Have you considered diagnosing and managing sleep apnea patients who live hours away by letting an HST vendor handle some of the work?

By Lindsey Nolen

Assigning certain aspects of your home sleep testing (HST) program to a vendor with logistical expertise makes sense in some scenarios. After all, ensuring that the needed single-use items accompany the device and navigating the back-and-forth of the HST and its data can become an inefficient use of resources. During the pandemic in particular, outsourced mail-order HST has become a lifeline for patients and providers.

Some sleep care providers are finding that outsourcing HST logistics—which can include everything from mailing devices, patient education, on up to scoring and analysis—can have benefits beyond increased efficiency. They are using mail-order HST to grow their patient bases beyond their facility’s geographic area—diagnosing and treating people with sleep apnea they could not have reached otherwise.

“Reaching out to underserved populations, like rural areas, is clearly is a worthwhile pursuit,” says Hani Kayyali, CEO at CleveMed, which offers the SleepView Direct mail-order program. “Reaching out to affluent areas with high insurance coverage to increase revenue is another reason to expand a sleep center’s reach.

“Another important reason is to prevent ‘patient leakage’ to national HSAT [home sleep apnea testing] providers who have been quite successful in targeting thousands of referring sources, often in the immediate vicinity of sleep centers, resulting in business leakage away from health systems. All these factors make the expansion not only worthwhile but a necessity; one can argue that such expansion effort is not a ‘nice-to-have’ but ‘have-to-have’ to remain competitive in the future.”

Kyle Miko, founder and chief marketing officer at Virtuox, which offers the HST Your Way program, says that before expanding into a new area, providers should look into the health of the people there (how many are likely to have sleep apnea?) and the payer mix. “Do you accept their insurance or what is the ability for the demographic to self-pay if you don’t?” he says are some questions that should be answered first.

Dominic A. Munafo, MD, FABSM, chief medical officer at Sleep Data and BetterNight, which offers flexible sleep health solutions including HST logistics services, says it’s also important “to understand the existing sleep services and referral patterns in the new geography.”

Munafo says a sleep practice should have minimal, if any, capital expenditure when outsourcing to an HST vendor. You do not have to pay for the devices, only contract for the HST to be performed. HST providers can then augment or replace some or most of a sleep practice’s studies. “This can increase case finding and therefore increase consult volume. The primary expenditure would be administrative to support another workflow and referral pathway,” Munafo says. “The HST program can increase the patient funnel of a practice and should make a positive impact on the bottom line.”

[RELATED: Home Sleep Testing: Should You Run an In-House Program or Outsource It?]

For uncomplicated sleep apnea cases, some patients can be managed solely via telemedicine and cloud-based therapy data upload tools. In other cases, patients may occasionally have to make the commute to your brick-and-mortar building or may need to be co-managed with a physician closer to their residence.

“One of the biggest challenges for an HST program is identifying those patients who need to be seen to evaluate either a different sleep disorder or a comorbid sleep disorder,” Munafo says. “Another important consideration is identifying those OSA [obstructive sleep apnea] patients whose apnea is severe enough to require an in-lab study, such as those with obesity-hypoventilation syndrome. Lastly, in-person visits may be required for those patients who are struggling with therapy or those for whom the payer requires an in-person assessment. Depending on geography and relevant laws, these visits can be either at the sleep center, via telemedicine, or with another local provider who works closely with the sleep center.”

Kayyali says a big obstacle regarding HST use is the idea that in-lab polysomnography will be restored as the dominant method for obstructive sleep apnea evaluation after the pandemic—and the related belief that home sleep study expansions are temporary.

“I believe a ‘new normal’ is taking hold, which will turn the diagnostic process on its head,” he says. “Reasons for why this new normal will persist range from the ongoing effort by [Centers for Medicare and Medicaid Services] and other insurance companies to make reimbursement for tele-consultation permanent, to a heightened awareness [regarding] the speed and convenience of [HST].”

Kayyali has experience with servicing large home sleep testing patient volumes, which generates downstream revenue, without compromising care or causing major changes to sleep staff or workflow. So he hopes that sleep centers, especially those with established referral networks within health systems, will increase the use of outsourced home testing across their services to maintain an edge in the future. “As HSAT grows and becomes a major part of any health system, affiliated sleep centers [will] want to take more control of the HSAT process by outsourcing only those aspects deemed inefficient to them (like logistics and support), while retaining other aspects like interpretation and follow-up care to maximize revenue and patient retention,” Kayyali says.

Gilad Glick, president and CEO of Itamar Medical, which offers the WatchPAT Direct program, says, “These are challenging times that make everyone rethink their traditional business models. Mail-order programs can help clinics expand their catchment area both geographically and by diversifying the referral sources, scale up their HSAT programs significantly—all with minimal effort required and create a funnel to other services as well.

“In short, increased accessibility to more patients, higher patient satisfaction, and better success rates with reduced safety concerns yielding more sustainable business is the value of mail-order programs.”

One sleep physician-neurologist who has done just this is Wesley E. Fleming, MD. In May, Fleming transitioned his brick-and-mortar practice to an entirely online practice. The Irvine, Calif-based physician now plans to attract patients from all parts of California. “Most of the time I go on a portal to consult with the patient then I order the [HST]. Eighty-five to 90% of sleep apnea patients can be effectively evaluated and treated through an online portal process,” Fleming says. “The benefit to outsourcing HST is logistics, including mailing, inventory, patient education on use, tracking the HST, liability, insurance verification for testing, etc. [Deciding to outsource] comes down to a matter of cost and infrastructure for the business.”

One caution is that if expanding your practice means crossing state lines, providers must be licensed in the state where the patient lives, says Virtuox’s Miko. This also extends to the interpreting physician.

To measure success of an outsourced HST program, Miko says, “Set up a marketing budget for the spend, monitor the clicks from your ads, and follow the trail all the way down to how many patients tested,” he says. “For example, we look to pay no more than $50 per lead that converts to a consult and HST, where we charge $399 for both.”

Ryan C. Javanbakht, president and CEO of mail-order company SleepTest.com, says a measure of success of an at-home test is assessed by the amount of data collected. He says anyone can turn on the device and turn it off, but if all the signals and channels aren’t operating for a minimum evaluation time, then results will be compromised. “Looking at evaluation time and having enough evaluation time to provide a proper diagnosis is necessary, which would be correlating with all the proper channels functioning simultaneously,” he says.

In Javanbakht’s experience, many physicians want to see data from more than four hours of sleep, so SleepTest.com prefers to conduct two-night home sleep studies. “Home sleep testing can help labs, physicians, and dentists because, whether it’s COVID times or not, these patients don’t even have to leave the comfort of their own home. It’s giving patients what they want but also providing a diagnosis that’s required for therapy,” Javanbakht says. “The best test that someone’s going to do is the test they’re going to do this week, because [sleep apnea] is a life-threatening disease.”

Lindsey Nolen is a Jacksonville, Fla-based journalist who has been writing about healthcare for over 5 years.

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