Popularity of HST

Home sleep tests have risen in popularity because of their convenience and ability to identify obstructive sleep apnea (OSA) before the patient is too unhealthy. OSA is characterized by repetitive episodes of apnea or reduced inspiratory airflow due to upper airway obstruction during sleep.

A staggering 95 percent of those with sleep disorders have reportedly gone undiagnosed. “Sleep is a complex subject because there are so many sleep disorders,” explained Lauri Leadley, RPSGT, RCT, president of Valley Sleep Center in Phoenix, Ariz. “There needs to be more education across all levels.”

When home sleep testing (HST) is prescribed-and is used for its intended purpose-the method is less expensive for insurance companies, the patient and the laboratory than an in-lab test. The choice to give a patient a home sleep test, however, could translate to more money over the long-term for all parties involved.

HST in Favor
“Home sleep tests are more convenient and less intimidating for patients,” said Doug Liepert, MD, FRCS(C), of Michiana Sleep Solutions at Michiana ENT Specialty Center in South Bend, Ind. “Even though labs have worked hard to make them comfortable and hotel-like, the experience is not the same as in your home.”

Home sleep testing is more attractive to patients because they don’t have to sleep overnight in a strange place, observed Kelly Jo Gullo, RPSGT/RCP, Sleep Disorders Center Coordinator at Sacred Heart Hospital in Eau Claire, Wis. “There is also less equipment to hook up to the patient so it’s more comfortable,” she said.

There are many advantages to HST so long as the correct patient is participating. Home sleep tests work well in identifying early signs of OSA in young, overall healthy patients before comorbities emerge, said Leadley.

“Literature supports the accuracy and safety of HST, which has helped providers be supportive of the shift,” said Liepert, who specializes in sleep medicine and otorhinolaryngology. “These studies have given me the confidence to prescribe home sleep testing to take care of my patients and ensure they are safe and happy.”

The United States Centers for Medicare and Medicaid Services (CMS) released guidelines on May 21, 2014, stating that results from HST can be used to support a prescription for positive airway pressure therapy.

“The CMS guidelines do not make any specific recommendations about which type of HST device should be used, nor do they specify the appropriate population to undergo HST,” Gullo explained. “However, the organization does indicate that positive airway pressure therapy prescriptions will be covered by Medicare and Medicaid only if OSA is diagnosed using a type 1, 2, or 3 device, or a type 4 device that measures at least three variables.”

There are different types of HST units and reimbursement depends on the unit. According to Gullo, the most common HST and the one used in her clinic is the type 3 unit, which usually has 4 to 7 channels.

home sleep testing
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The Role of Insurance Companies
The biggest factor for the shift to increased use of HST is insurance companies. “Many private insurance companies are covering HST but require preauthorization for an in-lab polysomnogram,” said Gullo. “Unless the patient has comorbidities or other covered conditions, companies only cover HST.”

Insurance companies have historically dictated the option of HST with changing reimbursement rules. When Valley Sleep Center opened, for example, they offered HSTbefore in-lab testing. “Insurance companies were paying for them in the 1990s and then when they stopped paying for them, we started doing tests in the lab,” Leadley explained. “We recently began offering home testing again.”

Liepert wishes insurance companies were aware that sleep medicine professionals are trained to make good decisions that lead to quality care for patients. “When it’s appropriate, we are happy to do the home test first,” he stated. “It just doesn’t always meet our practice standards but the insurance companies’ guidelines are rigid.”

According to Liepert, the requests of insurance companies are not always based on clinical direction and decisions. “We’ve had a couple of insurance carriers that have published their own guidelines that require HST before any other testing,” he explained. “It ties our hands because we have to test our patients at home first and then we may still have to bring them into the lab.”

In the Phoenix metro area, Medicare allows $180 for home sleep tests, and $615 for in-lab testing without CPAP, Leadley explained. “Supplying an auto titrator costs the provider more money because we cannot bill it separately,” she said. “If patients pay in cash, then they save money on the sleep study side but pay more for the auto titrator so does it really work out in the end?”

