Sleep On It

Home medical equipment providers who focus on treating patients with sleep disordered breathing are faced with a harsh reality: The market continues to grow as more patients are being diagnosed and treated while reimbursement is decreasing among all payer sources. That means marketing efforts, patient compliance and smarter operational approaches are essential to sustain growth and long-term success.

“A key challenge for the sleep market in the current environment is the dichotomy of an enormous unmet need to diagnose the 85 to 90 percent of 40 million Americans who have undiagnosed sleep disordered breathing while simultaneously feeling the pinch from payers who are looking to reduce their health care costs across the board,” says Michael Farrell, senior vice president, sleep strategic business unit, ResMed, Poway, Calif.

Gretchen Jezerc, director, U.S. marketing, sleep disordered breathing, Philips Respironics, Murrysville, Pa., adds that increased research into the relationship between SDB and other diseases has promoted the market’s growth.

“This awareness creates an interesting opportunity to reach out to physicians who are treating these patients and work with them to ensure they are up to speed on screening their at-risk patients,” she says.

But recent changes in government policy and payments — including new PAP requirements and a mandate from the Centers for Medicare and Medicaid Services that prohibits provider involvement in home sleep tests — could prompt HME providers to reconsider their involvement with Medicare patients.

“HME providers have been recently impacted by the Medicare policy changes to the requirements for CPAP and bilevel devices,” notes Jason Jacobs, MSM, RRT, RCP, vice president of operations, Barnes Healthcare, Valdosta, Ga. “Already faced with large reductions in reimbursement for 2009, many providers will likely find the Medicare sleep market less attractive due to the cost-prohibitive nature of the requirements.”

According to Farrell, the 9.5 percent reduction in CMS payments for HME reimbursement, specifically on codes E0601 and E0470, is significant.

“Our biggest challenge as a medical device manufacturer and HME provider partnership is to show the savings in the acute and hospital care environment from effectively treating sleep disordered breathing patients,” he says.

“If we can show the government that $1,000 of Part B Medicare spent saves $3,000, $4,000 or more in Part A Medicare costs, and even better, focus that specifically on the use of positive airway pressure treatment and its reduction in hospitalizations and chronic care costs, we have a chance to move the discussion to economic health care outcomes.”

While the Medicare market has its problems, however, most payers in the sector are private insurers, and experts say the number of sleep therapy patients will only continue to grow. But with any payer, validation of positive outcomes is now an essential.

Bob McCoy, RRT, managing director of Valley Inspired Products in Apple Valley, Minn., says specific challenges involve a focus on both diagnosis and therapy.

“The market is large and we are moving quickly to try to address the need, yet, clinical evidence on new products and procedures is lacking,” he explains. “If we do not lay down the evidence for the benefit in improved outcomes, sleep therapy may fall to the same fate as oxygen in the home.”

Another concern is the effect of the DME MACs’ re-issued PAP Local Coverage Determination.

“The main challenge for sleep providers right now is how to interpret the new CPAP LCD. Some of the new LCD rules are clear and other items are not,” says Todd Cressler, CEO of CressCare Medical in Harrisburg, Pa. “One thing is very clear … The harder it is to do this business, the less people will be interested in providing the service.

“Common sense tells you that the easier it is to deny payment or recoup monies in an audit, the more money Medicare can save to balance the budget. Our goal as a sleep provider is to get clarification from the right people on what we need to do to ensure we are in compliance in case we get an audit — and, of course, do a little kicking and screaming along the way.”

There is a lot of confusion, points out Bob Messenger, BS, RRT, product manager, sleep products and clinical manager, respiratory products, Invacare Corp., Elyria, Ohio.

“CMS has been unclear on the requirements for documenting usage, both on how much time the patient must spend using CPAP and on how that information is to be obtained,” he says. “Although debate continues on these issues, the reality is that the coverage rules — CPAP usage 70 percent of nights for at least four hours — will result in up to half of all Medicare-covered patients losing coverage for CPAP after 90 days.

“With these criteria, providers that continue to service Medicare patients may find themselves faced with increasing inventories of used CPAP equipment or may choose to scale up their use of the Advance Beneficiary Notice.”

In the meantime, Cressler is taking a proactive approach.

“We teamed up with a local competitor to develop protocols which both of us feel at this point comply with CMS medical policy. Together we are sending the same message to our referral sources,” he says.

Show Them the Results

As providers work to comply with the new regulations, it is crucial to continue marketing efforts to grow their businesses. In order to effectively market to referral sources, providers must gain a sense of what their referral sources want and provide concrete solutions for them and their patients.

