Sleep Review editor Sree Roy recently hosted a roundtable discussion with experts in the sleep medicine field. A series of questions about how the Affordable Care Act (ACA) will affect sleep medicine were asked of our expert panelists, who provided their insights on such topics as how sleep doctors and sleep techs can prepare for the changes as a result of the ACA. View the recorded webinar here, courtesy of CareCredit.
Charles Atwood, MD, is an Associate Professor of Medicine at the University of Pittsburgh School of Medicine. Dr. Atwood also serves as a staff physician and director of the sleep disorders program at the VA Medical Center and as the associate director of the University of Pittsburgh Medical Center’s Sleep Medicine Center. In addition, he is the director of the University of Pittsburgh’s Sleep Medicine fellowship program. He is certified in Internal, Pulmonary, Critical Care and Sleep Medicine. In addition to serving on the Board of Registered Polysomnographic Technologists (BRPT) as a director, he is also active with the American College of Chest Physicians (ACCP) and is the past chair of the ACCP’s Sleep Institute.
M. Safwan Badr, MD, is a national leader in the medical subspecialty of sleep medicine, is the 2013-2014 president of the American Academy of Sleep Medicine (AASM), and is board-certified in sleep medicine, pulmonary medicine, critical care medicine and internal medicine. Dr. Badr serves as professor and chief of the division of pulmonary, critical care and sleep medicine at Wayne State University School of Medicine in Detroit. He is a staff physician at the John D. Dingell VA Medical Center and the Detroit Medical Center. Dr. Badr directs the sleep fellowship program at Wayne State University School of Medicine, where he has served in multiple positions, including professor of medicine, since 1996. His research program focuses on the pathophysiology and epidemiology of sleep apnea.
Dennis Hwang, MD, FCCP, is medical director of the Sleep Medicine Department at the Kaiser Permanente Fontana Medical Center and co-chair of sleep medicine for the Southern California Permanente Medical Group. He is also part of the AASM Practice Development Advisory Council.
David P. White, MD, is a Clinical Professor of Medicine at the Harvard Medical School and the Chief Scientific Officer for Apnicure Inc. Some of his major accomplishments include being President of the American Academy of Sleep Medicine, Chairing the Task Force to write the research plan addressing sleep and its disorders for the National Institutes of Health and being the Editor-in-Chief of the journal Sleep. His principal research interest has been the pathophysiology of disorders of breathing during sleep, a subject on which he has published more than 180 original papers.
Topics Covered in the Webinar
- The impact of high-deductible insurance plans on the diagnosis and treatment of sleep apnea
- How sleep doctors can stay in the loop on insurance plans as plans are moving toward smaller networks
- How to prepare for changes due to the Affordable Care Act
Email your questions about the ACA to email@example.com.
How do you see the future for smaller independent diagnostic testing facility (IDTF) sleep labs that are not associated/affiliated with a larger hospital system?
I think they will have difficulty surviving, similar to private practice clinics in general. I think sleep centers will eventually need to integrate themselves into some type of closed-loop network (whether a specific healthcare system or within a narrow-network). This will provide a dedicated referral source; furthermore, I believe that the integration of care is both better for our patients and more cost-efficient for the healthcare system.—Dennis Hwang, MD
More than 50% of in-webinar poll respondents said they expect that the Affordable Care Act (ACA) will affect their income in a negative way. What do you think—will it affect income in a positive or negative way (or not at all)? And why? And do you have any advice for those who think it will affect them in a negative way to exceed their own expectations?
With the current sleep medicine model, the ACA will almost certainly affect income in a negative way. The most obvious direct solution is to join an accountable care organization (ACO) or narrow-network or be employed directly by a hospital, with the understanding that ultimately we need to radically change the way we structure our sleep medicine practice.—Dennis Hwang, MD
With lower reimbursements within polysomnography, and the growth of home sleep testing, what are the future roles of registered techs? And what does the viability look like with salaries?
I ask those questions because many colleges claim numbers off 2007 statistics. Also more schools are popping up for polysomnography. Plus, the education is getting higher (such as the new Bachelor’s degree in Charlotte).
