As has been the case in recent years, the awareness of sleep-disordered breathing and the health problems it causes continues to rise. The identification of symptoms and risks are highlighted continually in both the mainstream media and through personal and clinical blogs. Likewise, primary care physicians are increasingly becoming more attuned to the needs of their at-risk patients.
Finding
So it would appear safe to say the market is growing. But with growth comes change.
"It is pretty much a unanimous agreement that the sleep market is changing. There are a lot of forces at play that all of the parties — from vendors to HME providers to physicians — are wide awake about, and [they are] thinking seriously about what it means to them and the roles they play in the diagnostic and treatment pathway," says Maura Weis, Philips Respironics' director of sleep marketing for North America. "Sometimes these challenges create new and better ways of providing positive care.
"There is growth, for sure," Weis says, "but it is a matter of how to obtain the growth in a profitable way while maintaining the appropriate level of care. What this calls for is for the different entities to look at things with a different mind and, ideally, look at each other as to how to work together to maintain the growth and make it profitable while maintaining the high level of care that patients deserve."
Citing the nation's obesity epidemic and an increased level of acceptance by patients to get tested, Bob Hoffman, director of VGM Group's Nationwide Respiratory division, agrees that the opportunity for growth still exists. "Most individuals know somebody who is on a CPAP and have heard firsthand the benefits it can offer," he says.
But he does note that the country's economic slowdown has hurt. "With higher deductibles now commonplace, getting the sleep test is oftentimes something that can easily be put off from the patient's perspective," he says.
Weis expands on his point. "Another issue is patient coverage plans and the changes in some of the deductible models. This is influencing the patient's perspective on what they want to do for themselves related to recognizing the sleep issue and moving into a treatment plan," she says.
The effects of the recently announced rates under Round 1 of the DMEPOS competitive bidding program, with the average cut for CPAP, RADs and related supplies at 34 percent, also will certainly affect the sleep market and its providers.
"In terms of the competitive bidding rates that we just learned about — wow. What a shocker to us all. People are even questioning the accuracy of it all and saying that there has to be some bad math here," says Weis. "The results are what they are, and they are pretty alarming. Obviously, we are still waiting to see what the next steps are and what contracts will be secured."
She also points to the likely trickle-down effect from other payers once the bid program is implemented (January 2011).
Kristin Mastin, director of marketing for DeVilbiss Healthcare, had a similar reaction to the Round 1 rates.
"With average CPAP fees dwindling by another 34 percent under competitive bidding, it's clear that our industry remains under attack," she says.
Compliance = Success
Following diagnosis and a treatment prescription, clinical success for the patient and economic success for providers are completely dependent on compliance.
"Compliance is key," stresses provider Todd Cressler of Pennsylvania-based CressCare Medical. Calling it one of his company's key metrics, he says, "We promote and encourage our staff to come up with programs and ideas that positively affect compliance."
Even with a dedicated focus, however, compliance can still be a hurdle. For Cressler, that means about 12 percent of set-ups result in pick-ups due to lack of compliance. Of those, Cressler says, a quarter are attributable to insurance medical policy, while the remainder are patients who, despite all best efforts, simply are not CPAP-compliant.
"Keeping the patient compliant and documenting that compliance continues to be the biggest challenge," agrees Hoffman. "Some initial compliance issues will never go away, such as congestion, claustrophobia and pressure sores. The good news is that with the improved CPAP systems and a variety of interfaces available, these obstacles can be overcome with the proper initial education and follow-up."
For some, however, compliance documentation has become the bigger issue, especially since CMS issued new coverage mandates.
"Compliance has always been what this industry has worked for and, now, with the requirements coming out, starting with CMS and, certainly, moving into the private payer models as well, there is more of a need to focus on it because it will now determine if and when you get paid," says Weis.
Hoffman notes that documentation takes "technician time, added provider expense and patient and physician cooperation to ensure all the guidelines for continued reimbursement are met."
Mastin also acknowledges the difficulty. "It's clear providers are facing some challenges with obtaining this information as evidenced from the recent Jurisdiction C audit that indicated that 23 percent of claims did not include objective proof of adherence to therapy in the patient's file, and 14 percent of claims did not meet the CMS requirements for adherence," she explains.
