Diagnosis of Sleep Apnea Moves From Lab to Home

Treating sleep apnea greatly reduces global costs, but compliance remains a concern

In 2009, officials at Fallon Community Health Plan noticed a significant increase of 12 percent in the per-member cost for sleep treatments in its commercial business, and even larger increases in its Medicare business — requests usually granted. “It is a medically necessary service,” says Elizabeth Malko, MD, Fallon’s senior vice president and CMO. “Most people do in fact have symptoms that warrant having a sleep study. There is a significant percentage of members who have a sleep study done who warrant ongoing treatment.”

If obesity is an epidemic, then sleep apnea is one of its byproducts, a byproduct that has byproducts of its own. Obstructive sleep apnea (OSA) is comorbid with heart failure, diabetes, stroke, and hypertension — enormously costly conditions.

Fallon officials noticed that not only were more sleep studies being done, but they also noticed a large increase in the average cost per patient treated. Managing sleep apnea is a burgeoning industry. “Two labs opened here in Massachusetts two miles apart,” says Malko. “And one of the sleep labs actually was advertising that it had 400-thread count linen on the bed. I’m not making that up. It had a plated breakfast in the morning.”

No wonder, then, that study costs were increasing. “When we’re trying to keep the cost of insurance in the single digits, that becomes problematic,” says Malko.

“It’s on everybody’s radar screen,” says Robert Nierman, MD, medical director for medical and payment policy at Tufts Health Plan. “Care management companies who assist plans in dealing with multiple high drivers of cost have added sleep medicine to their repertoire.”

Of the approximately 18 million Americans who suffer from OSA, 85 percent are undiagnosed and untreated, according to studies in the American Journal of Respiratory and Critical Care Medicine. Beside higher health care costs for employers and payers, repercussions include car accidents and lower worker productivity. OSA sufferers on the job are 20 percent less productive than their colleagues, and a 2010 study in the Journal of Occupational and Environmental Medicine estimates that fatigue causes $1,967 in lost productivity per employee per year.

People who drive for a living are especially vulnerable. Thirty percent of accidents involving commercial truck drivers are sleep-related, according to a 2004 study in the American Journal of Respiratory and Critical Care Medicine. Treating all drivers who have OSA would save $11 billion in collision costs, and 980 lives each year.

Employer demands

“For the majority of sufferers, obstructive sleep apnea is a straightforward diagnosis for which an expensive and inconvenient in-lab sleep test is not necessary,” says Richard Hassett, MD, the CEO of NovaSom, a vendor that helps with home-testing and treatment. He contends that in-home testing allows insurers to realize “considerable, quantifiable … savings. Importantly, employers are demanding unit cost savings that can make diagnosis of the next 15 million sufferers affordable.”

A vendor touts his product; that’s expected. What’s undeniable is that health insurers are buying. Malko says that the medical community has been more receptive to the use of home sleep testing technology since the release of the 2008 payment standards for it by the Centers for Medicare & Medicaid Services. In 2011, the American Academy of Sleep Medicine established a new accreditation for providers using home testing technology with its “out-of-center testing standards” (OCTSs).

These sorts of affirmations were what the managed care industry was waiting for. In-lab testing, says Malko, meant that “you went into one of the labs in the evening, climbed into a strange bed, and a strange human being would put a whole lot of electrodes and other things on you and then watched you while you slept.”

To which one might reasonably respond: “No way.” Malko says, “Bingo. That’s exactly the situation. The thought of somebody watching me sleep bolts me right awake.”

Home monitoring became a goal. “Which made a lot of sense in terms of the thinking that if you really want to get an assessment of whether somebody has sleep apnea, you’d like to see him sleeping as he slept every night,” says Malko. “But the technology wasn’t there and the home sleep studies were not very good. Over the last five or six years that technology has evolved significantly.”

It’s more user-friendly, she says, and allows for better self-administration by members. “The technology has also improved showing that it can provide results similar to lab tests for the appropriate patients — those with high pre-test probability of having moderate-to-severe OSA,” says Malko.

One example of that technology is something called the “iBrain,” whose maker, NeuroVigil, describes as “a light and flexible elastic head harness and electrodes that can effortlessly be applied to the head during sleep” for monitoring and diagnosis. An article in the April 3 edition of the New York Times states that it can also be used for depression and autism.

The article notes that “the device uses a single channel to pick up waves of electrical brain signals which change with different activities and thoughts, or with the pathologies that accompany brain disorders.”

Fallon launched its home monitoring program on Jan. 11, 2010. “From that day, the difference in cost from doing the study in the lab versus doing the study in the home — home study costs a third of in-lab studies,” says Malko. “Not only is it costing us a third of what it had cost, but you’re getting a better study. Because you’re actually seeing the real sleep of the patient.”

Main therapy

The number of patients approved for home treatment varies from month to month. “As we have instituted this program, we have seen that the percent of patients that are able to be evaluated by way of a home sleep study — as opposed to an in-lab study — has consistently been over 50 percent. Sometimes it is greater than 70 percent,” says Malko.

The main therapy for OSA is what Fallon calls “continuous positive airway pressure therapy” or C-PAP, which has been around for 30 years. Many insurers, such as Tufts, drop the “continuous,” and call it PAP. Either way, it means wearing a mask connected to a machine that forces air into the airway. It sounds worse than it is.

