Traditionally, insurers follow the innovations and approaches that stem from the medical community, but with the case of home sleep testing (HST), private insurers are taking steps indicating that they are more willing to embrace this diagnostic method. The lead that private insurers like Aetna are taking—and the potential cost-savings intertwined with HST—is sure to be noticed by other payors. If the approaches taken by Aetna show signs of effectiveness and cost-savings, that will not reflect well on those who have taken a steer-clear approach to home testing.

Two approaches, one where Aetna has teamed up with CareCore, and another where Aetna is working with SleepQuest, have launched this summer. The Aetna/CareCore program is a pilot program limited to HMO plans (including Medicare) in one local geographic area. “As with most insurance carriers, Aetna has several pathways for diagnosing sleep apnea,” says Robert Koenigsberg, president and chief executive officer of SleepQuest Inc. “The agreement between Aetna and CareCore/SMS [Sleep Management Solutions] is a pilot program to reduce costs even further within an HMO plan through care coordination and utilization management, including eligibility checks, prior authorization, diagnostic triage (in-lab or at-home), and measured therapeutic interventions.

“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,” Koenigsberg notes.

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However, the CareCore/SMS program is not the only pathway for diagnosis taken by Aetna. The program linked to SleepQuest is more extensive and will be implemented on a national level. “Unlike the CareCore ‘cost-control’ approach, SleepQuest will be employing a ‘cost-effective’ approach for Aetna physicians and patients,” says Koenigsberg. “The 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 ensure that the insurance company only pays for the necessary testing and treatment services at the lowest total cost possible.”

The goal of the program is 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.

“Both the CareCore/SMS program, and the SleepQuest program, permit Aetna to manage its increasing exposure to home sleep testing since the medical community reached its ‘tipping point’ in acceptance of HST,” says Koenigsberg. “Other major payors, including Blue Cross/Blue Shield, are also expected to follow their lead by allowing for home sleep testing.”

With private insurers taking hold of HST approaches, the testing method could start to see more usage. If HST naysayers hold fast to their philosophy, they could get sidelined by the private insurers’ push to advance portable monitoring.

—Franklin A. Holman,
[email protected]