According to Jezerc, referral sources are most interested in their patients being compliant and want providers to work from their end to offer “maximized chances for success … Regular and consistent follow-up is important as well as programs that focus on things such as mask satisfaction where they can return the mask within the first 30 days to achieve the highest rate of compliance,” she says.

“Providers must first find out what is important to the referral source and work to exceed these expectations. A world-class sleep program must include the essential elements of care: the appropriate PAP device for the client, family and client education and access to qualified respiratory therapists,” says Jacobs. “Sleep referral sources want to know providers will handle their customers with care since the customer will associate the HME provider with the referral source.”

Surveying your referral sources can be an effective method to understand their expectations. For instance, CressCare Medical conducts annual surveys to get input from each staff member at each sleep lab that sends referrals.

“Most referral sources are looking for outstanding communication along with an extensive compliance program,” says Cressler. “It helps to provide the best technology and product selection along with patients who love your services. If your patients are not happy, your referral sources will not be. We focus our company around four key core values: communication, commitment, integrity and teamwork.”

And lip-service is not good enough — you have to deliver.

“Referral sources are looking for results,” says McCoy. “Compliance is only a term. If the patient uses CPAP therapy and does not improve outcomes, they will start to reconsider their options. The best marketing an HME can provide is education.”

However, educating referral sources can be tricky. It is best done when clinical evidence is available to offer the latest information, says Jezerc. She advises that sales and marketing staff learn how to sell their services using clinical studies.

Educate, Educate, Educate

Once the expectations of the referral sources are determined, providers should be specific as they market their services.

“Create a marketing tool that highlights the services and care provided to CPAP patients. Ultimately, referrals want to know that their patients will receive thorough and ongoing care from the provider,” says Kristin Mastin, director of marketing for DeVilbiss Healthcare in Somerset, Pa. “Adherence is the key measure of a successful CPAP therapy program, so providers should tout their compliance rates.”

Cressler adds there are many ways to enhance marketing efforts and says that introducing new programs on a consistent basis should be the No. 1 priority. “You should have something each month, if not more, that your company is doing to enhance its sleep program. At CressCare Medical, new ideas are developed weekly. You must encourage new ideas from your staff,” he says.

Although consumer awareness of sleep disordered breathing is on the rise, there are many misconceptions. HME providers can help with this process in a number of ways, thus enhancing their business and solidifying their reputation with referral sources.

“Consumer awareness of sleep disordered breathing has increased significantly during recent years, and there are many opportunities for providers to get involved,” says Barnes’ Jacobs. “Providers can partner with sleep labs to offer mask clinics, participate in wellness fairs and join or sponsor support groups.”

When providers can offer education, they can distinguish themselves and offer a valid solution for consumers.

“Everyone knows about sleep disorders, they just don’t know what causes the problems. They try sleep beds with numbers and other options yet don’t clearly understand the cause of sleep disorders or the options that are available for treatment,” says McCoy of Valley Inspired Products. “Few people like to be sold a solution; they prefer to have all the information presented and then choose the option that is best for them.”

Creativity helps as well.

“There are many things you can do to create awareness. One idea we implemented this year was to put CressCare Medical displays in seven Sleep’s Mattress Company retail outlets, which is a big mattress chain in our area. They have many folks who walk into their doors to solve their ‘sleep problem,’ and our displays provide information on sleep disorders,” says Cressler.

Another way to increase consumer awareness is to offer educational programs to corporations and local manufacturers.

“Targeting local corporations is a tremendous growth opportunity. Many organizations are looking for opportunities to manage disease processes to control health insurance costs,” says Jacobs. “Since it is well documented that sleep disordered breathing has comorbidities such as hypertension, stroke and congestive heart failure, a provider can add value to a corporation’s wellness initiatives.”

Invacare’s Messenger advises HME providers to participate in health fairs held at local businesses and institutions and to educate company leaders about the consequences of poor sleep.

“Find the appropriate person in the company, whether it be the director of human resources or the company nurse, and offer to provide a program that addresses the dangers of their employees falling asleep on the job and the financial consequences of employees being less than fully productive,” he says. “Anyone who will listen is your target audience.”

He adds that providers should not dismiss the value of “word-of-mouth” advertising. “It is invaluable. If patients believe you have an honest interest in their care, they will tell their physician and their friends.”

Boost Compliance with Early Intervention

Compliance is king when it comes to increasing patient outcomes. No attempt at therapy will be successful unless the patient is compliant.

