sleepapneacommunity.com

Robert Koenigsberg, Pres. & CEO of SleepQuest joins SyndicatedNews to discuss “Medicare’s” new position on sleep apnea and the financial impact Medicare’s turnabout is going to have on SleepQuest’s bottom line.

This is an excerpt from a letter written by the President of SleepQuest to Department of Health and Human Services

CMS is unfortunately missing the mark with what is proposed in 1403 – P. If the status quo in sleep medicine were to continue, then the proposed provision would be necessary. However, with the approval of home sleep testing by CMS, this will truly require a paradigm shift away from the current model. If the sleep physician has any ownership interest in the Home Care Company that provides the equipment for the patient, then clearly a conflict of interest exists. As sleep apnea becomes as widely accepted as asthma and diabetes as a chronic condition, the primary care physician will and should be at the center of the referral process for sleep testing and CPAP treatment as they do for other chronic disease states. This shouldn’t apply to all sleep disorders but specifically for the most commonly prescribed sleep related breathing disorders. If the patient has a neurological condition then the sleep lab should be where the primary care physician refers the patient. The question is, why does the following statement not lead to the best care for the patient?

“Prohibit payment to the supplier of the CPAP device when such supplier, or its affiliate, directly or indirectly is the provider of the sleep test that is used to diagnose a Medicare beneficiary with OSA.”

With the approval of home sleep testing by CMS, access for sleep testing and treatment will increase substantially and we simply do not have enough board certified sleep physicians to handle the upcoming demand. Consider other disease states where the referring PCP has a choice as to whom and where he/she believes will provide the best care for his/her patient. Sleep apnea will soon be considered like asthma and diabetes as a chronic condition which makes the above statement apply only to sleep labs that have an ownership interest in a DME company.

If our goal is to look out for what is best for the patient, then we must STOP viewing sleep medicine as we have since its inception in 1970. With the existing fragmented model, the sleep lab sends the patient to a home care company who provides CPAP as just one of their 1,500 products. These companies employ staff that are responsible for patients with over 150 disease and disorders, which is why the national compliance level for home care companies has been shown to be a dreadful 41% for CPAP use. With the current model, patients complain of being caught in a game of “pickle” between the sleep laboratory and the home care company; neither one often taking accountability for successful treatment.

Our organization has provided in-home diagnostic testing and treatment for patients with sleep related breathing disorders and has done so for almost fifteen years. We provide a continuum-of-care for these patients that have resulted in an unmatched compliance level of 93%. We partner and empower primary care physicians and others with the knowledge to manage their OSA patients at a cost that is far below the current method of testing and treating their patients. Our Board certified sleep physicians do not write prescriptions but only review and interpret our studies to provide expert oversight and consent with PCP’s as needed.

By offering a focused approach including both testing and treatment, our organization is able to shift responsibility for the patient’s care from day one and should anything go wrong with the testing or treatment, the patient contacts one provider directly thus providing a simpler point of contact for the patient

With our model, it’s the referring physician who has a choice of where he/she sends the testing and treatment, therefore no conflict of interest exists. I am writing you because we would like to continue to provide both testing and treatment for CMS patients if requested by a referring physician for the benefit of the patient. My concern is that we won’t be able to do this with the way the current policy is written. We know our model works based on a study performed with Board certified sleep physicians from the Stanford Sleep Clinic in 2005 – 2006.

If our organization were allowed to become an IDTF for CMS, the patient benefits from our disease management approach to OSA because our professionals can provide the necessary expertise to troubleshoot problems that patients encounter when adjusting to treatment.

My understanding is that CMS is concerned that the physician who interprets the in-home sleep study may gain financially by recommending that the patient be placed on treatment when in actuality the patient’s study is normal. First of all this would be a clear sign of malpractice and I doubt a physician would subject himself or herself to this possibility. Second, the provider could be required to share with CMS the legal agreement between the company and the physician that shows that the physician can in no way gain financially by misinterpreting sleep studies and furthermore there is a clear separation between his/her duties as an interpreter and the provision of durable medical equipment.

I hope for the patient’s sake that CMS does not implement the current proposed policy but demonstrates open mindedness concerning which pathway will obtain the best outcome for each of their beneficiaries.

Read full CMS post: http://edocket.access.gpo.gov/2008/E8-14949.htm

- Robert B. Koenigsberg, President/CEO

The Centers for Medicare and Medicaid services (CMS) have, as of March 2008, approved at-home sleep testing for obstructive sleep apnea (OSA). Previous policy had mandated that suspected sleep apnea sufferers must undergo facility-based polysomnography. The new policy allows continuous positive airway pressure (CPAP) treatment for Medicare patients who are diagnosed via unattended home monitoring devices. It is expected that this decision will prompt increased coverage from insurance companies around the country, because many providers follow the lead of CMS in determining their medical policies.

We are very excited about the change in coverage as it demonstrates that our portable sleep testing program, which we have successfully offered for the past 14 years, is a viable and effective alternative to sleep lab testing. This policy change will almost certainly allow us to provide services for many sleep apnea sufferers who previously could not avail themselves of our services, because they were not covered by their insurance providers.

