February 4, 2013
(The New York Times News Service) -- Sleep apnea testing was a time commitment. For years, patients were required to stay overnight at a sleep clinic, plugged in to machines and watched over for seven hours by sleep technologists. Now, most people can strap a portable monitor to their chest and get tested as they doze in their own beds.
Researchers have found that the cheaper and often more convenient home tests are about as good at detecting the breathing interruptions that characterize obstructive sleep apnea. Massachusetts insurance companies looking to clamp down on the booming field of sleep medicine have responded by restricting use of the in-lab tests, which run about $650 to $1,000, in favor of home testing at about one-third the cost.
Sleep HealthCenters, a chain of sleep clinics that included 11 in Massachusetts, cited the drop in insurance payments when it closed suddenly last week, leaving nearly 150 employees looking for work.
Sleep medicine physicians say the change, which is likely to spread to other states, has occurred too quickly for them to adjust their business models and that insurers have taken it to an extreme, cutting some patients off from tests their doctors think they need. But a report released last week estimated that shifting three-quarters of the tests to the home could save New England's health care system about $35 million a year.
Though workers have lost their jobs, the change in sleep testing is a prime example of the kind of shift -- the replacement of an outmoded and expensive health care service with a cheaper technology -- that's necessary to control health care costs, said Austin Frakt, a Boston University health economist. "If we're really going to save money in health care, it means that somebody's going to get paid less," said Frakt, a member of the New England Comparative Effectiveness Public Advisory Council, which issued the report. "Maybe some of the ways of delivering health care just won't be viable."
The council, a group of physicians and policy makers who evaluate tests and treatments based on effectiveness and cost, found that home testing is "functionally equivalent" to in-lab tests for obstructive sleep apnea in those patients who do not have other serious conditions, such as heart failure or lung disease. Both tests track oxygen levels, heart rate, and breathing, while those done in clinics also monitor brain waves and other factors.
The shift to home testing, however, could increase the number of incorrect test results compared with those done at sleep clinics, the council found. And some members were concerned the convenience could lead patients unlikely to have apnea to be tested at home, resulting in overdiagnosis.
Sleep medicine is an attractive target for cost-cutters. It is a young field, formalized as a medical specialty little more than a decade ago. But it has grown quickly, with greater public awareness that apnea -- affecting up to 7 percent of men and 5 percent of women -- can lead to dangerous drowsy driving and increase the risk of heart failure or stroke. For-profit companies such as Sleep HealthCenters that saw an opportunity to make money from testing and treating these patients also have driven the expansion.
In 2002, 623 sleep centers were accredited by the American Academy of Sleep Medicine. Last year, there were 2,517. Medicare spending on sleep testing in clinics increased nearly fourfold in eight years, to $235 million in 2009, according to a report from the US Office of the Inspector General, which highlighted sleep testing as an area it plans to examine for patterns of fraud or overuse.
Dr. Sam Fleishman, president of the American Academy of Sleep Medicine, said there may be too few sleep doctors to meet demand for treatment -- which often involves sleeping with a mask and a device that blows air into the throat to keep the airway open. The challenge the field is facing now is not because it grew too quickly in recent years, he said, but because it was too focused on diagnostic testing rather than caring for patients over time.
The movement toward home testing is appropriate in theory, said Dr. Lawrence Epstein, Sleep HealthCenters chief medical officer and an associate physician at Brigham and Women's Hospital, but it came when the down economy had caused some patients to put off care and the company was locked into building leases.
"When revenue and volume drop and expenses don't, it causes a problem," he said.
Sleep technologist Joyce Mor, who worked at the company's Weymouth clinic, said her manager called her Jan. 23 to tell her not to come to work that night.
"Are we canceled tomorrow night too?" Mor recalled asking. "And she said, 'Yes.' I said, 'How about the next night?' And she said, 'Yes.' I said, 'So, we're done?' And she said, 'Yes.'"
Paul Valentine, chief executive, made the official announcement by conference call. Mor said she is upset about how the closure was handled, with little information provided to employees. She hopes to get a new job as a daytime sleep technologist, but she knows there are many people with similar qualifications looking for work.
Other sleep clinics in Massachusetts have shrunk their overnight capacity and cut staff, citing the change in insurance payments. The Sleep Disorders Center at UMass Memorial Medical Center now operates 10 bedrooms five nights a week, down from 14 rooms filled seven nights a week, said medical director Dr. Stacia Sailer.
Until about four years ago, many insurers would not cover home sleep tests because there was little evidence to show they worked. As the technology changed and research around it grew, insurers in Massachusetts -- Fallon Community Health Plan, Tufts Health Plan, and others -- embraced it.
Many subcontract with companies that specialize in coverage of sleep testing and provide the equipment necessary to do the home test and treatment. Blue Cross Blue Shield of Massachusetts, the state's largest health insurer, plans to roll out a a sleep management program later this year to shift testing to the home.
Sailer said the process for getting approval for in-lab tests, when necessary, can be onerous and some companies are slow to mail and process home tests.
Harvard Pilgrim Health Care began using a sleep management contractor in July 2011. About 73 percent of sleep studies now are done in patients' homes, said Dr. Michael Sherman, chief medical officer. Harvard Pilgrim uses similar specialists to oversee payments for high-cost imaging tests, such as CT scans and magnetic resonance imaging.
Sherman said the federal Affordable Care Act and a state law passed last summer that set health care spending targets put pressure on insurers to control costs.
Epstein, who said he was not notified of the Sleep HealthCenters closure until the day the doors were shut last week, said sleep medicine has hit a turning point. "It's had a technological disruption, just like a lot of different industries that we see," he said. "We weren't nimble enough to adjust in time."
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