DME Companies Left Out of Home Testing

It appears that Durable Medical Equipment companies have been left out of home testing by most of the regional Medicare carriers.
Here is part of the Local Coverage Determination for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L11518) for Cigna Government Services:

No aspect of an HST, including but not limited to delivery and/or pickup of the device, may be performed by a DME supplier. This prohibition does not extend to the results of studies conducted by hospitals certified to do such tests.

The LCD also states:

The test must be ordered by the beneficiary’s treating physician and conducted by an entity that qualifies as a Medicare provider of sleep tests and is in compliance with all applicable state regulatory requirements.

I interpret this section is not allowing individual doctors to perform home testing in the area covered by Cigna Government Services. It seems that home testing must be performed by a sleep center/sleep lab.

Near Death Experiences Linked to REM Intrusion

According to a new study, many persons with a Near Death Experience (NDE) have symptoms of REM sleep intruding into wakefulness:
For 60 percent of those who had been through an NDE, the rapid-eye movement (REM) state of sleep intrudes into their regular consciousness while awake, the study found. Both before and after their traumatic event, these people had experiences that include waking up and not being able to move, sudden muscle weakness in their legs, and hearing sounds that no one else hears upon waking or falling asleep.
Persons with narcolepsy commonly have symptoms of REM sleep intruding into wakefulness, including sleep paralysis (waking up and not being able to move), cataplexy (sudden bilateral muscle weakness/limpness in response to strong emotion) and hypnagogic/hypnopompic hallucinations (hallucinations, usually visual, as one is falling asleep or waking up).
These symptoms occur when features of REM sleep (muscle paralysis, dreams) occur during wakefulness.
I wonder Near Death Experiences are more common in narcoleptics??

Home Testing Reimbursement Announced

The AASM reports that Trailblazer, the Medicare carrier for Texas and surrounding states (not Mississippi) has decided reimbursement rates for home testing for OSA:

G0399: Home Sleep Testing, Type III portable monitor; minimum 4 channels - $125.00 - $85 is recognized for the Professional Component - $35 is recognized for the Technical Component

With a low reimbursement like this, home testing is not going to quickly become widespread.

Somnus Sleep Clinic is trying out its Type III home testing device tonight. I should be able to let you know next week how it worked out.

Patient Problems at Sleep Labs

A reader commented:
"The problems of sleep labs are not just compliance with regulations. Sleep lab operators need to run good facilities which are tolerable for patients. It took me a long time to recover from the emotional torment of lousy techs who answer every question "you would have to ask your doctor." Insurance companies pay through the nose for the testing, but there is never a doctor available to help the hapless patient. When I couldn't fall asleep during titration and asked for sleeping pills, the tech said he would ask a supervisor, the supervisor hummed and hawed "What kind of meds did you bring with you?" "None, " I said, "never needed any." "Then I will call the doctor, maybe we can get some presecribed for you for tonight." When the doctor did not call back, she said "He hasn't called, but actually you were sleeping beautifully for nearly 3 hours you just woke up a few minutes agao and began calling out for help, which is why I came in!"

Thanks for reading. Actually, the problem is with government regulation. From your description I am assuming that sleep center you went to was an Independent Diagnostic and Testing Facility (IDTF)- a slight majority of sleep centers are IDTF's as opposed to hospital-associated sleep centers or sleep centers that are an extension of a physician practice.
Somnus sleep clinic, which I am a minority owner of, is an IDTF. Because of anti-kickback rules, only a minority of patients can see me prior to the sleep study. Government regulations require a majority of patients to be referred by an outside physician directly for a sleep study.
As medical director, I am available to the technicians for patient emergencies. However, if the techs call me in the middle of the night for a directly referred patient who can't sleep, it puts me in a legally awkward situation of giving a medication to someone who is not my patient. And where is the sleeping pill supposed to come from? Should I call in a prescription to an all-night pharmacy and have the patient drive to go get it (with all the electrodes pasted in their hair)? I guess I could give them one of the samples from my private practice- however new CMS (Medicare) regulations that take effect Jan 1 2009 put new restrictions on the interactions between physicians and IDTF's.
If all of this seems confusing to you, I would encourage you to look through the archives and look at my posts on management of a sleep lab and ownership of a sleep lab.
And technicians are supposed to tell you to ask your doctor about any medical inquiries.

If any sleep physicians out there who practice in IDTF's or hospital-associated sleep labs have a solution for patient requests for hypnotics, I'd be interested in hearing them.