However, with this model usually the salary would increase, ie, higher education equals higher salary gain. For example, take occupational therapy as a medical and business model. Occupational therapists (OTs) in 2005 made roughly $48,000 a year in the Northeast. Now assistants (OTAs) make that salary, and the occupational therapists make around $63,000 (a low estimate in some regions). Note: The Bureau of Labor Statistics (BLS) has OTs making $75,000 median average salary. Also, there is no BLS statistic on polysomnography.
What am I getting at? In 2005, to become an occupational therapist went from a B.S. to a Master’s degree. Hence more education and an increase in salary. I know sleep isn’t rehab; however is there insight on my questions/concerns above?
I agree that several factors will force the role of the polysomnographic (PSG) technologist to evolve:
1. Changes in reimbursement will shift testing away from in-lab testing to home testing. This will reduce the need for the skills of a traditional PSG tech.
2. This will filter only the most complex patients (such as respiratory failure) to in-lab testing, which will require a higher degree of expertise.
3. Healthcare will continue to shift away from a traditional fee-for-service model toward an outcomes-based system, and this will promote a shift to a team-based approach with use of case managers (a possible role for technologists) as a more cost-effective model of caring for patients.
I think it’s possible that the future sleep technologist will have “sub-specialty” training, some as case managers and some as in-lab techs with dedicated training in respiratory failure. I believe that the American Association of Sleep Technologists also recognizes this and is already moving to change the educational curriculum accordingly. I agree that some providers (such as nurse practitioners) have in some circumstances priced themselves out of being cost-effective options, but I do believe that some type of educational standard is necessary given the increased responsibilities of the future technologist.—Dennis Hwang, MD
Shouldn’t patients having positive results with home sleep testing (HST) and provided AutoPAP be monitored with a follow-up HST to assess effectiveness of therapy—either during AutoPAP trial or once a baseline therapy level has been determined and applied? Or do we just guess at therapeutic effectiveness by waiting for a patient narrative/report of a modification/elimination of symptomatology? I am specifically concerned about the population of complex sleep apnea patients who are only revealed after application of PAP therapy. Will the higher end PAP devices provide adequate documentation of effective outcomes? In today’s market will the patients be provided these higher end PAP devices?
The data card download from most PAP machines provides an estimate of residual AHI, which is acceptable within certain limitations. Therefore, the decision to obtain a follow-up study is a clinical decision. In my opinion, patients with central apnea or conditions that predispose to central apnea (congestive heart failure or opiate use) may not be optimal candidates for an auto-PAP device and may be best served with an in-lab polysomnography and appropriate titration.—M. Safwan Badr, MD
AutoCPAP devices are crucial for the home testing pathway, sometimes used to titrate pressure or increasingly used as primary therapy. As technology becomes cheaper, the standard PAP devices dispensed to patients will have the technology to capture information regarding residual sleep-disordered breathing events and provide airflow information. In patients with significant hypoxemia on the diagnostic sleep study, these PAP devices can also be interfaced with an oximeter to confirm adequate oxygenation. This information along with assessment of symptoms should be adequate in confirming effectiveness of therapy.—Dennis Hwang, MD
How will Affordable Care Act affect polysomnography (PSG)? Will PSGs be needed in the future?
As reimbursement for polysomnography decreases and as healthcare shifts towards outcomes-based medicine, this will incentivize sleep providers towards using home sleep testing for the majority of patients with suspected obstructive sleep apnea, while in-lab polysomnography will be reserved for patients with complex disease such as respiratory failure. Our own sleep center functions in a capitated system where home testing has been dominant for many years, but in-lab testing is still necessary for select patients (65% of our in-lab studies are for respiratory failure, central sleep apnea, and pediatrics). Our current ratio of home testing to in-lab testing is about 4:1.—Dennis Hwang, MD
The Affordable Care Act has resulted in decreased reimbursements to the level of payment received about 10 years ago. How are sleep labs going to survive when faced with increasing operating costs?
Decreasing reimbursement is going to force us to find ways of being more cost-effective, and I don’t see any way out of this unless we radically change how we structure our sleep practices. First, the emphasis is going to have to shift away from testing (which will likely have progressively low margins) and toward an emphasis on clinical follow-up (that will be rewarded in an outcomes-based system). Second, the traditional paradigm of the physician handling most aspects of a patient’s care and interacting with a patient primarily through an office visit is unsustainable, and we are going to have to rethink how we interact with patients.
