1. { Home Sleep Testing and Impacts for Sleep Centers Presented by Rebecca Boarts, RPSGT

2. An eye catching story... January 2013 January 2013 Sleep HealthCenters operating mostly in New England with some sites in Arizona abruptly closes all of its sleep centers. Sleep HealthCenters operating mostly in New England with some sites in Arizona abruptly closes all of its sleep centers. Over 150 employees and thousands of patients are affected immediately Over 150 employees and thousands of patients are affected immediately

3. Sadly many sleep centers started to react like this...more on that later

4. Home Sleep Testing (HST) is typically defined as an unattended form of polysomnogrpahy Home Sleep Testing (HST) is typically defined as an unattended form of polysomnogrpahy Generally HST is performed in the patient home, but can be done in the sleep center or inpatient hospital room. Generally HST is performed in the patient home, but can be done in the sleep center or inpatient hospital room. Generally done with less measuring channels than traditional polysomnogram. Generally done with less measuring channels than traditional polysomnogram. What is Home Sleep Testing (HST)?

5. There are a variety of devices. There are a variety of devices. Commonly known as a type I, II, III or IV. Commonly known as a type I, II, III or IV. What devices are used for HST?

6. Attended full polysomnogram recording with full staging of sleep EEG patterns. Attended full polysomnogram recording with full staging of sleep EEG patterns. Must include these channels Must include these channels EEG EEG EOG EOG ECG ECG Limb EMG Limb EMG Respiratory effort at chest and abdomen Respiratory effort at chest and abdomen Airflow Airflow Pulse oximetry Pulse oximetry CPAP, CO2, PH, etc channels CPAP, CO2, PH, etc channels Type I Devices

7. Examples of Type 1 devices Sapphire PSG with DreamPort by CleveMed Grael on Portable Unit by Compumedics

8. Unattended polysomnogram, with a minimum of 7 channels. Unattended polysomnogram, with a minimum of 7 channels. Must include these channels Must include these channels EOG EOG ECG ECG EMG EMG Airflow Airflow Respiratory effort Respiratory effort Oxygen saturation Oxygen saturation Type 2 devices

9. Example of a Type II device Somte system by Compumedics, no video recording or technologist present, no EEG channels

10. Unattended polysomnogram, with a minimum of 4 channels Unattended polysomnogram, with a minimum of 4 channels Must include these channels Must include these channels respiratory effort respiratory effort airflow airflow ECG or heartrate ECG or heartrate oxygen saturation oxygen saturation Type III devices

11. Examples of Type III Devices Nomad by Nihon Kohden ApneaLink Plus by Resmed

12. Unattended polysomnogram, with a minimum of 3 channels. Unattended polysomnogram, with a minimum of 3 channels. Must include these channels or ability to measure the following Must include these channels or ability to measure the following Channels that allow direct calculation of an AHI or RDI as the result of measuring airflow or thoracoabdominal movement Channels that allow direct calculation of an AHI or RDI as the result of measuring airflow or thoracoabdominal movement Type IV devices

13. Example of a Type IV device ApneaLink by Resmed, no effort measured, only heartrate, airflow and pulse oximetry.

14. Cost Cost Patient Convenience and Comfort Patient Convenience and Comfort Push from insurance payers and CMS Push from insurance payers and CMS Why do Home Sleep Testing?

15. Cost is typically about 35-25% of a traditional in center polysomnogram Cost is typically about 35-25% of a traditional in center polysomnogram For example patient cash cost at SMHC is approx. $300 for HST vs. $1200 for an in center polysomnogram For example patient cash cost at SMHC is approx. $300 for HST vs. $1200 for an in center polysomnogram Affects both patients and medical providers Affects both patients and medical providers Home Sleep Testing Costs

16. Homebound patients-elderly, transportation issues, medical issues Homebound patients-elderly, transportation issues, medical issues Inpatient sleep testing Inpatient sleep testing The comfort of the patients own bed The comfort of the patients own bed Home Sleep Testing Convenience

17. As part of the Affordable Care Act, more commonly known as Obamacare more patients will enter healthcare on a whole. As part of the Affordable Care Act, more commonly known as Obamacare more patients will enter healthcare on a whole. Public aide programs, i.e. Medicaid and Medicare will undergo cost cutting measures including sleep testing. Public aide programs, i.e. Medicaid and Medicare will undergo cost cutting measures including sleep testing. Affordable Care Act Impacts

