News regarding sleep disorders and sleep-disordered breathing continues to make headlines, sparking interest from health care professionals and consumers. Fortunately, technology is keeping pace with research and the field is ripe for home medical equipment providers who want to meet patient and referral-source needs.
When analyzing the sleep market, one of the first things a provider must do is understand that patients with sleep disorders will most likely look and act differently than those in their traditional patient base.
Dave Henry, RRT, Sunrise Medical's respiratory education coordinator, says the “typical” sleep patient is 35 to 55 years old and still in the work force. “This presents different circumstances with setup and follow-up, since these cannot always take place during normal working hours of an HME provider,” explains Henry. “The use of [continuous positive airway pressure] technology requires a lot of upfront follow-up to get patients compliant with therapy, which also may be different than what HME providers are used to with a Medicare market.”
There is another element that should also be considered, according to Robyn Longford-Woidtke, RN, RPSGT, manager of clinical affairs and strategies for Puritan Bennett Respiratory Homecare. “The sleep apnea market is becoming increasingly sophisticated and consumer-driven. The demographics are changing as the population is aging and may require a different set of features.”
Once considered to be a market comprised of overweight, middle-aged men, recent research reveals that sleep disorders affect both genders — from childhood to the elderly — and this new information is changing the market.
“It can be said that the average patient is a male over 40 who is overweight, but as more people are being diagnosed, we are finding that there are children and elderly people with sleep apnea — it really runs the gamut of people,” says Nancy Smoot, Invacare Corp.'s sleep product manager. “This, in turn, impacts product design. You have to have a product that is easy to use for patients of any age or physical characteristics.”
Recent studies have linked sleep disorders to cardiovascular disease, including high blood pressure, congestive heart failure, stroke and, now, diabetes.
“There is further evidence now based on new studies that have been published recently confirming the link between cardiovascular diseases, such as hypertension, with sleep-disordered breathing,” says Ron Richard, vice president of marketing for the Americas for ResMed.
“Also, other studies show a very, very high prevalence — in some cases up to 50 percent — of type 2 diabetics who may have moderate-to-severe sleep-disordered breathing, which has an impact on their ability to metabolize nutritional elements as well as an impact on their insulin production.”
Richard goes on to say the effects of sleep-disordered breathing are “insidious” and have a “cumulative effect on multiple organs in the body,” taking a toll on the heart, lungs, kidneys and brain.
Compared to home oxygen therapy, “sleep is a relatively new market,” says Earl Yager, Chad Therapeutics' president and CEO. “It's at a much earlier stage of understanding what it takes to treat patients successfully.”
Chad has plans to introduce the company's first sleep products during the next nine to 12 months. Their business strategy, Yager explains, includes treatment as well as diagnosis solutions.
“We're focusing on the diagnosis and treatment sides,” he says. The larger market is on the treatment side, he explains, “but to allow for growth, you need technology to allow patients to get to the treatment side more rapidly.”
No More Excuses
Since the goal of any treatment plan for sleep-disordered breathing is compliance, manufacturers of both CPAP machines and their interfaces focus on comfort, ease-of-use and aesthetics. For many, that involves portability.
“Patients simply want smaller, lighter and more mobile types of CPAP devices that can go wherever they want to go — it's about portability and ease-of-use,” says Richard. “The cosmetics [of the devices] are starting to blend more into the bedroom, so the patients aren't ashamed to have them sitting at their bedside.”
AeioMed CEO Steve Bordewick says offering consumers what they desire increases compliance. “As much as possible, we want to remove those excuses so people will use the device,” he says. “More now than ever, there is a reason for people to be compliant with the therapy, but people aren't going to be if it's not easy to travel with, if it's clumsy or if it's just a big annoyance.”
Compliance is not only good for patients but also increases profitability for providers.
