PHOENIX – Sleep medicine doctors need to get ahead of the curve on home sleep apnea testing or risk being put out of business, according to Dr. Charles W. Atwood Jr., director of the Sleep Disorders Program at the Veterans Affairs Pittsburgh Healthcare System.
Those "who can integrate this are going to survive, and [those] who can’t integrate this are not going to do as well," said Dr. Atwood, who is also an associate professor of medicine at the University of Pittsburgh.
Home sleep apnea testing (HSAT) is gaining traction among U.S. insurers because, among other things, it costs a lot less than traditional sleep lab apnea screening. Physician reimbursement is generally in the range of $180, compared with $700 or so for polysomnography. The Centers for Medicare and Medicaid Services are on board, as well, and have begun reimbursing for HSAT.
HSAT patients hook themselves up before bed to one of several HSAT devices on the market. The monitors typically measure airflow, respiratory effort, and heart rate, and include pulse oximetry. Results are later interpreted in the doctor’s office.
HSAT has only about 10% of the U.S. sleep study market at the moment, "quite small despite all the attention it gets," but with a lower price tag and studies showing that it is a viable alternative to polysomnography, the market is "likely to continue to increase. Most private [insurance] companies are going to want you do to this," Dr. Atwood said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.
Sleep medicine physicians "need to think about companies that want to contract with primary care providers or insurance companies and get an exclusive contract that bars you from doing this kind of work. That has happened in certain markets, and it’s really devastated traditional sleep labs," he said.
Forestalling that means "getting to your insurance companies first and saying, ‘Look, we know this is coming. This is something that we can do. You’ll be happy with our services. Let’s talk,’ " Dr. Atwood said.
In the meantime, "network with your primary care and other referrers to make sure that they know you are doing this. They will want to know who’s going to take care of these patients if they can’t get a traditional sleep study," he said.
Overall, home sleep apnea testing "is not that hard," said Dr. Atwood, who researches HSAT and is a consultant for companies that make the devices.
Pick one system and get to know it well, and start with the easiest, least-complicated patients. Give some thought to who is going to teach patients how to use the devices – how-to videos are available for many – and how to get the devices back after patients are done with them. FedEx and UPS are options.
"You’ll also need to think about what to do with negative studies," he noted. You could take them at face value, repeat the test, or send patients to sleep labs for follow-up.
Home tests won’t work in about 10%-15% of patients, mostly because they will be noncompliant or will slip the pulse oximeter off while asleep. Also, because home testing generates fewer signals than does polysomnography, "you have to get comfortable making decisions with less information," Dr. Atwood said.
Nonetheless, he and his colleagues found that HSAT patients had no worse 3-month functional outcomes and continuous positive airway pressure (CPAP) adherence than did patients whose sleep apnea was diagnosed in a lab (Am. J. Respir. Crit. Care Med. 2011;183:1238-44).
Dr. Atwood receives commercial research support from Philips Respironics, Resmed, Embla, and Vapotherm. He is a consultant to Carecore, Resmed, and Philips Respironics.