Sleep apnea is an inadequate breathing pattern that develops in the upper airway. “The airway collapses for a variety of anatomic reasons,” Nierman explains. “Basically you’re just forcing that airway to open up with positive pressure, thus allowing healthy breathing during sleep. Mild cases may improve with diet, weight loss, and positional changes during sleep. There are also surgical options either in the palate or on the jaw, but those are the last options. There are custom-fabricated oral devices that can be worn at night in the mouth. But the treatment of choice is the positive pressure.”

Malko says, “You do the test to make the diagnosis in one of two ways. You can just do the whole night, where you test and monitor to see if they are having episodes where they are not breathing during sleep. Or, you can do what’s called a split-night study. In a split-night study, in the first half of the study you will actually measure and see if the person does have sleep apnea. In the second half of the study you will actually try to have him sleep with the C-PAP mask on to see if he responds. Because even if they have sleep apnea, they may not be responsive.”

Tufts requires prior authorization for a sleep study, whether at home or in a lab, Nierman says. “We often redirect from laboratory to home if the patient is asking for a lab-based sleep study and yet he’s an excellent candidate for a home study, based on his general medical history, sleep-related symptoms, and a rating of his degree of sleepiness. We then have a vendor who actually manages the delivery to, and use of, the proper equipment in the patient’s home.”

The test results are interpreted by a board-certified sleep medicine specialist from the Tufts Plan network.

Tufts uses two vendors, one to determine who’s eligible for sleep testing and another to manage the home testing, implementation of treatment, and measurement of compliance. Nierman declined to name the vendors.

Vendors may be a good way to go, but not all are the same. “The concern is vendors who are going to go out and sell the home sleep testing management directly to primary care physicians,” says Nierman. “That’s a bad idea. PCPs are not necessarily the best MDs to manage sleep-related breathing problems. Our members have access to sleep specialists and the highest quality of sleep testing and treatment throughout the program.”

Fallon also uses two vendors. Sleep Management Solutions oversees the equipment and the home studies, says Malko. Care Core National does the prior authorizations. When a physician requests that a patient have a sleep study he’ll call Care Core National, which will determine whether the request is medically necessary and whether it is clinically appropriate to be done in the home setting.

“We send the respiratory therapist out when we start members on C-PAP,” says Malko. “We make sure that the masks fit. We make sure they know how to use it. Then we monitor them.”

Trying everything

If the member isn’t compliant, the insurer will make contact. “We try to find out why he’s not using the equipment. If that doesn’t work, we’ll send the respiratory therapist out to the home again. Each time we have an interaction with a member who is not being compliant, we notify the ordering provider so that he can intervene as well. If, at the end of the day, the patient simply cannot use the equipment, we will take it out of the home. We want to conserve resources. Leaving the C-PAP equipment in the home and hoping that the patient is going to use it isn’t really good treatment.”

Only a small fraction of patients wind up having the equipment taken out. “We fix the things that are making it hard to use.”

An intensive interaction, and yet Fallon’s numbers prove that home monitoring is cost effective. “We have saved millions of dollars,” says Malko. “In comparing our baseline expenses to the period after we implemented the program, we saved $2.3 million in one year through a 53 percent reduction in both the use and average cost of sleep studies. Getting the right service to the right member in the right situation is usually very effective.”

Compliance remains a problem

So we can all sleep easier when it comes to managing sleep apnea? No. Despite the smaller hassle of being tested at home, and despite the existence of an effective treatment, compliance remains a problem, says Malko. “At best, only about 70 percent of the patients who are started on treatment continue the treatment. Even in those members, very few of them are consistent about using it day in and day out.”

It comes down to: Who wants to wear a mask to bed? “The treatment is not particularly pleasant,” says Malko. “You find a tremendous number of patients who don’t actually continue with their treatment. If the purpose of diagnosis and treatment is to prevent more significant disease with longer-term consequences, then it’s important that we manage OSA well in order to prevent the additional consequences of OSA such as heart disease.

The Tufts program has been in operation about two years for about 3,000 beneficiaries. “We were managing aspects of this piecemeal over the years until it occurred to us that we should work with a vendor and pull everything into one program,” says Nierman. “Previously, we had very little in the way of getting any decent compliance data, and that was a big sale point.

“The positive-pressure equipment our members get is able to send real-time information about hours per night and nights per week of use.”

Tidbits like that are garnering attention. “In 2012, many national payers are driving awareness and adoption of the home sleep test alternative,” says Hassett of the sleep-test vendor NovaSom. “In the end, there’s great news for health plans, patients and employers alike: Once diagnosed, treatment is very cost-effective and reduces total health care costs, absenteeism, and presenteeism dramatically.”-

“Most people do in fact have symptoms that warrant having a sleep study,” says Elizabeth Malko, MD, Fallon Community Health Plan’s CMO.

Earlier diagnosis could reduce later costs

Looking at physician claims in sleep apnea sufferers in the years preceding diagnosis, compared with a control group, shows that care for these people is consistently more expensive, with costs skyrocketing in the two years before diagnosis. The chart shows physician claims numbers in 10 years preceding diagnosis; the red line reflects the amount spent on physician care by people without OSA, and the blue shows the amount spent for people with OSA. People with undiagnosed, untreated OSA are sicker, and need more care.

In 2011, approximately $5.4 billion was spent on testing (both in labs and at home) for obstructive sleep apnea. Clinical executives at health insurance plans argue that home testing should be appropriate for 80 percent of the undiagnosed population. That’s significant savings, over what it would cost to test in sleep laboratories.

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