According to Gullo, home sleep tests cost anywhere from $400 to $800. An in-lab polysomnography, she said, ranges from $2,000 to $5,000 depending on what happens during the night. Factors that may affect the cost include split nights, the need for CPAP/BiLevel and whether the lab is hospital-based or independent, she said.

When is In-lab Testing Right?
“There is a place for home sleep testing but it’s not always the solution,” said Leadley. “Home sleep tests are only designed to identify OSA in patients with no comorbidities.”

Whether its lack of education on sleep disorders or failing to prescribe HST at the right time and for the right patient, some patients land in the lab for further testing after a home sleep test. That results in multiple charges to the insurance companies and multiple copays for the patient. Not to mention the resources that the lab needs to allocate.

Unlike HST, in-lab polysomnography monitors many parameters and can uncover other sleep disorders or health issues such as periodic limb movements and cardiac arrhythmias, Gullo said.

Patients who need titrating or require observation should be tested in the lab, Leadley told ADVANCE. “Automatic titrators don’t always do what they need to,” she said. “Then patients have complications and have to come into our lab which translates to more money for the lab and the patient.”

Managing Extra Costs with HST
“The main hidden cost for both the patient and the lab is a poor quality study due to the battery failing or something falling off during the night,” Gullo said. “These tests are unattended so if that happens and the patient is sleeping, they may not realize it for many hours.”

Home sleep tests may be repeated when study results are inconclusive. Some labs try to offset this issue by ordering two to three nights with a unit and charging accordingly, Gullo explained.

According to Gullo, different laboratories take different approaches. “Some labs have the patient keep the machine, test multiple nights and charge for the additional nights,” she said. “Some labs do one night, download the information and if it isn’t good enough to score, have the patient come back and get the equipment to repeat the test.”

The standard at Leadley’s clinic is to offer sleep tests over one night. “If we have to redo the test because of insufficient data, we have to bill twice and the patient has to pay two copays,” Leadley said. “The result is more time and money for the patient and provider.”

According to Leadley, sleep labs need to partner with their patients to be successful. “If it is costing all of us more money, then we want our patients to understand that,” she said.

The experts at Michiana Sleep Solutions try to be sympathetic to the costs incurred by the patients. “Prescribing a home sleep test and then an in-lab test increases my practice cost which affects my bottom line but the extra cost is more detrimental to the patient,” Liepert qualified.

When it works, home sleep testing is less expensive than testing in a lab, said Liepert. “We haven’t encountered a situation that required multiple nights but if we did, the patient could use the same equipment to keep the costs down,” he stated. “The only cost would be more analysis of data once the patient returns the unit.”

This scenario would increase Liepert’s costs because the availability of the unit has decreased. He cannot assign it to another patient and cannot bill the company again. “I feel that a company should be able to be reimbursed for services provided, whether it’s one night or three,” he said. “The industry needs to determine what the fair rate is for the machine being out and used for more than one night. I don’t know any company that can provide services for free.”

From a diagnostic standpoint, however, it would be beneficial to have more than one night’s data to study because the outcomes could be averaged, Liepert told ADVANCE.

The largest cost of lab studies, according to Liepert, is the personnel. “The costs of salaries and benefits in my private practice are huge,” he stated. “Adopting more complicated testing that reduces the number of personnel would help the practice’s bottom line.”

With improved and less intimidating tests, sleep professionals could treat more people and improve patient satisfaction. “The technology explosion has changed so much, the industry is only going to get better,” Liepert said. “In the future, it may be possible to evaluate sleep fragmentation, movement disorders and abnormalities andmultichannel home testing could become a standard of care.”

Rebecca Mayer Knutsen is on staff at ADVANCE. Contact: rknutsen@advanceweb.com

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