The interactions between the field of sleep medicine and two primary institutions, government regulators and insurance carriers, have not always been fruitful. Perhaps the overarching problem has been the defensiveness frequently observed within the field of sleep medicine due both to the newness of the field and the lack of respect for sleep and sleep disorders demonstrated by so many people, institutions, and medical professionals who operate outside our specialty. You only need to imagine the hundreds, nay thousands of movies, television shows, books and other media portraying the humorous side of snoring or napping and the scathing side of sloth or laziness attributed to individuals who suffer from sleep problems to realize a sizeable proportion of humanity does not share our “snooze you can use” mindset. Usually, the perspective is downright negative.
This derogatory slant on sleep disorders and related symptoms remains ever-present in our society and greatly influences the views of those outside the field of sleep medicine. Sometimes, in the field itself we may not recognize this aspect of the problem, because we are so well wrapped in our cocoon of a sleep center or lab environment where nearly everyone who presents for care is a treatment-seeking patient who is troubled by some concerning features of a sleep condition and wishes to be educated and treated. A sleep doctor or technologist could literally step just a few feet outside the domain of practice and run into the sizeable proportion of people who either think sleep centers are places to buy mattresses or some medical enterprise scam trying to bilk people out of thousands of dollars by testing them and prescribing PAP machines.
No small wonder, the field of sleep medicine repeatedly finds itself playing defense and often forgets the adage (the NFL training camps recently started) “the best defense is a great offense.” By the way, while there is no attribution for this commonly used quote in sports or military strategy planning, George Washington was quoted as saying something very similar in 1799, and he had a pretty good record for winning the things that mattered the most.
There are several key places where the battles between sleep medicine and non-sleep institutions have had the most impact on our field. In no particular order the following areas have manifested conflicts hampering clinical care:
- Medicare rules on the apnea-hypopnea index have thwarted patient care, encouraging the development of harmful treatment perspectives that ignore scientific evidence and which create considerable medical-legal exposure to sleep professionals.
- The UARS diagnostic concept has been inconsistently acknowledged and accepted, which has led to fewer resources to treat such patients who suffer this treatable condition.
- Confusion in CPT coding issues involving patient-sleep professional encounters has yielded incorrect use of and reimbursement for these patient visits, resulting in a loss of time and money at sleep center operations, not to mention the impact on administrative time to manage what should otherwise have been straightforward billing steps.
- Stark rule issues have circumscribed sleep centers’ capacity to facilitate the sale of durable medical equipment.
The above is not designed to curse Medicare and other insurance carriers; they perform many admirable services for our patients, and in the big picture help an enormous number of people receive healthcare.
The problems listed above, as I see them, are more about the inability of the field of sleep medicine at all levels to aggressively interact with and educate the decision-makers at these non-sleep institutions; and when attempts are made to influence decision-makers, it appears the efforts are often limited or too late to yield the best results.
If you know something of the history of sleep medicine, then you may be aware that originally the only acceptable diagnosis for OSA required 30 or more apneas (90% or greater reduction in airflow) on an overnight sleep test. Without 30 apneas, one did not qualify for insurance coverage per Medicare. This definition was established and used in the 1980s when the treatment of OSA with CPAP first arrived on the medical landscape. Yet, many researchers and clinicians soon realized hypopneas (usually defined as a 30 to 70% reduction in airflow) were frequently occurring in patients with sleep apnea; and it was clearly apparent hypopneas were a clinically relevant component of the patient’s sleep breathing condition.
As more knowledge emerged on the necessity of scoring and treating hypopneas in the early 1990s, both from the perspective of clinical and research professionals in the field of sleep, it was evident sleep apnea was much more common than anyone had previously anticipated. These two emerging pieces of sleep-disordered breathing puzzle made it even more clear sleep apnea was going to cost a lot of healthcare dollars, because many more patients would qualify for the condition if hypopneas were included in the diagnostic criteria. As many sleep facilities had already begun scoring hypopneas and as many insurance carriers except for Medicare were acknowledging the relevance of hypopneas, the prevalence numbers for sleep apnea were rising rapidly.
At that point, which was in the early to mid-1990s, there was push back from Medicare asking for a clearer definition of hypopneas, and the slant unequivocally demanded by this government-run insurance institution was in the direction of stricter definitions to yield fewer patients receiving the diagnosis of sleep apnea. As a result, despite the long-held understanding of the links between arousal activity and apneas and hypopneas, a paper was published defining hypopneas only with 4% desaturations. Many in the field of sleep medicine were outraged by this paper, because it failed to attend to the clinical relevance of arousals in OSA or UARS patients.
From the grapevine, the only explanation offered unofficially was that Medicare threatened to dismiss all hypopneas unless this stricter one was recognized. Yet, everyone who practiced in the field of sleep medicine recognized that many elderly patients with a predominant problem of sleep fragmentation due to excessive arousal activity caused by hypopneas would no longer be covered by Medicare if they did not manifest enough of the 4% desaturations with these hypopneas. To the chagrin of many in the field of sleep medicine, the American Academy of Sleep Medicine never adopted an aggressive posture toward this new Medicare ruling and only recently has begun to push back in very limited fashion on this inherently unjust and non-scientific definition that clearly excludes a host of patients from insurance coverage. Worse, seeing a way to save more money, several private insurance carriers adopted Medicare’s hypopnea rules to further exclude the diagnosis in their patients who otherwise suffer from severe daytime sleepiness due to their arousals, despite the absence of these 4% desaturations.
This disregard for advancing the science of sleep medicine is a prime example of how the field played defense instead of aggressively asserting its unique role and capacity in educating non-sleep institutions on the clinical relevance of what we practice in our clinics and labs day in and day out. The failure to have addressed this problem 20 years ago continues to hamper clinical care throughout the USA as well as around the world.