Type 3 Home Testing Device

At Somnus Sleep Clinic, we finally obtained a type 3 home testing device, the SleepTrek 3:

SleepTrek3, a 6-channel Home Sleep Screener, is a small lightweight physiological data recorder specifically designed to assist the clinician in the diagnosis of sleep-disordered breathing. SleepTrek3, Type III Sleep Screener, uses sensors to record oxygen saturation, pulse rate, airflow, snoring, respiratory effort and body position. The screener is designed to be used in a supervised (hospital/institutional) or unsupervised (home) environment. It is capable of recording 12+ hours of patient data using a single 3.6-volt Lithium battery and a CompactFlashCard.

The SleepTrek 3 has been available for several months. Our holdup in getting it was that we were waiting for the software that would allow it to be fully integrated with the Grass Twin PSG system.
We plan to test it over the next week, I'll let you know how it turns out.

Careers in Sleep Medicine for Psychiatrists

A reader asks:
I have a question about joining the real world as a psychiatrist and sleep physician. It seems everyone is geared toward pulm/cc guys. I think I will have some benefit with a wife in a gen med practice but only if I open up my own practice. Are there jobs out there for regular shrinks?

The number of pure sleep medicine jobs has decreased over the last several years, but there are some 100% sleep medicine jobs out there that are open to all the underlying sleep medicine specialties. You can find out about these opportunities on the AASM website, the sleep journals, and the websites of recruiting firms like locumtenens.com and MDJobsite.com.

Another possibility is starting your own sleep lab. Check out the ads in Sleep Review for companies that you can hire/partner with to assist in this process.

Another possiblity is taking a psychiatry job with a hospital that has a sleep lab and make it a condition of your employment that you can read (and get paid for) the patients you refer to the lab.

Check out the Sleep forum on the Student Doctor Network for more ideas.

Treating Resistant Insomnia

I posted this on the Medscape message boards today:
I see a lot of pts who have failed the standard hypnotics (Rozerem, Ambien, Ambien CR, Lunesta, Sonata). It's important to screen for secondary causes, including restless legs. If they haven't taken Restoril yet, that's sometimes effective. I have found chloral hydrate effective for short term use (no more than 1 month), for breaking the cycle of insomnia. I have one patient on Xyrem for insomnia (and several who take it for narcolepsy). Before prescribing xyrem, it's important to rule out obstructive sleep apnea. I'll occasionally use Seroquel for insomnia, but only if there is comorbid psychiatric illness. I'll also sometimes use neurontin, but usually only if there are also neuropathic/RLS symptoms present.

Sexual Behavior during Sleep

Current Psychiatry has an article this month on "sexsomnia":
Sexual behavior during sleep (SBS)—or “sexsomnia” ...is more than a sensational defense for a high-profile court case. Sleep physicians are finding that sexual behaviors during sleep are real and more common than previously thought. Although SBS cases sound psychological in origin, it appears that the problem lies in the brain itself.
SBS can cause great distress to its initiators and recipients but often goes unreported and untreated because of embarrassment about seeking help. Among patients who report their symptoms, many say they experienced SBS 10 to 15 years before seeking help. SBS not only disrupts sleep but can damage relationships and lead to allegations of sexual assault and rape.

I have had only one case of this in my sleep practice- a woman with masturbatory behavior during sleep. She failed all the standard treatments- benzodiazepines, tricyclic antidepressants, and anticonvulsants. Her polysomnogram and EEG were essentially negative. I ended up referring to the local university sleep center for a second opionion. She didn't keep her follow up appt with me and I have no idea what happened to her.

Insomnia Tips

5 tips on battling insomnia from Healthy Living, including:
Remove the television.

Running A Sleep Lab

A key part of running a sleep lab is keeping on top of the constantly changing regulatory environment, on both the federal and state levels. This link does a good job of describing the new federal regulations for independent diagnostic and testing facilites (IDTF's) that went into effect January 2008 (though for pre-existing IDTF's, many of the provisions do not apply until January 2009). Every February the AASM gives a course on sleep lab management that is very useful for anyone running a sleep lab.

Treating OSA improves cognitive dysfunction in Alzheimer's disease

Increases in total sleep time (TST) related to treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) are associated with improvements in cognition in patients with Alzheimer's disease, a new study shows.
The study is summarized on Medscape.

obstructive sleep apnea and diabetes

The International Diabetes Federation reports on the close relationship between type 2 Diabetes and Obstructive Sleep Apnea:

Obstructive Sleep Apnea (OSA) is the most common form of sleep-disordered breathing, accounting for over 80% of cases.
Estimates suggest that up to 40% of people with OSA will have diabetes, but the incidence of new diabetes in people with OSA is not known.[i]
In people who have diabetes, the prevalence of OSA may be up to 23%[ii], and the prevalence of some form of sleep disordered breathing may be as high as 58%.[iii]
Overweight and obesity may play a role, but some recent studies show an association between the two conditions that is independent of overweight/ obesity.
OSA may have effects on glycemic control in people with type 2 diabetes.
OSA is associated with a range of cardiovascular complications such as hypertension, stroke and heart failure.
IDF calls on health decision makers to encourage further research into the links between the two conditions and urges healthcare professionals to adopt new clinical practices to ensure that a person with one condition is considered for the other.

