A couple of years ago, in 2008, there was a moment of angst in the sleep-medicine specialist field, when Medicare decreed that they were no longer going to pay for home sleep studies.
At that time, there was no ‘item number’ to cover a home sleep study. The place of home sleep studies in the diagnosis and management of obstructive sleep apnoea, let alone other sleep disorders, had been examined in only a few studies in the literature and there was not a consensus from the community of specialist sleep physicians as to how and when these studies should be done.
Nevertheless, home sleep studies could be done and were being done. Aggressive expansion of home sleep study business models, some industry-driven (ie CPAP companies) and some physician-owned, was occurring. And it was occurring in the country.
From where I sit (that is, in Hamilton) the reason given for this expansion didn’t really hold water. City based specialists and companies were saying that home sleep studies needed to be done because patients such as mine needed access to services. Reading between the lines, that meant that it was easier to stay in the big cities and to negotiate with a chain of pharmacies to put 200 home sleep study devices in towns around the state than to negotiate with hospital administrators to set up state-of-the-art sleep labs, and to back them up with specialist consulting services. The resulting service was limited. The development of skills in regional centres was scant (pharmacy staff trained to put on leads). Medicare fees were drained from the country back to Melbourne, rather than reinvested locally (for example, in a local medical practice or sleep lab). When things got tricky, country people still had to travel to the city to see a sleep specialist. And the impression was given that sleep studies are easy. Like getting your blood pressure checked.
In spite of the above uncertainty, a review of the evidence did suggest that home sleep studies were useful in people with a very high clinical probability of having severe obstructive sleep apnoea. After careful consideration, we decided that it was a service that we should carefully offer, and so we established a handful of home sleep study outlets in our region. We considered the distinctives of our service to be; a sleep specialist reviewed every referral to ensure that a home sleep study is appropriate, prior to authorising performance of the home sleep study; analysis and reporting of the sleep study occur locally (it can’t be assumed that sleep study analysis for home sleep studies in Australia even occurs in Australia any more, with at least one of the major providers of home sleep studies outsourcing analysis of data to sleep scientists in India); the reporting sleep specialist always analyses the raw data (not just the analysis summary provided by the scientist); sleep specialist clinical review is available locally if required.
When Medicare declared a moratorium of sorts on home sleep studies I thought that sounded reasonable. Of course, with substantial business under threat the big providers of home sleep studies negotiated hard for an allowance to continue to provide home sleep studies as they already were. And that permission was granted, in October 2008, although with a much lower fee from medicare for the service, while the whole area was carefully reevaluated.
The Medical Services Advisory Committee has just reported to the Minister for Health after an evaluation of all the literature related to ‘unattended’, or home based, sleep studies. Eighty studies were identified, evaluating home sleep studies performed in ‘non-specialist’ (for example a GP clinic or pharmacy) setting, a ‘referral setting’ (ie referred to a specialist for the study) and a paediatric setting. (14, 60 and 6 studies applicable to each setting respectively).
The document reads:
The Committee recommended funding of Type 2 (unattended) studies in patients >18 years of age once within a 12 month period with the following conditions.
(a) the patient is referred for the investigation by a medical practitioner who has formed a reasonable clinical view that the patient has a high probability of having OSA
*[(b) the necessity for the investigation is determined by a qualified sleep medicine practitioner (as defined in the explanatory notes to the MBS) prior to the investigation;] [*referred study]
(c) a qualified sleep medicine practitioner has:
(i) established quality assurance procedures for the data acquisition; and
(ii) personally analysed the data and written the report;
(d) during a period of sleep, the investigation is a recording of a minimum of seven channels which must include continuous EEG, continuous ECG, airflow, thoraco‐abdominal movement , oxygen saturation; and two or more of EOG, chin EMG and body position.
(e) interpretation and report of the investigation (with analysis of sleep stage, arousals, respiratory events and assessment of clinically significant alterations in heart rate) are provided by a qualified sleep medicine practitioner based on reviewing the parameters recorded under (d) above.
The home sleep study service which we provide, and the business behind it (for example, who reports the sleep study, and how carefully is the data analysed by the sleep specialist, all of which is invisible to the ‘consumer”) meets all of the above requirements. We will continue to provide this service.
A home sleep study service in country towns does not, however, live up to our goal of providing a regional sleep medicine service which is equal to anything available in the major cities. Excellent inpatient sleep laboratories and availability of clinical expertise in sleep medicine (doctors, nurses, psychologists), along with access to therapeutic devices such as CPAP at reasonable prices, are all required. We’ve achieved a lot in this regard over the last 4 to 5 years, but there’s more on the agenda.
