Numbers don't lie. The proof is in the pudding. Both of these familiar adages could be used to describe the exploding market growth for treatment of sleep-disordered breathing. But it could also be said that if it sounds too good to be true, it just might be.
SDB is a strong segment in home health care, but some experts warn that does not guarantee instant success. Home medical equipment providers must make sure the market is right for their companies and, if it is, that they can provide the necessary service to patients and remain profitable.
The growth rate of the SDB market continues to hit double-digit gains. And as awareness continues to spread, potential remains for even better performance in the near future. Currently, it is estimated that 18 million Americans have been diagnosed with obstructive sleep apnea, and millions more may be undiagnosed.
According to Invacare Corp.'s Ann McGregor, vice president of sleep, “The market is still growing at 15 to 20 percent, although there are some securities reports that show in the next couple of years it may grow faster at a rate of 22 percent.”
On average, sleep growth is estimated to continue at 20 percent, says Dave Myers, Respironics' director of marketing for SDB. “You are going to find certain areas that grow more and other areas that grow less based on how many labs there are in the area, how much communication there is with the labs and the labs' capability of getting people tested,” he explains.
Myers' comment on testing is certainly a factor. Awareness of SDB and other sleep disorders is on the rise, placing a high demand on sleep labs — and creating opportunities for the HME industry.
Media attention, consumer awareness campaigns and substantiated clinical research have been beneficial in educating SDB patients about their disease and its risks. Fortunately, this has also had an impact on general practitioners and how they screen their patients.
“Primary care doctors want to know more; they have known that for years they haven't been doing that great of a job in truly diagnosing the cause of people's sleep problems,” says Ron Richard, ResMed's senior vice president of strategic marketing initiatives. “They have just generically been giving [patients] a prescription for Ambien or another drug that masks the symptoms. They are not getting to the root cause of their problem.”
McGregor adds that there is increased awareness among general practitioners of the links between sleep disorders and other disease states like hypertension, cardiac disease and stroke. “Therefore,” she says, “[these physicians] are starting to talk about sleep to their patients more and are making more referrals to sleep labs for testing.”
And Richard notes that the attention the disorder is receiving in the consumer press is only increasing the number of Americans who are being diagnosed. “People are more aware, and the influence that awareness has is that consumers now are becoming more active in making decisions about how they're going to treat their sleep-disordered breathing problems,” he says. “That is going to force home care providers to become more educated about those choices as well.”
While the good news is that growth in sleep therapy is established, only a careful look at its specialized requirements, reimbursements and the costs of servicing this patient population will determine whether it is a good fit for your HME.
Home care companies have to balance the degree of patient care needed with the cost of that care and the technology they are providing, says McGregor. “This has been an obstacle in the past for HME providers,” she explains.
“We are seeing a lot of sleep labs in hospitals starting to become durable medical equipment providers, so if the reimbursement continues to decrease, the HME provider is going to have a tough time doing both jobs and providing what type of care is actually needed for the patient.”
Reimbursement is certainly a big concern, agrees Dennis Cook, president of Medline Industries' Respiratory Division. “[Providers'] reimbursement is fixed, and if somebody has a [continuous positive airway pressure device] that has all the bells and whistles on it, they have to pay for all those bells and whistles — but their reimbursement does not change.”
Experts say there are also other factors that should be considered.
“HME providers need to ensure they have staff who are knowledgeable about sleep therapy and have a well-defined and instituted follow-up program that will pave the way for improved adherence to therapy,” says Robyn Longford-Woidtke, RN, RPSGT, CCRA, RAC, manager, clinical affairs and strategies, Puritan Bennett Respiratory Home Care.
“Initial acceptance of therapy can be influenced by something as basic as a well-written and concise training guide. These materials should include the risks of not using the therapy as prescribed and also the benefits that patients can expect when they adhere to therapy,” she explains.
Myers also says a strong patient focus is necessary to achieve positive outcomes. “Doing this will address the needs of referral sources and will keep [providers] in good graces with their referring physicians or referring sleep centers,” he says. “If providers can keep a patient happy and keep them in their system, they will build opportunities for future growth.”
This requires several things, Myers continues. “Providers will need to have strong clinical and customer service departments. If [providers] have patients achieving effective therapy — meaning they accept their therapy, receive comfort from it and achieve positive results, such as a better quality of life — then providers are better able to leverage their results with referring physicians and the sleep facilities,” he explains.
Patient compliance can make or break a sleep program, making it ever important to ensure patients are given the proper equipment and education, according Michael Knepper, DeVilbiss sleep product manager of Sunrise Medical's Respiratory Products Division.
Cook emphasizes the importance of follow-up. “Providers need to focus on patient follow-up to make sure they don't have any problems with compliance, because compliance is the issue,” he says. “Troubleshooting goes hand-in-hand with follow-up. If the patient is having trouble being compliant, you have to find out why and see if you can come up with a solution for it, whether that is a new mask or a different type of machine.”
McGregor adds that follow-up also means staying in contact with referral sources. “The HME provider absolutely has to stay in touch with the sleep lab [to show] that they are taking care of the patient,” she says. That comes back again to compliance. “I cannot stress enough that the HME provider has to find — through the manufacturers — a way to give the patient adequate care in becoming compliant.
“A good plan for starting out is actually to make sure [that] respiratory therapists are up-to-date on what's available,” she continues. “[Providers] need to understand all of the manufacturers' devices, what they do and how they provide the best care with the least cost. It seems obvious, but it hasn't been practiced.”
There are a variety of new technologies currently in the works to treat OSA using CPAP therapy, says Longford-Woidtke.
