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The recent CMS decision allowing home testing to qualify Medicare patients for CPAP provides a window of opportunity for home care providers to enter further into the world of sleep medicine. However, the details for this new prospect of work have yet to fall into place, leaving parties from both sides searching for the role they will play and how it will affect their work. Sleep Review spoke with Aaron Morse, MD, owner, Central Coast Sleep Disorders Center, Santa Cruz, Calif, and Diana Guth, RRT, owner of Los Angeles-based Home Respiratory Care (HRC), to get a feel for how each side sees the future of potential collaboration.
Aaron Morse, MD
Give me a little background on yourself in the sleep and home medical equipment (HME) industry.
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I have been in practice for 25 years, having trained in pulmonary and critical care medicine. I’ve been doing sleep medicine along with pulmonary and critical care for about 23 of those years, and I was medical director of an ICU during much of that time. Because sleep medicine had become such a large part of my practice, in 2004 I decided to limit my practice to sleep disorders. I am board certified by the American Board of Sleep Medicine and also by the American Board of Internal Medicine, subspecialty of sleep disorders.
Our main focus at our center is the comprehensive care of all sleep disorders, and we also have a very extensive disease management program for sleep apnea. Our full-time respiratory therapist does mask fitting and follow-up for troubleshooting. We also have a nurse practitioner seeing patients, as well as a sleep technologist who calls patients regularly regarding problems and issues with CPAP.
What is your opinion of the recent CMS decision on home testing?
Portable monitoring has been a significant part of our process here for more than 20 years, but I am of mixed opinion about CMS’ decision. I think that portable, ambulatory monitoring has its place when used properly in the setting of a sleep center that can provide comprehensive management. (You will notice that I refer to a sleep center, not a sleep laboratory.) The key to making portable monitoring work is to provide the same level of care to patients irrespective of what type of study they are having.
My concern about the CMS decision is that they went from one extreme to another. They seem to have made any kind of monitoring available to anyone who wants to do it. I do not think that is going to get the results that they anticipate. Portable monitoring definitely has a very acceptable role in the management of these often complex patients, but it has to be taken in the context of understanding the limitations of the studies, and within the context of comprehensive management of the patient.
What role will HME providers have in home testing?
I don’t think they should be doing testing. Period. There is so much more to the diagnosis and treatment of sleep apnea than reading a test and supplying equipment. I don’t think home care companies do the job they’re supposed to be doing, and to add testing to that is really the wild west. I think home companies should focus on improving their abilities in managing the difficulties patients experience with CPAP, doing patient follow-up, and providing feedback to sleep centers.
Their role needs to be better defined. Are they just going to be like drugstores selling equipment or are they going to manage patients once they’re on CPAP? They have to decide whether they are going to be retail companies or are going to provide a medical service. Right now, that’s not at all clear.
Where does the role of the sleep professional end and the role of the HME provider begin?
My own bias is that sleep labs should be able to do their own CPAPs on everybody because everything is in one place. Personally, I don’t think home care companies are likely to be in a position where they can adequately manage patients. There is too much variability between companies and their policies as well as personnel turnover. They should focus more on providing the best equipment in a timely fashion, and the sleep centers should have a way to pay for personnel to manage patients. Either that or the sleep labs should provide equipment and pay for the personnel to manage patients out of the income they derive from the equipment.
How will home testing impact sleep labs financially?
I don’t know. It depends—with the current situation, it is going to vary a lot from community to community. I don’t think that, just because Medicare approves it, primary care physicians are going to go out and buy their own equipment … unless the testing equipment manufacturers start banging on their doors promising extra income. As I stated before, proper patient management is much more involved than testing.
It may make sleep labs busier because the level of awareness of sleep disorders is going to be raised. There still will be a very significant need for PSG, and many patients are going to want the “gold standard” for diagnosis as well as care. Medicare is not telling anyone that they have to do home testing.
How can HME providers and sleep professionals work together to help achieve better compliance with CPAP?
The literature on CPAP compliance says that the more patients are followed, the better they do. Again, HME providers, as a group, need to decide what their role is going to be and then coordinate with the sleep professionals to be part of a continuum of care. Availability, responsiveness, and close follow-up are what need to come out of this, and decisions need to be made as to how this is going to be accomplished, including what role the HME companies really want to play.
What is the biggest misconception that HME providers have about sleep clinicians?
I think they see a lot of sleep labs as mills, where they grind out tests and just send them off to the HME provider without much information. And I’m not sure how much that is a misconception in many cases. There are certainly a lot of entrepreneurs out there whose only goal is to grind out as many sleep studies as they can.