Andrew
At that time, there was no ‘item number’ to cover a home sleep study. The place of home sleep studies in the diagnosis and management of obstructive sleep apnoea, let alone other sleep disorders, had been examined in only a few studies in the literature and there was not a consensus from the community of specialist sleep physicians as to how and when these studies should be done.
Nevertheless, home sleep studies could be done and were being done. Aggressive expansion of home sleep study business models, some industry-driven (ie CPAP companies) and some physician-owned, was occurring. And it was occurring in the country.
From where I sit (that is, in Hamilton) the reason given for this expansion didn’t really hold water. City based specialists and companies were saying that home sleep studies needed to be done because patients such as mine needed access to services. Reading between the lines, that meant that it was easier to stay in the big cities and to negotiate with a chain of pharmacies to put 200 home sleep study devices in towns around the state than to negotiate with hospital administrators to set up state-of-the-art sleep labs, and to back them up with specialist consulting services. The resulting service was limited. The development of skills in regional centres was scant (pharmacy staff trained to put on leads). Medicare fees were drained from the country back to Melbourne, rather than reinvested locally (for example, in a local medical practice or sleep lab). When things got tricky, country people still had to travel to the city to see a sleep specialist. And the impression was given that sleep studies are easy. Like getting your blood pressure checked.
In spite of the above uncertainty, a review of the evidence did suggest that home sleep studies were useful in people with a very high clinical probability of having severe obstructive sleep apnoea. After careful consideration, we decided that it was a service that we should carefully offer, and so we established a handful of home sleep study outlets in our region. We considered the distinctives of our service to be; a sleep specialist reviewed every referral to ensure that a home sleep study is appropriate, prior to authorising performance of the home sleep study; analysis and reporting of the sleep study occur locally (it can’t be assumed that sleep study analysis for home sleep studies in Australia even occurs in Australia any more, with at least one of the major providers of home sleep studies outsourcing analysis of data to sleep scientists in India); the reporting sleep specialist always analyses the raw data (not just the analysis summary provided by the scientist); sleep specialist clinical review is available locally if required.
When Medicare declared a moratorium of sorts on home sleep studies I thought that sounded reasonable. Of course, with substantial business under threat the big providers of home sleep studies negotiated hard for an allowance to continue to provide home sleep studies as they already were. And that permission was granted, in October 2008, although with a much lower fee from medicare for the service, while the whole area was carefully reevaluated.
The Medical Services Advisory Committee has just reported to the Minister for Health after an evaluation of all the literature related to ‘unattended’, or home based, sleep studies. Eighty studies were identified, evaluating home sleep studies performed in ‘non-specialist’ (for example a GP clinic or pharmacy) setting, a ‘referral setting’ (ie referred to a specialist for the study) and a paediatric setting. (14, 60 and 6 studies applicable to each setting respectively).
The document reads:
The Committee recommended funding of Type 2 (unattended) studies in patients >18 years of age once within a 12 month period with the following conditions.
(a) the patient is referred for the investigation by a medical practitioner who has formed a reasonable clinical view that the patient has a high probability of having OSA
*[(b) the necessity for the investigation is determined by a qualified sleep medicine practitioner (as defined in the explanatory notes to the MBS) prior to the investigation;] [*referred study]
(c) a qualified sleep medicine practitioner has:
(i) established quality assurance procedures for the data acquisition; and
(ii) personally analysed the data and written the report;
(d) during a period of sleep, the investigation is a recording of a minimum of seven channels which must include continuous EEG, continuous ECG, airflow, thoraco‐abdominal movement , oxygen saturation; and two or more of EOG, chin EMG and body position.
(e) interpretation and report of the investigation (with analysis of sleep stage, arousals, respiratory events and assessment of clinically significant alterations in heart rate) are provided by a qualified sleep medicine practitioner based on reviewing the parameters recorded under (d) above.
The home sleep study service which we provide, and the business behind it (for example, who reports the sleep study, and how carefully is the data analysed by the sleep specialist, all of which is invisible to the ‘consumer”) meets all of the above requirements. We will continue to provide this service.
A home sleep study service in country towns does not, however, live up to our goal of providing a regional sleep medicine service which is equal to anything available in the major cities. Excellent inpatient sleep laboratories and availability of clinical expertise in sleep medicine (doctors, nurses, psychologists), along with access to therapeutic devices such as CPAP at reasonable prices, are all required. We’ve achieved a lot in this regard over the last 4 to 5 years, but there’s more on the agenda.
Andrew
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