like a rocket.”

Michael Gibbons can be reached at [email protected].