Although improvements in PAP devices have made the therapy more comfortable, which positively impacts initial compliance, Weis points to the ongoing challenge in keeping patients compliant.
"A bigger impact is how providers are able to work with their patients to keep them compliant," she says. "When [providers] can get access to data quickly, such as through a modem, they are in a much better role to take action and work with that patient to get them compliant."
Supply Replacement Programs: Not Optional
"Whether a provider sets up five or 500 new patients a month, a functional and efficient supply replacement program is a must," says Hoffman, noting that such programs can help with both patient compliance and profitability.
"Routinely replaced equipment will help ensure proper fit and compliance. The revenue generated from the reoccurring mask sales is essential to keeping providers not only profitable but, in some instances, keeping them in business."
Weis recommends a holistic approach that includes focusing on set-up and re-supply.
"Keep in touch with patients who are compliant and stay engaged with them in an efficient way so you can continue to provide them with supplies. The return on that type of model is very easy to measure," she says.
Both Hoffman and Weis acknowledge that supply fulfillment programs can be challenging in themselves.
"The good news is that there are resources that can fulfill those different parts. Providers have the option to decide what they are going to do in-house and what they are going to outsource. The return can be strong either way," says Weis.
Because of the active nature of the typical CPAP user, the success rate of contacting them during normal business hours for supply replenishment is poor, so outsourcing the function can be a necessity, Hoffman believes.
Mastin advises providers to proceed cautiously and explore all options that are available, as the outsourcing solution is an extension of their company.
"Service levels are critically important to retain customers," she says.
Enhance Referrals, Move Forward
A comprehensive and organized compliance program is imperative both for patient success and for business growth, according to Hoffman. "It demonstrates to your referral sources that you are the provider of choice, and it opens up an ongoing cash flow opportunity for your business," he says.
Cressler notes it is important to understand referral sources and help them understand your business.
"The most successful HME providers listen to what their referrals want and give it to them," adds Mastin. "Physicians really want to work with a provider that will take good care of their patients."
Strong, clinical care is essential.
"Given all the dynamics of the market, let's all stay focused on great care. That is what is going to drive referrals and drive business," says Weis. She also encourages providers not to be shortsighted as they navigate the changes ahead.
"We are going through some changes and we all want to get through this together. Let's be open-minded to new models and new technologies and work with each other to make them both effective for patient care as well as cost-efficient," she says.
Adds Cressler: Know what you do and do it well.
"Stop doing some things just to do them. Get the right people on the bus and get them in the right positions," he advises. "Keep changing. If you are not changing, you are moving backward."
'Lessons Learned' from E0601 Claims
A recent review of claims for CPAPs in Jurisdiction C "showed that suppliers are not following published Medicare guidelines and policies in submitting claims for necessary and reasonable HCPCS code E0601 services," according to Cigna.
The review included 100 randomly selected claims paid between Oct. 1 and Dec. 31, 2009, and submitted by 96 different providers. An analysis showed these "lessons learned," the DME MAC said:
- Seven claims had no written order in the file.
- On 17 claims, the order did not list all separately billed items.
- The order on 69 claims did not have refill/replacement instructions.
- Length of need was not on the order for 12 claims.
- No medical records were submitted for six claims.
- The file for 19 claims did not include a face-to-face clinical evaluation conducted by the treating physician prior to the sleep test.
- No sleep test was provided for 10 claims.
- The file for 26 claims did not include a clinical re-evaluation conducted by the treating physician between the 31st and 91st day after initiating therapy.
- On 23 claims, the file did not include proof of adherence to therapy.
- The adherence report on 14 claims did not verify use of the device four hours per night on 70 percent of nights in a 30-day period.
Experts Interviewed
- Todd Cressler, owner, CressCare Medical, Harrisurg, Pa.
- Bob Hoffman, director, Nationwide Respiratory, a division of VGM Group, Waterloo, Iowa
- Kristin Mastin, director of marketing, DeVilbiss Healthcare, Somerset, Pa.
- Maura Weis, director, sleep marketing, North America, Philips Respironics, Murrysville, Pa.
