home sleep study not a medically necessary

[mstevens]

My contention is that a physician should be allowed to diagnose based on observation alone, as far as those with a high probability of moderate to severe OSA.

To be clear, we're allowed to diagnose based on dowsing rods or chicken entrails if we want to. Silliness aside, the main issue is that practically nobody cares what a physician thinks in the first place.

The only reason he can't is that payers want proof of response to treatment that is not "merely" subjective observations of doc and patient. THAT is what is being paid for, the proof, not the treatment itself.

This is the primary point - payers (Mediwhatever, insurance, governments, etc.) using guidelines as concrete rules in the hope that it'll save them money, not out of any particular interest in improving clinical outcomes. (Any time an insurer talks about "improved outcomes", assume they mean financial outcome for them.)

Once you factor in the retests, the number of patients missed in the screening and who go on to more serious problems, the number who have to have a PSG anyway so that now two tests have to be paid for instead of one, the mailing/transporting of the equipment, the reading by a certified doc anyway, etc, I don't think there is any real cost savings over the long-haul either, myself.

My thought exactly.

Remember folks, "medical necessity" is not based on what your doctor says, it's based on what your insurer says.

[BlackSpinner]

Once you factor in the retests, the number of patients missed in the screening and who go on to more serious problems, the number who have to have a PSG anyway so that now two tests have to be paid for instead of one, the mailing/transporting of the equipment, the reading by a certified doc anyway, etc, I don't think there is any real cost savings over the long-haul either, myself.

Well that doesn't say much for your math training.
If out of 100 people 75 are diagnosed with garden variety OSA at $300 that is $22,500 while 75 at $2000 (cheap sleep lab) is $150,000 for difference of $147,750. For the rest of the 25 people who fail the home test, because it is designed to catch garden variety OSA and NOT to rule out sleep apnea you now run them through the whole sleep lab experience but for the 75 people with valid diagnosis you have saved $147,750. Which means the people who have problems putting on their little belt and finger clip - they end up in the 25% group.
And 75% is low balling it.

And if you are really challenged arithmetically that means for 100,000 people you save $147,750,000 which is a nice number.

[NightMonkey]

Well that doesn't say much for your math training.
If out of 100 people 75 are diagnosed with garden variety OSA at $300 that is $22,500 while 75 at $2000 (cheap sleep lab) is $150,000 for difference of $147,750. For the rest of the 25 people who fail the home test, because it is designed to catch garden variety OSA and NOT to rule out sleep apnea you now run them through the whole sleep lab experience but for the 75 people with valid diagnosis you have saved $147,750. Which means the people who have problems putting on their little belt and finger clip - they end up in the 25% group.
And 75% is low balling it.

And if you are really challenged arithmetically that means for 100,000 people you save $147,750,000 which is a nice number.

My God! cpaptalk's left wing is into economics and economic calculations now! And is doing it quite well!

I am leaving the forum for today. I want to enjoy the idea that this is really true for at least the next 12 hours.

[jnk]

Well that doesn't say much for your math training.

Thank you for not making your attack personal. But my math teachers would like to say to you, "a pox on you." I would never say that myself, of course. I respect you too much.

If out of 100 people 75 are diagnosed with garden variety OSA

So, good math is where you just make up your own statistics out of thin air? Cool. I did not know that. I learn so MUCH on this forum.

at $300 that is $22,500 while 75 at $2000 (cheap sleep lab) is $150,000 for difference of $147,750. For the rest of the 25 people who fail the home test, because it is designed to catch garden variety OSA and NOT to rule out sleep apnea you now run them through the whole sleep lab experience but for the 75 people with valid diagnosis you have saved $147,750. Which means the people who have problems putting on their little belt and finger clip - they end up in the 25% group.
And 75% is low balling it.

And if you are really challenged arithmetically that means for 100,000 people you save $147,750,000 which is a nice number.

Very imaginative.

But, to my eyes you did not address one of my points to the wording you quoted before your little exercise of imagination.

Many, many patients don't qualify for HST if you use the AASM standard, so they are going to get a PSG. So now we are only talking the number of patients that DO meet the AASM criteria, if we are keeping up standards. That lessens the suppposed savings before we even start.

Now for the other issues with the ones who do meet the criteria:

How many retests of the HST are needed, on average, even among the age group and literacy group and aptitude group served, because of test issues that render the data, miniscule though it is, inconclusive? How much time and money is wasted on that? After several retests for one patient, all the "savings" from the inferior test melt away quickly.

How many patients test positive on the HST but eventually should have an attended diagnostic PSG anyway? Maybe they don't get one. But how many SHOULD have it? Because if they should, but don't, that is directly opposed to the interests of that patient in a VERY significant way.

