Wednesday, January 02, 2008

Why I am not commenting (officially) on Home Testing

On the AASM discussion forum (open to members only), some have been advocating that sleep physicians comment on the CMS (Medicare) website either 1) in oppostion to home testing for osa or 2) to request that home testing be limited to certain devices or to AASM accredited sleep labs. I posted this on the AASM discussion forum a few minutes ago:

I am not going to comment on the CMS website comment section because:
1. Home testing is inevitable. How can a sleep physician argue against home testing when industry publications, such as Sleep Review Magazine, have "AASM Approves Home Sleep Testing to Detect Sleep Apnea" as one of their headlines.
2. Some have argued that sleep physicians should try to limit home testing to type 3 devices, as opposed to type 4. This would make very little economic difference to sleep centers. Frankly, if home testing is going to be a reality, I would like the freedom to pick the device that I, as a sleep professional, felt was most appropriate for the situation. For example, home oximetry could be useful for triaging patients to psg vs split-night study. Here is a study from the JCSM that supports the use of the ApneaLink, a single channel recording device:
3. Some have argued that home testing should be limited to AASM-accredited labs. As an accreditation site visitor for nearly a year, it is my understanding that AASM accreditation was always meant to be voluntary, and that the AASM's position was that it did not promote accreditation status as being necessary for insurance reimbursement. The AASM is not a government agency! I don't think that the AASM should have the power to determine which sleep labs are elgible for government (Medicare) reimbursement. Michael Rack, MD


respbarb said...

And neither does Medicare, that is why any doctor can read a polysomnogram and be reimbursed.

Should I gather that is why you didn't respond to my request for an interview?
What I found interesting is that in the MEDPAC transcripts the issue came up about resticting use of PM devices and it was commented...
“Dr. Barkley: I’m unaware of any diagnosis that Medicare allows that some physicians can make and not others….”
“Dr. Satya-Murti: … So to single out this clinical entity as deserving more of a higher standard would be setting precedent…..”

Whereas another doctor states that it would not be setting precedent because in the DME world there already is a piece of equipment tied to a diagnostic test resticted to certain specialties.

Do you know which piece of equipment he is talking about?

I fell that opening up the question to public comment again and having manufacuturers of PM devices and respiratory therapists whom want to adminsister such PM testing to comment is obvioulsy just inviting commercials.
The "experts" presented technology assessments that reflect best evidence and best practices and they still decide to propose coverage of PM devices and type IV to boot!
And next year they are convening to study why the use of polysomnograms are up!
It's all about the bejamins.
Why would surgeons ask CMS to revisit the reimbursement of CPAP?
Do they routinely order a lot of CPAP in their practices? Do they do a lot of "sleep apnea" surgeries on Medicare age patients?

Michael Rack, MD said...

Please call my office at 601-939-1808 to schedule in an interview.
(I am not sure how to contact you)
Thanks for your comments. I am not sure what DME is limited to certain specialties. The FDA limits a few drugs to certain specialties or requires special training to prescribe: Suboxone, Accutane, one of the irritable bowel syndrome drugs- because of the addictive potential of suboxone and because of the high toxicity of accutane.
As far as adult ENT surgeons, most do not do a high volume of osa surgeries (UPPP/tongue base surgery). However, some ENT clinics do advertise themselves as snoring centers and do prescribe cpap, as well as do adjunctive nasal/sinus surgeries.
There is one ENT doctor in my town who refers patients to the sleep center for psgs and titrations, but handles follow-up himself, including prescribing cpap.

Perplexed said...

As a patient, rather than a sleep "professional" I fail to understand what the "types" of "sleep tests" are under this proposal. I am aware of Resmed's ApneaLink, what "type" is that considered to be under this proposal? I'm also aware of the use of autoPAPs to better titrate a patient's OSA therapy pressure needs (what "type" would this be considered?) as well as a full sleep evaluation w/follow up titration study in a sleep lab and/or a "split-night" study in a sleep lab. I have no use for a sleep lab that doesn't keep a "sleep doctor" on staff to actually see and evaluate patients and would NOT accept equipment or an equipment order w/o first seeing the "sleep doctor" PERSONALLY with a thorough discussion of results and suggested equipment. This common practice of some "prima donna" sleep "professional" dictating the study results and sending recommendations to the referring doctor who likely knows little to nothing about OSA and CPAP capabilities and never having any personal contact w/the patients is totally unacceptable to me. The equipment is much too expensive for the patient to have no say in what equipment they receive. In my situation I absolutely would NOT accept anything less than a fully data capable CPAP, yet the orginal equipment order written before I had any input would have allowed the common practice of the local DME supplier foisting a bare-bones CPAP not even capable of reporting compliance data on me and no choice of mask or type of mask. Once the proper CPAP pressure has been established NOTHING IS MORE IMPORTANT TO CPAP COMPLIANCE than a COMFORTABLE mask!

Michael Rack, MD said...

perplexed: agree with you 100% regarding the mask and the need for a thorough sleep evaluation. A heated humidifier is also important for compliance. I don't do compliance downloads in my practice, but I know other sleep docs who find them helpful. thanks for commenting.

Michael Rack, MD said...

I believe the REsmed apnealink is a type 4 device; my understanding is that it just measures airflow via nasal pressure transducer.

auto-cpap isn't a "type" under the proposal. When auto-cpap is used on a permanent basis for treatment, it is billed the same (and the reimbursement is the same) as a regular cpap machine.
When auto-cpap is loaned out to a patient for a few days to titrate a patient, it is a non-reimbursable service.