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Posted Sep 12 2008 1:12pm

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:

- Robert B. Koenigsberg, President/CEO

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