How many patients test negative but get an attended PSG anyway? Don't ALL of them, since they were all suspected of having OSA? If so, the HST was an awfully expensive pretest to the real test and one that was a complete waste of time, since it didn't rule out or rule in anything in its "results." In that case, the HST represents an ADDED expense, not a savings of ANY sort.

And then, what if the patient is denied a PSG because of negative results of the HST, and that patient goes on to develop serious health problems, the payments for which come out of your pocket and can't be used toward your knee replacements, to use your example. How did you factor those patients into your math? You didn't? Oh, sorry. My math teachers would like to talk to you about that after class.

If only a relatively small subset of patients qualify for HST, it is never good math to make it sound as if all who are suspected of OSA can take one instead of PSG to save money. And trying to compare them one-to-one the way you did looks good on paper, but doesn't always work that way in the real world, I don't think. That's why imaginary math is fine. Insurers get fooled by that "logic" all the time. But the points I made were an attempt to point out the limitations of the theories about money saved. I have nothing against saving money when it doesn't sacrifice patient care. But HST is inferior to PSG by far. If no PSG is needed, then, in my opinion, no HST is needed either, since there are better ways to diagnose and treat patients than using HSTs to prove to insurance what the doc and patient already know. And when the criteria for HST are met, doc and patient usually already know.

That said, I agree that there are some circumstances in which HST is very valuable. They are one of many tools that should be available to sleep docs. But educated sleep docs should be deciding when they are useful by using judgment that is not unduly influenced by the bean counters, in my opinion. Cheaper isn't always better. Sometimes, cheaper means you get what you pay for. In this case, a test that proves next to nothing is very expensive compared to a test that actually proves something.

In my opinion.

But hey, I only made C's in math. That's why your words hurt my feelings.

[archangle]

Response to treatment from a one-month rental will confirm the diagnosis more efficiently and more cheaply in that sort of patient anyway, if we're talking medicine, not insurance.

Standard CPAP equipment can't work below 4 cmH2O because that's needed to work the exhale vent. There might be no apneas at all at 4 cm, and severe apnea without CPAP.

It's also not an apnea unless you have an O2 desaturation or an EEG arousal.

You can't depend on the patient's feelings telling you whether it's working or not, either. Many CPAP users don't feel a difference.

Those are drawbacks to the "(JGHAA) just give him an APAP" technique. That doesn't mean JGHAA is wrong, but it's not a clearcut choice.

[jnk]

Response to treatment from a one-month rental will confirm the diagnosis more efficiently and more cheaply in that sort of patient anyway, if we're talking medicine, not insurance.

Standard CPAP equipment can't work below 4 cmH2O because that's needed to work the exhale vent. There might be no apneas at all at 4 cm, and severe apnea without CPAP.

It's also not an apnea unless you have an O2 desaturation or an EEG arousal.

You can't depend on the patient's feelings telling you whether it's working or not, either. Many CPAP users don't feel a difference.

Those are drawbacks to the "(JGHAA) just give him an APAP" technique. That doesn't mean JGHAA is wrong, but it's not a clearcut choice.

I am not suggesting using CPAP to diagnose at low pressure. I am suggesting that if you already know the patient has OSA, just treat it, without wasting time on a pretend, substandard test, that is of value to no one but the insurance company. As for the importance of EEG arousals, HST can't measure EEG like PSG either, can it? Or am I confused?

My larger point is that all an HST really does is say "yep, he's got it." It doesn't even measure sleep. (In fact, home "sleep" test is a misnomer, in my opinion, since it can't even tell when a patient is asleep or, if he is, what stage he is in.) Not only that, having an HST diagnostic makes the attended-PSG titration worth less too, since there is no PSG-diagnostic to compare it to! Even the "AHI" it gives is not useful, since there is no way of knowing how much of the recording time that the patient was awake.

An HST is less an OSA-diagnostic test as it is an OSA-diagnosis-verification test. Big difference, in my opinion.

That is why comparing HST to attended PSG is a false comparison. The cost of the HST should be compared to having no test at all. Then it becomes clear that the "test" is an overpriced charade that provides "information" that is much more likely to be abused by the bean counters that to be of any practical use to any medical person or for any patient.

In my over-the-top-not-so-humble opinion, that is.

[Cotay]

This needs to be appealed by the physician's office. Be aware, though, that Medicare doesn't pay to rule anything out (!!), so wording is paramount.

Home sleep studies are worth about what you see here - little to nothing - because they're limited in data channels and have to be confirmed with a lab study most of the time. That may be another reason insurance doesn't want to cover it.