“The interfaces have changed dramatically. They are much more comfortable, lighter in weight and less obtrusive,” Richard says. “We have seen a big jump in sales in terms of the number of masks and the number of flow generators. We know that people are replacing their masks more and they are more compliant with therapy. That must mean the therapy is working and it is comfortable.”
Other advances are seen in three areas, according to Sunrise Medical's Henry: interfaces, humidification and autotitrating CPAPs.
“There has been a flurry of new interfaces, including nasal pillow-type devices, full face masks and alterations in nasal masks,” he says. “[The plethora of options] may be overwhelming, but it is great for the patient needing the treatment. With so many choices, the patient should find something that will work to fit comfortably and help them tolerate the CPAP therapy.”
He also says humidification has become the norm rather than the exception during the past couple of years. “This has increased patient compliance, which has been a great advantage for patients requiring CPAP therapy,” he adds.
It has been a decade since autotitrating CPAPs have been on the market, and compliance data is encouraging; yet, payer sources have not seen the benefits, according to Henry.
“There has been a lot of research to show the benefits of autotitrating CPAPs, but the people controlling the reimbursement have not seen those benefits,” he explains. “The Health Industry Manufacturers Association and other industry groups have attempted to get a billing code approved for these devices and, hopefully, will continue to fight a joint effort to get these devices reimbursed as they should be.”
Tracking compliance is critical — not only for patient outcomes but also for reimbursement, says Invacare's Smoot.
“Compliance affects provider reimbursement, and that information is available very early on in therapy. You can measure it after the first couple of days,” she says. “Studies show that usage behaviors begin very early in treatment, so if a patient is not compliant in the first week or so, they are probably not going to be compliant after that.”
Getting Paid
According to the experts, there are ways to ensure proper reimbursement.
“Keep current with new decisions from Medicare and make a practice of ongoing communication with other third-party payers,” advises Longford-Woidtke of Puritan Bennett. “Potential revenue loss can occur when patient interfaces are not replaced on a schedule.”
She also urges providers to get to know local payers and develop programs that meet their needs. “Make sure they understand the full value of the services you provide and the impact you have on compliance and reducing their overall cost of care,” she says.
Sunrise Medical's Henry reminds providers that a majority of patients who are prescribed CPAPs have some form of health insurance, particularly HMOs. He says one way to ensure proper reimbursement is to be prepared during contract negotiation.
“If the HME provider is able to negotiate the contract and show [he is] not only providing equipment but also the support to increase patient compliance as well as proper follow-up, this will influence the financial aspects of the contract,” he says.
“Objectively measuring CPAP compliance is seen primarily as a necessity for referrals and insurance companies, but it may be an important part of an HME provider's marketing strategy. This data can demonstrate how well the education and follow-up really is and can be used to market to referral sources and also to insurance companies when bidding for business.”
Looking Ahead
Providing care for the sleep-disordered breathing population offers many opportunities for HME providers. By joining forces, manufacturers, providers and the entire health care community can continue meeting the needs of patients who can benefit from this treatment.
And the effort has produced enviable market growth, according to Chad's Yager. “Right now, the market is growing at 18 to 20 percent per year,” he says. “That's double the rate of [home] oxygen, according to most statistics.”
ResMed's Richard says the health care system has a way to go before it completely understands and recognizes the complications of sleep-disordered breathing; yet, he is encouraged. He recently had a discussion with an official at the Centers for Disease Control and Prevention in Atlanta about recognizing sleep disorders as a long-term illness, such as chronic obstructive pulmonary disease or asthma.
“Sleep-disordered breathing is not something that you fix overnight,” he says. “Once people recognize that, there will be better long-term follow-up programs that will help patients who have special needs related to sleep, and that will also improve compliance and adherence to therapy.”
The good news, according to Longford-Woidtke, is that technology is constantly evolving, and each company uses its research and development funds to explore the next greatest improvement.
