Aetna Inc, Hartford, Conn, has introduced a new sleep study management program through a partnership with CareCore National and Sleep Management Solutions (SMS). The new program will include all Aetna patients enrolled in HMO-based benefits plans (including Medicare) in certain counties in the greater metropolitan New York market.
Those counties include: Bronx, Dutchess, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Sullivan, Ulster, and Westchester.
According to Aetna, “The program is designed to improve the overall quality of sleep services and ensures appropriate use of home sleep testing. Utilizing AASM and CMS guidelines, CareCore will review [the health care provider’s] request for a sleep study and make recommendations for those studies that can be performed in the member’s home. In addition, CareCore will assist with referrals to participating providers who can perform a home study.”
“Aetna is the first insurance company to allow for a change in the delivery of sleep services encompassing a home-based continuum of care approach that focuses on successful patient outcomes at a reduced cost. Other major payors, including Blue Cross/Blue Shield, are also expected to follow their lead by allowing for home sleep testing,” says Robert Koenigsberg, president and chief executive officer of SleepQuest Inc.
CareCore will be in charge of making sure all requests meet quality standards. Health care providers must contact CareCore National to obtain authorization prior to providing these covered services or they will not be reimbursed.
“One concern is that the program places a new intermediary between the HMO and patient, as if sleep medicine, as well as all of health care, needs another agent (ie, hurdle) between the provider and patient,” adds Koenigsberg.
CareCore National and Sleep Management Solutions forged a partnership in January to provide a “value-added product to payors by providing an integrated approach to patient management,” according to an announcement from CareCore.
“At its basis, the CareCore program is relying on Sleep Management Solutions’ cost management program to prevent over-utilization of sleep diagnostic services and therapy. In fact, SMS promotes its primary goal to ‘protect the payor’ and realize a decrease in the payor’s annual sleep spend. However, the program does offer an opportunity for providing a continuity of care that has often been missing,” says Koenigsberg. “As with any program, success of the CareCore/SMS program will be completely dependent on finding the balance between cost controls and providing the necessary level of patient resources to ensure evidence-based outcomes.”
Aetna Partners with SleepQuest
Last week, Aetna and SleepQuest also announced a new national program to provide centralized, and consistent sleep patient, screening, diagnosis, therapy and compliance support.
"The Aetna SleepQuest program is designed to ensure that home sleep testing is successful and cost-effective by providing screening, diagnostic and CPAP therapy services as part of an integrated program that measures both the economic and clinical outcomes of the patients," says Koenigsberg.
Unlike the CareCore "cost-control" approach, SleepQuest will be employing a "cost-effective" approach for Aetna physicians and patients. The comprehensive program begins by providing initial screening tools to choose the most appropriate care pathway. This is done prior to any testing commencing and therefore acts as a triage mechanism to assure that the insurance company only pays for the necessary testing and treatment services at the lowest total cost possible.
As a national contract provider with Aetna, SleepQuest will now be able to serve more patients with sleep-related illnesses such as OSA who are in need of sleep testing services and CPAP treatment.
Is this model a move in the right direction for sleep diagnostics? Join the discussion at Sleep Review’s Facebook page.
*Article updated June 29