What is the most important thing HME providers should know about home testing?
There are significant limitations, especially if mild sleep apnea or upper airway resistance syndrome is present. Because sleep itself is not measured, the severity of the respiratory sleep disorder may be underestimated if the patient is awake at all during the study. More importantly, the limitations are not so much the technology, as who is doing the test, interpreting the test, and managing the patient. When they get a report that says “sleep apnea” or “no sleep apnea,” they have to be aware that this statement may not be entirely accurate. The quality of the study may not be great, and the raw data needs to be reviewed by a clinician to assess the adequacy of the study. There is often a tendency to tell patients that they are “normal” if the study is negative, and this is frequently not the case. In particular, the patient’s symptoms need to be explained, as sleep apnea is not the sole cause of daytime sleepiness. It is also very common for patients to have multiple sleep disorders, and this is one of the reasons why evaluation by a sleep specialist is so important.
HME providers often say they are far better equipped to fit masks and follow up with patients. Why do you think they say this?
That’s nonsense. We employ a full-time respiratory therapist who does nothing but mask fitting all day long. We discuss patients’ needs frequently throughout the day because she is on site here with me. There was an editorial, titled “Time to Treat Obstructive Sleep Apnea like a Chronic Disease,” in Chest Physician, published by the American College of Chest Physicians. That article discussed the marginal job that HME providers often do in managing patients. This is a common impression of sleep physicians who are really taking care of patients. HME providers are right, they may be equipped to do mask fitting, etc, but they often don’t do a very good job of it, especially with follow-up. They need to put their money where their mouth is, because so far that hasn’t been demonstrated.
DIANA GUTH, RRT
Could you give me a little background about your experience in the home care industry?
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I’ve been in the home care industry for more than 22 years, and I have been the owner of my own company for over 13 years. I’m a registered respiratory therapist, and we specialize in treating people who have sleep apnea.
What is your opinion of the recent CMS decision on home testing?
I’m very concerned about it. I worry that there doesn’t appear to be any regulation in place on the actual testing, and I worry about the quality of the tests and who is going to be performing them.
Having had a lot of one on one with patients with CPAP, [I know that] some of them are very mechanically challenged. Even if they come in and are told to attach different leads and press this button to start, a lot is going to go wrong. I’ve had patients who have put CPAP masks on upside down and they are completely unaware.
My concerns also have to do with the freestanding labs that are doing excellent studies. It is doubtful that the home studies that are unattended can even begin to compare to the excellent attended studies being done in the good labs.
What role will HME providers have in home testing?
Some may partner with some sleep labs to do this. There is a risk of endangering your referral source if you do this without talking to them first, or even talking with them might be a big risk, depending on the neighborhood you’re in and the relationship you have with the sleep labs. I’m not sure how it’s going to shake out.
Where does the role of the sleep professional end and the role of the HME provider begin?
Different levels of service are provided by different companies. I can only speak for myself. My vision is: I’m a respiratory therapist and the equipment is the tools of our trade. We do a tremendous amount of patient care and follow-up. You’re talking to someone who really values patient care, and I put the resources into it. There are other companies that do not do the same.
How will home testing impact HME providers financially?
It could be an advantage; I don’t know. If more people are tested and qualified, we might get more business. It could be quite positive if the companies that are doing the testing also provide the HME equipment, then there will be more competition.
What is the biggest misconception that sleep clinicians have about HME providers?
The misconception is that we have an endless pot of gold. They don’t understand the economics. Their expectations for us to provide top of the line equipment when prices are fixed (and going down) make it very difficult for us. They don’t want patients to have out of pocket [costs]. These are conscientious clinicians who are really very clueless about what it takes to run this kind of business and the economics of it.
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What is the most important thing HME providers should know about home testing?
I would have to acquire that information myself should I venture out in that. I’ve never done any testing myself, other than oximetry. I would say that if you are going to do this, you should investigate it carefully, and try to determine the consequences, both pros and cons.
Do you work with any sleep labs that self-dispense CPAP units? If so, how do you keep the peace and what is your arrangement?
Yes, I do. There are some that do, and most of them (either from the beginning or through a bad experience) won’t touch Medicare with a 10-foot pole. They actually get pressured by the insurance companies to be a one-stop, but they still refer us the VIPs, because they know they aren’t able to do the same kind of follow-up that we do. It all depends on the sleep lab.
Katie Griffith is associate editor for Sleep Review. She can be reached at [email protected].
