Vol. 20 • Issue 3 • Page 6
Home sleep testing devices are cheaper, more accurate, and easier to use than ever before. But questions remain about how best to integrate the technology into an established sleep practice.
“There is legitimate concern that you could be decreasing the number of people who will fill your beds,” said Kenneth Plotkin, MD, medical director and chief executive officer of Sleep Insights in Rochester, N.Y.
Medicare decreased reimbursement beginning this year for home sleep testing to less than one-third the reimbursement value for overnight polysomnography in a sleep facility. Many sleep experts expect that private carriers will soon follow suit. So how can the average sleep facility turn this technology investment into a financial gain?
Corner the market
Nidra Sleep Institute in Jacksonville, Fla., claims the distinction of being the only office-based sleep practice in northern Florida to offer home sleep testing. But Chief Executive Officer Rahul Kakkar, MD, also wants the center to be known for the speed with which it returns study results. Patients come into the office for an initial consultation and take home a battery-powered Type III three-channel home sleep testing device the same night. The device auto-generates a one-page report color-coded by risk factors, then the study is manually scored and interpreted the next day.
“We do it very fast,” Dr. Kakkar said. “That was very appealing to many of our referring physicians, particularly when (their patients) have to go for surgery, or they have to go for a cardiac ablation, or a basic operation, and can’t wait.” Physicians get the process started by downloading the STOP questionnaire from Nidra’s website and faxing the answers to Dr. Kakkar’s practice. When the patient arrives, Dr. Kakkar does a face-to-face evaluation, then he or a medical assistant instruct the patient on the home sleep testing device. “The failure rate was about 8 percent initially when we started to use the device,” Dr. Kakkar said. Careful patient instruction about correct placement and operation of the device has reduced that number to 5 percent.
Last year, the practice tested as many as 40 patients per month outside the center. Dr. Kakkar expects to see fewer Medicare patients this year because of decreased reimbursement and the requirement to have a physician, respiratory therapist, or registered polysomnographic technologist instruct the patient about the home sleep testing device.
But the number of tests the center performs for patients with other types of insurance might climb as high as 20 each month. “We still get many patients who just don’t want to go into the sleep lab and specifically come to us for home sleep testing,” Dr. Kakkar said.
While Kris Servidio, RPSGT, describes Complete Sleep Solutions in Murrieta, Calif., as a “mom and pop type of situation,” the sleep center has implemented a forward-thinking marketing plan. The practice generates sleep testing referrals by offering free overnight pulse oximetry screening services to any primary care physician with questions about his patients’ risk for obstructive sleep apnea.
The PCP fills out a pre-printed order form and directs the patient to schedule an appointment to learn how to set up the device. After testing, the center’s medical director calls the referring physician with the results, answers any questions, and when appropriate recommends that the patient come into the center for a full PSG. This free oximetry service is a loss-leader, Servidio said, but it “may lead to some decent paying in-lab test. That is where we get the most revenue.”
The southern California sleep center also uses home sleep testing for patients who do not adhere to continuous positive airway pressure therapy despite technologists’ follow-up efforts. After an in-office consultation with the practice’s medical director, the patient is sent home with an auto-titrating positive airway pressure device and sometimes a pulse oximeter or a Type II device. This “cut and paste” type study, as Servidio calls it, gives the center more information about a patient’s airflow and heart rate, which can help determine whether the patient requires a different air pressure or mask.
It also prevents the center from needing to repeat the at-home follow-up study, which has a slim profit margin at the Medicare reimbursement rate of $228. “If you repeated that two or three times because the patient did not understand or forgot to plug something in, you have to repeat the whole thing for the same amount of money,” Servidio said.
The six-bed center keeps down the cost of doing on average 52 home sleep tests each month by allowing sleep technologists to pop in on their days off and make some extra money scoring the studies.
Tried and true
Dr. Plotkin’s New York sleep center provides about 20 patients each month with home sleep testing, and his priority is to provide accurate results. Whenever possible, Dr. Plotkin brings patients whose home sleep test is positive for OSA into the sleep center for a split-night study, getting a two-hour diagnostic baseline before titration of their positive airway pressure therapy. “Until home sleep testing is completely, routinely accepted. why not make sure that you have what is considered the gold standard?” he said.
Sleep technologists respond to any unexpected events by initiating a full night PSG study and scheduling a titration study for a separate night. Few, if any, insurance company medical directors will deny a sleep center’s claim for a second center-based test if they offer solid rationale for the additional study, Dr. Plotkin said.
Kristen Ziegler can be reached at [email protected].