“Most address the unmet needs of patient comfort and improved adherence, which is essential as some studies show adherence rates below 50 percent for CPAP,” she says.
“Advances in these areas will significantly improve outcomes and health care economics.” Puritan Bennett offers its family of small, lightweight GoodKnight 420 CPAPs in three models.
Knepper says the DeVilbiss eCompliance System is a service available with its total sleep business that allows providers to review daily compliance data from their offices without having to see the patient.
“This is one way to cut down on the amount of labor used to identify who is using the equipment and who is not,” he says. “It is really a simple matter of logging in and checking on the Internet and seeing [how patients are doing].”
Knepper also believes that auto-titrating devices play an important part in successful treatment. “The features of auto-titration will bring the therapy of the patient closer to them in terms of their ‘owning’ it, so we continue to work on how to get the patient involved in understanding day-to-day how the therapy is progressing,” he says.
“Technology can be used to alienate the patient or to become a part of the person's lifestyle. I think the latter is really what we need to strive toward.”
According to Richard, customers with active lifestyles are looking for CPAPs that are both compact and lightweight — and that don't look “medical.” He says designs that look like consumer electronics, such as CPAPs that look more like a clock radio or a stereo component, are popular.
ResMed's S8 Elite features optional integrated humidification and remote data downloading with a choice of fixed CPAP or expiratory pressure relief mode.
Invacare's SoftX technology, available in the Polaris EX CPAP, “keeps the patient close to their prescription all night and allows them to exhale with more comfort,” says McGregor.
The model also features Quick Code, which gives providers access to compliance information. Usage can be tracked from the first day of treatment and can accumulate for more than seven years, or can be reset to track a specified period of time to identify patients in need of intervention.
Respironics is launching its new REMstar M Series CPAP platform this spring, including a new line of devices that utilize a common platform that is compact and lightweight. The company's ComfortLite 2 mask features multiple cushions, giving patients the ability to personalize each mask for their unique comfort preferences.
“Basically, you have multiple cushions within one product,” explains Myers. “If you put somebody on a pillow and they get a little nasal irritation or it doesn't seal quite as well as you want, you just go in and unhook that particular cushion and place a different one on.”
Hoffman Laboratories introduced a new “wearable” CPAP product at Medtrade Spring last month. Called BreatheX, the device resembles an air travel pillow that fits around the neck. The product provides one to two nights of therapy with a built-in, rechargeable battery, and can be used with most interfaces on the market.
According to Dennis Nasto, the company's vice president of sales and marketing, the device can be beneficial for users who decline treatment using conventional CPAP therapy or are noncompliant.
“Although the industry trend is toward smaller, less obtrusive and easier to use CPAP devices, the basic configuration — a bedside CPAP unit, a 6-foot hose and a patient interface — hasn't changed for 20 years. We're offering an alternative, in particular for those patients,” Nasto says.
With all technology, it is important to remember that this patient population has different educational levels and different technological abilities, reminds Myers.
“You will have users who are Internet-savvy who might be learning everything about sleep-disordered breathing and every different piece of equipment that's out there, which means your customer service and your therapists and clinicians are going to have to be able to address those questions,” he explains.
“You also have elderly populations who are most interested in ease of use, and you have to make it easy for them to understand and use their equipment.”
So can providers count on continued profit from the sleep therapy market? According to these experts, if staff members are knowledgeable, a consistent marketing plan is in place and the right products are used to facilitate patient compliance, the answer is yes.
“The bottom line is establishing early compliance or adherence to the therapy. That's key,” concludes Knepper. “Identifying the problems early through technology will have an important role going forward.”
Dennis Cook, president of Medline Industries' Respiratory Division, Mundelein, Ill.; Michael Knepper, DeVilbiss sleep product manager, Respiratory Products Division, Sunrise Medical, Longmont, Colo.; Robyn Longford-Woidtke, RN, RPSGT, CCRA, RAC, manager, clinical affairs and strategies, Puritan Bennett Respiratory Home Care, Pleasanton, Calif; Ann McGregor, vice president of sleep, Invacare Corp., Elyria, Ohio; Dave Myers, director of marketing for sleep-disordered breathing, Respironics, Murrysville, Pa.; Dennis Nasto, vice president of sales and marketing, Hoffman Laboratories, Los Angeles; Ron Richard, senior vice president of strategic marketing initiatives, ResMed, Poway, Calif.
Although there are Medicare patients who are treated for OSA, the typical CPAP user is younger than Medicare-eligible clients. This may mean they are likely to have private insurance coverage as well as disposable income that can be used for additional products and services for them and their families.
“HME providers can continue to generate ongoing revenue from this group; remember, this is a disease that lasts for life, so [these patients are] going to need masks, headgear and tubing,” points out Dave Myers of Respironics.
“In general, the population is middle-aged, so if you take great care of these particular patients who have parents and grandparents — and if the name of your business is in the forefront of these patients' minds — then they will refer other business opportunities to you.”
But Robyn Longford-Woidtke of Puritan Bennett adds that the demographics of this patient group also pose challenges.
“People will be living longer and will experience more co-morbidities. There will most likely be more patients with heart failure, arthritis and visual problems who may need to use therapy for OSA. Device manufacturers will need to be in tune with these changes and plan to accommodate different needs,” she explains.
She adds that as baby boomers age, their expectations will be different than those of earlier generations. “They will expect faster access to care, and thanks to the Internet, they will be more aware of treatment options and will be more willing to pay for treatments and therapies that are not covered by insurance,” she says.
