Written by Chris Vu, Dec 20th 2010:
Sleep medicine in the Home and the Lab
With each passing month, sleep professionals continue to ponder the best way to use in-lab sleep testing in conjunction with proper home testing. Economic pressures are driving the evolution, which began in earnest 18 months ago when Medicare allowed the diagnosis of apnea, in certain patients, with home testing. “Medicare again has announced in certain areas they are reducing the reimbursement for full PSG, and this has been the trigger for some to try to be smarter about sleep testing. The financial pressures on labs have made many people more willing to accept home testing.
Specifically, the Centers for Medicare and Medicaid Services (CMS) targeted a local coverage area for reimbursement reduction on full polysomnography, a trend that is likely to continue. In a separate local coverage determination (LCD), CMS stated that starting in January you must be AASM-accredited, JCAHO accredited, or have a board-certified doctor as your medical director to bill Medicare for studies. Most hospital facilities already have that, but it will have a dramatic effect on the alternate care sites—the off-hospital sleep labs. A greater percentage of those are not AASM accredited. These rules may improve labs, but will probably limit the number of people who can get care because fewer labs will be available.
At least for uncomplicated patients, the medical community has come to accept home sleep testing is clinically effective in appropriate patients. Full PSG will likely never go away, at least in the foreseeable future, because home studies are simply not indicated for everybody.
Experts acknowledge that many in the sleep community are still struggling to reconcile the high clinical standards achieved in sleep labs with the home environment. Right now, the opportunity for manufacturers who have a device that can comply with the high standards of the AASM. Those who can, will be successful. The tradeoff is that those high-standard devices can often be more difficult and more cumbersome to use.
On the other side of the Atlantic, these important questions have largely been answered, with greater acceptance of home testing found in much of Europe. We believe that outside the U.S. the number one opportunity is full PSG unattended, which is a Type 2 device. Reimbursement outside the U.S. also continues to decline. The full sleep labs must figure out a way to stay in business, and the next step for them is to do unattended full PSGs. In Japan, they have a rule this year where you get the same reimbursement whether the test is attended or not. The big incentive is to do unattended studies, because the reimbursement in Japan is the highest in the world.