While coverage has been approved, we are still waiting to hear the specific date that the policy will actually go into effect. It may be different in varying areas of California and across the country. In the meantime, several insurance providers have begun to change their coverage to align with Medicare and Medicaid

We were quite happy to learn that upon hearing of the approval, Aetna immediately revised their medical policy to mirror Medicare’s. We expect other plans that follow Medicare, such as Triwest, will also adopt this policy. SleepQuest will continue to work closely with Medicare and other insurance companies to ensure that coverage expands, making treatment more available and affordable to more patients. We have also been in contact with other providers such as Blue Cross of California, who currently allow home sleep testing but impose numerous coverage restrictions, in order to see how they intend to revise their policies.

An estimated 30 million Americans suffer from some form of sleep apnea.

SleepQuest anticipates significant growth and is planning for expansion. A new office conveniently located in San Francisco is scheduled to open by July of this year, and it will service current and new patients.

For almost 15 years, SleepQuest has been a leader in at-home testing and treatment of sleep apnea. We anticipate that as coverage continues expanding, we will be able to focus on getting more patients tested quickly and comfortably in the home environment.

We look forward to helping even more OSA sufferers with our comprehensive approach to wellness and vitality.

–Robert Koenigsberg

This is an excerpt from a letter written by the President of SleepQuest to the Director of Coverage and Analysis Group Centers for Medicare and Medicaid Services

My name is Robert Koenigsberg and I am the CEO and Founder of SleepQuest, Inc.  In 1996, we began providing in-home sleep testing and treatment exclusively, and currently have three field offices which continue to serve the needs of the local communities.  Demand for our sleep testing and therapy continues to expand in each of the areas we serve.  I started SleepQuest because my father had such a horrible experience during his in-lab test that he handed me a Polaroid picture that was taken the following morning after the in-lab test and said “son, do something about this as I just experienced the worst night of sleep of my life”. The past eleven years have been my and my company’s quest to fulfill his desire that all patients would have the ability to be tested and treated in their own home.

I learned early on that patients were caught in a game of pickle between the sleep center and the generalized home care company. The home care company was committed to providing 1500 diverse products for various disease states and didn’t have the specialization to properly educate OSA patients in all of the problems that patients encounter once beginning use of nasal PAP equipment. By taking accountability for the patient, we have now successfully diagnosed over 10,000 patients in their own home, provided in home titrations for those who required them and provided our unique sleep care specialization to insure patients are compliant with their treatment.

I understand why CMS currently doesn’t allow the provider who does the testing to also provide the treatment. I have redefined the delivery model for sleep care by placing the management of the sleep related breathing disorder (i.e. OSA) in the hands of the primary care physician who is currently caring for diabetics and asthmatics and can easily be informed on how to properly evaluate a sleep questionnaire as well as what to look for in their clinical assessment of the patient. Since we are not taking on the care of the patient but acting as an extension of his/her practice by providing a needed service, we don’t run into the same self-referral situation that a lab encounters. The referring physician and patient have a choice as to who they want to provide the service. By the way, this is the way other developed countries throughout the world practice sleep medicine.

Since OSA is more prevalent than either diabetes or asthma, it makes sense that the lower cost and competent PCP should be entrusted with the care of the patients sleep apnea condition. We work complementary with local sleep labs as we believe that roughly 10% of patients have sleep disorders that cannot be properly tested in the home setting. (Not including Insomnia or Restless Legs Syndrome) The PCP is empowered to make this determination by evaluating the questionnaire and doing a clinical assessment of the patient. By providing a continuum of care, the patient benefits from a disease management approach to their breathing disorder. We track outcomes and have successfully provided compliance for 93% of our patients.

In 1999 we began working with the father of sleep medicine, Dr. William Dement who became a believer in our unique approach after speaking to several patients who had become compliant with nasal PAP. In an effort to validate our pathway we undertook a research study to determine if our clinical model could improve the patient’s Quality of Life (QOL) while providing comparable results to previously published studies using traditional in-laboratory management. Quality of life as measured by SF-36 improved significantly for physical health, general health, vitality, social functioning, emotional and mental health subscales. Physical function trended towards improvement. Epworth scores improved from 13.21 (S.D.4.08) to 5.57 (S.D. 3.78) after treatment.

I am concerned that not providing initial diagnostic studies on patients suspected to have OSA, will not produce the outcomes desired. Although a patient with moderate to severe OSA can be properly assessed by a competent physician, the in-home titration is important in determining the type of device to be suggested as well as the type of mask or interface. If patients are placed on treatment without this analysis of their condition I fear that compliance will be less than optimal.

In 2004, we became certified as an Independent Diagnostic Testing Facility by CMS. An investigator came to our offices to perform an inspection prior to our receiving the IDTF status from CMS. During that short window of opportunity, we successfully performed sleep studies for Medicare patients, and received high satisfaction from these patients, again validating our pathway of providing in-home testing.

I would be willing to once again testify at a CMS hearing that may commence prior to the final NCD. Thank you for giving the public an opportunity to voice our opinions and share their experiences and clinical research findings.

Best regards,

Robert Koenigsberg