The future of medicine is going to evolve into:
1. Team-based care where the physician is the leader of a team of several mid-level providers including case managers who will end up providing a significant portion of the direct patient contact.
2. Provider-patient interaction will be more varied through the use of technology: use of telephone, text messaging, and email; furthermore, patients will be encouraged to utilize mechanisms of self-directed care.
The pressures on sleep medicine may force us to evolve faster than other fields, but some general considerations include:
1. Consider joining an accountable care organization (ACO) or another system where physicians are salaried.
2. How can integrating mid-level providers and use of classes be beneficial?
3. How can technology be used to make provider time more efficient (such as auto-scoring all home studies and simple in-lab studies; use of remote monitoring; use of Internet or smart phone based applications to assist in managing insomnia and obstructive sleep apnea)?
4. How can web programs (such as Emmi Solutions) be used to educate patients? Patient education is critical but is a time-consuming and costly process.
5. Will it be helpful to collaborate with cardiology, occupational medicine, and anesthesiology on relevant programs with the goal of increasing patient volume?
6. Is there an opportunity to directly reach out to companies or municipalities and develop a sleep disorders screening program for their employees, with the goal of improving productivity?
Through many of these factors and emphasizing the follow-up care, our own referral rate has grown by 9 times over the past 4 years to 900 referrals each month. By improving the relevancy of care to our patients and our health system, it unlocked a large unmet demand of patients.—Dennis Hwang, MD
Currently the American Academy of Sleep Medicine (AASM) has guidelines on comorbidities that exclude patients from having a home sleep test (HST). Do you see that the comorbidities criteria will be revised so more patients are able to have HST?
It is difficult to give a simple answer to this question. The guiding principle is excluding conditions that may degrade the quality of the recording and lead to a false negative study.— M. Safwan Badr, MD
The practice parameter was created when there was less experience with portable monitoring, and some revisions are probably necessary. However, the indications for HST as described in the practice parameter remain very appropriate even as we have gained more experience with HST. For example, the practice parameter recommends not using portable monitoring if there is suspected central sleep apnea (CSA) or respiratory failure. While we can clearly recognize persistent hypoxemia and CSA on most portable monitors, patients with a high pre-test probability with one of these conditions are better served with an in-lab study. Thus the principle that HST is appropriate primarily when a patient has suspected OSA without other complicating factors is a principle that remains appropriate.
What I think needs to be addressed, however, is whether portable monitoring should be used as a screening tool or as a definitive diagnostic tool. For example, should a negative portable monitoring study necessitate a follow-up in-lab study? There are a couple of studies that suggest if a patient has suspected OSA without complicating factors, clinical decision making does not change whether an in-lab or HST study was performed. Thus, in our practice, we use HST as a fully diagnostic test to both “rule in” and “rule out” OSA, and multi-night HST studies are considered for select patients. — Dennis Hwang, MD
Why is the sleep workforce expected to get smaller?
As the field shifts from in-lab polysomnography (PSG) to home sleep testing (HST), the demand for sleep specialists and technologists may also decrease unless sleep medicine evolves. Furthermore, there is uncertainty regarding whether there are enough sleep specialists to adequately manage the large population of patients with obstructive sleep apnea (OSA). As a result, some specialties, such as pulmonary, would like a greater role in managing OSA, and many believe that OSA will be primarily the domain of primary care and decrease the need for sleep specialists (similar to how diabetes is largely managed by primary care, rather than by endocrinologists).
However, I believe that managing OSA is very different from diabetes and does not fit well into a primary care practice. While diabetes management is similar to a typical physician practice paradigm (office visit clinical assessment→run tests→prescribe or adjust medication dose), OSA is heavily dependent on use of equipment. OSA management requires a system to track CPAP data, equipment on-hand to troubleshoot use, and respiratory therapist/sleep technologist with the expertise to work with the patient. It is hard to imagine that this type of setup is feasible in most primary care practices. Rather, I think that the better solution is to transition the care of OSA into case management programs. This improves the efficiency of managing OSA while keeping the care under the expertise of sleep specialists. — Dennis Hwang, MD