18. As a result of the Affordable Care Act, many insurance companies are looking to cut costs to offset the expected losses. As a result of the Affordable Care Act, many insurance companies are looking to cut costs to offset the expected losses. Insurance Payer Impacts

19. Many Insurance Payers are now requiring prior authorization for sleep testing Many Insurance Payers are now requiring prior authorization for sleep testing Requirements may include that the pt have a co-morbid condition, i.e. hypertension, CHF, COPD Requirements may include that the pt have a co-morbid condition, i.e. hypertension, CHF, COPD May require the physician to fill out a qualification form May require the physician to fill out a qualification form Depending on the conditions of the form the patient may be required to proceed with HST, and traditional in center polysomnogram denied. Depending on the conditions of the form the patient may be required to proceed with HST, and traditional in center polysomnogram denied. Insurance Payer Impacts

20. Example of Pre-Auth/Qualification Form

21. Less in lab testing completed Less in lab testing completed Increase in or begin to offer HST alternative Increase in or begin to offer HST alternative Develop a total sleep health approach to patient care Develop a total sleep health approach to patient care Increase in physician facetime Increase in physician facetime Challenge to change model of care and train staff Challenge to change model of care and train staff What are the Impacts to Sleep Centers?

22. Estimates vary dramatically from up to 70% home based testing, to around 25% home based testing Estimates vary dramatically from up to 70% home based testing, to around 25% home based testing Shift to more HST expected Shift to more HST expected Choice of sleep center and/or insurance payer to offer sleep center based HST vs. mail order Choice of sleep center and/or insurance payer to offer sleep center based HST vs. mail order Less in Center Testing, More HST

23. Changed approach to providing more for patients than just a polysomnogram Changed approach to providing more for patients than just a polysomnogram Compliance with treatment Compliance with treatment Care managed by board certified sleep physician Care managed by board certified sleep physician Expected increase in clinic or office visits Expected increase in clinic or office visits Follow up testing for patient as needed Follow up testing for patient as needed What is Total Sleep Health?

24. Many sleep centers will have to adjust the types of services they offer Many sleep centers will have to adjust the types of services they offer Compliance follow up Compliance follow up HST HST PAP nap PAP nap And the skills and schedules of their staff And the skills and schedules of their staff Challenge of Model of Care Changes and Staff Training

25. Research supports that the effecacy of HST is adequate in making a positive diagnosis of OSA Research supports that the effecacy of HST is adequate in making a positive diagnosis of OSA However there are many conflicting studies about the outcomes and compliance of the patients months or years later However there are many conflicting studies about the outcomes and compliance of the patients months or years later Is HST Comparable to In Center Testing?

26. Studies published in the American Journal of Clinical Sleep Medicine indicated that HST patients had higher rate of dropout from therapy Studies published in the American Journal of Clinical Sleep Medicine indicated that HST patients had higher rate of dropout from therapy On the other hand studies performed by the University of Pittsburgh and VA of Pittsburgh found the outcomes and compliance were similar 3 months post study On the other hand studies performed by the University of Pittsburgh and VA of Pittsburgh found the outcomes and compliance were similar 3 months post study HST Outcomes and Compliance

27. In the fall of 2012 Priority Health became the first high volume local insurance payer to mandate HST in some cases, mostly though hospital based sleep centers In the fall of 2012 Priority Health became the first high volume local insurance payer to mandate HST in some cases, mostly though hospital based sleep centers Other insurance payers with high volume in Michigan; United, Blue Cross Blue Shield, Aetna have routed some testing to HST as well. Other insurance payers with high volume in Michigan; United, Blue Cross Blue Shield, Aetna have routed some testing to HST as well. Several sleep centers including all hospital based programs in Grand Rapids offer HST to applicable patients Several sleep centers including all hospital based programs in Grand Rapids offer HST to applicable patients Impacts for Michigan Sleep Centers

28. Executives and medical directors of Sleep HealthCenters did cite the changing sleep market as a factor Executives and medical directors of Sleep HealthCenters did cite the changing sleep market as a factor Other factors included the facilities lease contracts for sleep center space and lack of clear hospital base Other factors included the facilities lease contracts for sleep center space and lack of clear hospital base The AASM has issued a statement to all Sleep HealthCenter patients offering advice and assistance to find a new source for sleep care The AASM has issued a statement to all Sleep HealthCenter patients offering advice and assistance to find a new source for sleep care The Conclusion to Our Eye Catching Story?

29. The Moral of the Story...