More information about the relationship between diabetes and osa is available on the IDF website.

Memory dysfunction and obstructive sleep apnea

Obstuctive sleep apnea is associated with cognitive dysfunction, including memory problems.
A study reports that key brain structures involved in memory, the mammilary bodies, are shrunken in patients with Obstructive sleep apnea:
A study using high-resolution magnetic resolution imaging (MRI) scans reports that mammillary bodies — brain structures involved in memory — were 20% smaller in patients with sleep apnea than in controls.

More from Baltimore

Earlier this week preliminary data from the Sleep Heart Health Study was presented. It appears that in patients without significant preexisting cardiovascular disease, moderate to severe osa (apnea-hypopnea index of greater than 30 with events requiring a 4% desat) over a 10 year period led to only modest increases in the risk of incident coronary artery disease in men younger than 70 (about 1.35x risk), and no to minimal increased risk in older men and in women. The stroke risk however was significantly elevated in men, but not in women with an ahi of greater than 30. Sleepiness appeared to increase the risk of the development of coronary artery disease and stroke.

The implications of this large (over 6000 subjects) prospective cohort study is that osa may not increase the risk of developing cardiovascular disease (angina, coronary artery disease, congestive heart failure) as much as previously thought, though the risk of developing ischemic stroke is increased in younger men (about 2.7x).
Patients without significant cardiovascular disease should be treated if symptomatic (significant sleepiness). This study does not change the need to aggresively treat osa in patients with preexisting cardiovascular disease.

Greetings from Baltimore

Went to an interesting session today at SLEEP 2008 on portable home testing. Not much has changed over the last several months. Most Medicare carriers are still writing Local Coverage Determinations for home testing. It appears that the old code for home testing with a type 3 device (95806) is being replaced with a G code (G0399) with additional G codes for Type 2 and Type 4 devices. Trailblazer, the Medicare carrier for New Mexico and several neighboring states apparently won't cover home testing, though that decision is still under review.
Everyone is talking about home testing, but no one appears to be doing it yet to any great extent. It doesn't appear that home testing will be done to any great extent until 2009; it will take at least that long for the local Medicare carries to decide their policies regarding home testing, and more importantly, get the payment mechanisms/codes in place for home testing

SLEEP 2008

I just arrived at the SLEEP annual meeting, in Baltimore. Hope to be inspired at this meeting and post about it this week.

Congratulations to Top Sleep Technicians

Congratulations to the recipients of ADVANCE magazine's sixth annual National Sleep Achievement Awards.
The winner for Best Tech was Diana Chesnut, RRT, RPSGT.
Honorable Mention
Best Tech
Robert Parks, RPSGT Somnus Sleep Clinic, Flowood, Miss.
Roger Scott Dr. Zzzs Sleep Center Tulsa, Okla.

Sleepy

Sometimes I feel this way, after staying up too late the night before:
It's no secret our economy has reached the point that my eyelids…are drooping. Face…falling toward keyboard. Energy level…sinking fast, but cannot stop now! Must…keep…typing op-ed piece. Deadline…looming! Article due! Cannot allow…self to sleep…precious, precious sleep… until finished….

Hypnotic Prescribing Trends

A new survey finds that latency to sleep onset (rather than sleep maintenance) is what Primary care doctor's consider the most important attribute in selecting a hypnotic:
Decision Resources, a research and advisory firm focusing on pharmaceutical and health care issues, finds that a drug's effect on latency to sleep onset is the attribute that most influences the prescribing decisions of surveyed primary care physicians (PCPs) in the treatment of insomnia.
I prescribe Ambien, which is good for helping a person fall asleep, much more than Ambien CR, which is better for sleep maintenance. Ambien is also now generic and much cheaper than Ambien CR.

Pills don't cure Obstructive Sleep Apnea

The life sciences company BTG is developing a pill that will supposedly treat obstuctive sleep apnea:

BGC20-0166 is a novel combination of two marketed serotonin modulating drugs being developed for the treatment of OSA.

Various sertonergic and serotenergic/noradrenergic antidepressants, including Prozac and protriptyline, have been used to treat OSA. These medications have a mild effect on osa. They slightly improve osa by increasing upper airway tone and also possibly by decreasing REM sleep. The effects are mild and antidepressants are not considered to be an effective treatment for OSA.

I don't recommend buying stock in BTG.