“It's hard to say where sleep medicine will be in the next 10 years. Recent surgical procedures such as the Pillar (tiny woven inserts placed in the soft palate) have offered a minimally invasive approach to snoring and mild sleep apnea, and such technologies may be combined with CPAP in the future to lower pressures,” she says.
“[We] are always looking for ways to improve products — from masks that fit better and meet individual needs to CPAP devices that meet consumer demand in terms of noise, size, comfort and features that improve patient acceptance and compliance.
“The future is hard to predict, but with continued high patient needs and research, many positive developments are likely.”
Experts Interviewed
Steve Bordewick, CEO, AeioMed, Minneapolis; Dave Henry, RRT, respiratory education coordinator, Sunrise Medical, Longmont, Colo.; Robyn Longford-Woidtke, RN, RPSGT, manager of clinical affairs and strategies, Puritan Bennett Respiratory Homecare, Pleasanton, Calif.; John Miclot, president and CEO, Respironics, Murrysville, Pa.; Ron Richard, vice president of marketing for the Americas, ResMed, Poway, Calif.; Nancy Smoot, sleep product manager, Invacare Corp., Elyria, Ohio.; and Earl Yager, president and CEO, Chad Therapeutics, Chatsworth, Calif.
Creating a Successful Sleep Therapy Business
In the home medical equipment industry, growing a clinically and financially successful sleep business requires research, planning and a strong commitment to quality patient care and follow-up.
A sleep program requires two things: education and follow-up, says Dave Henry of Sunrise Medical. “Education should include what sleep-disordered breathing is, how to use the equipment properly and how to clean and maintain the CPAP device, interface and humidifier,” he suggests. “Follow-up requires collecting compliance data as to how well the patient is using his or her CPAP and, even more importantly, correcting problems when the patient is not handling the CPAP well.”
This takes good listening skills, reminds Henry. “For example, if someone complains of a bloody nose, dry air from the CPAP may be the cause, and humidification may help. But if the patient complains of a dry throat, this may indicate the patient is a mouth- breather and may require a chin strap or full face mask in that case,” he says, “so understanding what the patient is saying and getting it corrected is really important.”
Puritan Bennett's Robyn Longford-Woidtke, says there are three elements that must be present to create a successful sleep program.
“First, a needs assessment may help the HME provider decide whether to enter into this market space. A local market research study can help the HME provider determine the numbers of patients to expect initially, and, based on industry reports, the HME provider can expect a 15 percent to 20 percent increase yearly,” she says. “The HME provider should begin to establish relationships with referral sources, physicians and sleep labs. They should identify their main competitors and determine what the competition is doing right or wrong.”
She also advises HME providers not to forget the payers. “Managed care is increasingly focused on sleep-related health care issues, and being on their formulary and meeting their needs will be critical to the success of your business,” she cautions. “In addition, many employers are interested in sleep, not only as a health care issue but also as it affects both workplace safety and productivity.”
Finally, says Longford-Woidtke, HME providers should research the various product offerings available because both patients and referral sources will be grateful. “A sleep program needs to be patient-centric. Sleep apnea patients are not ‘one-size-fits-all,’” she says. “Based on the HME resources, plan a program in which the needs of the patient and referral source can be met.”
Longford-Woidtke adds that community awareness is essential. “As the public becomes increasingly informed about the risks of sleep-disordered breathing, health care providers will need to respond accordingly,” she says. “It is important for HME providers to aid in the education of their referral sources.”
Although most physicians are aware of the health risks and costs to the health system, they may not have considered the indirect costs of sleep-disordered breathing, such as decreased workplace productivity and traffic accidents. “Developing workplace educational programs can be a valuable service to the community and help you grow your sleep business,” says Longford-Woidtke.
She advises providers to participate in the National Sleep Foundation's National Sleep Awareness week — which coincides with the change to daylight-saving time each year — and attend health fairs that will help identify them as a leader in the sleep community. For more, visit the NSF Web site at www.sleepfoundation.org.