I'm actually of a different opinion on home sleep studies; although that may be generally less accurate, they are not worth "little to nothing". If anything, they tend to underestimate the incidents of sleep apnea. If you pay attention to your data, you can overcome the under-reporting issues once you receive an APAP and make minor adjustments as time goes on and you gain some history on your needs.

I'm not saying home studies are perfect for all patients, but for those of us who had them and are receiving excellent treatment...they were a huge blessing!

[jnk]

I agree with the following statements made in one study back in 1999:

"The finding that polysomnography was preferable to home study under all tested circumstances was not surprising . . . In contrast, we did not anticipate the extent to which polysomnography would also prove more cost-effective. . . . Future refinements in home study equipment or further research may show that health-outcome–related advantages of diagnostic testing in the home environment rival or exceed the advantages of laboratory-based polysomnography. In this situation, home studies could become both preferable and cost-effective."

I added the color.

http://www.annals.org/content/130/6/496.full.pdf

To the best of my knowledge, "health-outcome–related advantages of diagnostic testing in the home environment" have not yet been proved to "rival or exceed the advantages of laboratory-based polysomnography," which according to my understanding of that study, anyway, would be the ONLY circumstance in which home studies would be considered "both preferable and cost-effective." Until that day, it is NEITHER, as I understand it, according to the reasoning set forth in that study, anyway.

And if that day HAS come, and I just don't know it yet, I take it all back. That CAN be done with math, can't it?

I think this explanation is balanced:

Home Sleep Tests vs. In-Center Sleep Test (Polysomnography)

The gold standard for the diagnosis of sleep disorders is still overnight sleep study or polysomnography, attended by a sleep tech, in a Sleep Center. Only such tests are validated for the diagnosis of mild obstructive sleep apnea and many of the other (over one hundred) sleep disorders.

Recently insurers have been recommending home sleep tests for likely moderate to severe obstructive sleep apnea as a cost effective alternative to a traditional overnight sleep study. If the test turns out to be negative, or some other disorder is suspected, an overnight sleep study in the lab (polysomnography) will still be needed.

http://www.swedish.org/HomeSleepTest#axzz1kzkPZeEr

[ChicagoGranny]

And if that day HAS come, and I just don't know it yet, I take it all back.

Covering all bases?

This is one that I don't have an opinion on and did not even know there were home studies.

But I can appreciate the concept. I did the first miserable night in the lab. All they did was tell me I had apnea and told me my AHI.

When I went a second night to the lab to use the machine I told the attendant (a different one) my AHI and she said it did not matter because they always do the same thing no matter what the AHI is. So why was the first night so important?

Maybe a very simple device could check for apnea at home and save all that trouble for everyone?

I think my opinion is beginning to develop.

[jnk]

. . . Covering all bases? . . .

Consider it more a disclaimer.

I might word it this way:

"My life experience has taught me that there is always the possibility that I have no idea what I'm talking about or that I am a complete idiot, no matter how strongly I may feel about something."

[chunkyfrog]

All that has been said; what if the definition of medical necessity is simply a compromise between the insurance companie's actuaries and its lawyers?

[jnk]

. . . When I went a second night to the lab to use the machine I told the attendant (a different one) my AHI and she said it did not matter because they always do the same thing no matter what the AHI is. So why was the first night so important? . . .

It is true that the baseline AHI established at the diagnostic study ISN'T all that important to the tech who conducts the titration study the second night. That is because the titration is conducted the same way regardless of diagnostic AHI, since the AHI from the diagnostic study provides no real clue as to what pressure you need, and finding the right pressure is the big goal of the titration.

But the overall data collected at the diagnostic study is still useful for giving the sleep doc and his team something to compare the results of the titration to later. Information about your sleep architecture and sleep positions and limb movements and the like make it easier to assess you response to pressure during the titration and can help in choosing which pressure was most effective for you overall.

It is my feeling that the titration is the more valuable of the two studies, since it documents response to PAP and gives an opportunity for any sleep problems that may be unmasked by PAP to be observed and evaluated.

[ChicagoGranny]

Fancy that. All along I just thought they found the pressure for you, set the machine, and sent you home.

[jnk]

Fancy that. All along I just thought they found the pressure for you, set the machine, and sent you home.

Yeah, same thing; that's what I said.

But why should I use one sentence to say it when I can type a whole page? Weeeeeeeeeeee! I like the sound of my own keyboard clicks! Eeeeeeeee-HAH!!! Clickity, clickity, clickity, clickity . . .

[ChicagoGranny]

But why should I use one sentence to say it when I can type a whole page? Weeeeeeeeeeee! I like the sound of my own keyboard clicks! Eeeeeeeee-HAH!!! Clickity, clickity, clickity, clickity . . .

I thought I recognized you. You are that annoying pig on the zip line.