“Increasing patient compliance and driving better patient outcomes is our life’s work in the home care field, but there is no simple answer to the challenge of increasing compliance,” says Farrell. “In a broad-based statistical analysis of top reasons for CPAP compliance or non-compliance, follow-up from the HME company in the first few days of therapy was the No. 1 reason for increased compliance, even ahead of visits with the physicians.”

Providers should continue to focus on educating patients with both the “carrot and the stick,” he adds.

“The carrot is a potentially dramatic reduction of the symptoms of sleep disordered breathing, including excessive daytime sleepiness, nocturia, impotence and snoring, amongst other symptoms. The stick is the fact that untreated sleep apnea is a leading cause of high blood pressure, and high blood pressure is a leading cause of cardiovascular disease, including heart attack and stroke, and the number one and three killers in the Western world,” explains Farrell.

Education, early intervention and patient comfort are three factors that have been linked to improved CPAP adherence. Providers can rely on the expertise of their clinical respiratory staff and resources provided by manufacturers to enhance the process.

“It’s important to understand the mindset of a newly diagnosed CPAP patient. New CPAP patients are suffering from the effects of sleep apnea, so they may not be fully engaged initially in their diagnosis and treatment,” says Mastin. “It is critical for providers to use all tools possible to explain the condition and the importance of adhering to their therapy.”

To assist providers with this, she says, DeVilbiss includes a video “introduction to CPAP” with every IntelliPAP that explains the condition and treatment in laymen’s terms. In addition, the video offers tips to acclimate to therapy. “As research has proven, the first two weeks of therapy are the most critical for improving the likelihood of long-term CPAP therapy,” Mastin points out.

In addition to education about the disease and its prescribed treatment, equipment plays a large role in compliance outcomes.

“Proper device and mask selection is a key to success. There is so much technology available to assist clinicians with the comfort of their client,” says Jacobs. “Patient care is individualized based upon needs, and this should steer mask and PAP device selection. Further, providers must communicate well with the client and, if available, the family. Troubleshooting and coping strategies are essential and will help the client know what to expect.”

Cressler advises providers to offer programs that give patients every opportunity to be successful with their therapy.

“We know that it’s the first two weeks that are the most important and mask comfort and humidification are two key elements that must be addressed,” he says. “Keep coming out with new ideas that will help the patient become comfortable with therapy. We are ready to release a new ‘Desensitization Program’ that is aimed at increasing the likelihood of successful therapy that involves targeting the patient before they go in for the study.”

But long-term follow-up is also key. Here, supply replacement programs can help, and they also can be a boost to profits.

“When it comes to opportunities in sleep, many providers continue to leave money on the table by not pursuing accessory replacements. When a replacement program is done right, masks and supplies become the blades to the CPAP razor,” says Messenger. “Accessories provide a source of recurring sales with significant monthly growth potential. As the size of a provider’s sleep patient base grows, so does their monthly sales. Best of all, this sales growth comes from existing customers.”

It is also advisable to be prepared for patients who are informed about their choices.

“Because many payer sources require a high copayment for this equipment, a patient-directed retail approach is emerging,” says Jezerc of Philips Respironics. “Since they are investing more of their own money, patients are looking at what products are available and deciding which ones they want.”

She recommends that providers offer CPAP clinics to show patients new products.

“At these clinics, patients can see what is new, try on new masks and have their questions answered by a respiratory therapist. It provides a great opportunity to reconnect with them,” she says. “It also offers the opportunity for HME providers to show patients additional non-reimbursable items that can enhance compliance and comfort and increase retail sales.”

Messenger notes that research has demonstrated the benefits of providing patients with education, follow-up and reinforcement.

“Studies consistently show that providing these services results in large gains in compliance,” he explains. “Providers that currently offer these services know they benefit both their patients and their own reputations. In the long term, this may be the single most important factor that separates the dominant sleep providers from the rest of the pack.”

New Products Support Patients, Providers

Recent advances in product technology include a renewed focus on comfort and quietness, according to ResMed’s Farrell.

“The net result [of these products] for the HME provider is more comfortable and compliant patients, leading to better referrals and increased trailing revenues of masks and ancillary products,” he says. “And as a recent peer-reviewed study showed, insurance companies also win with a compliant CPAP patient; they have better long-term outcomes with a smaller burden on acute care and lower hospitalization costs versus an untreated patient.”

Jezerc adds that advances in product technology as well as mask satisfaction and resupply programs drive longer use times.

And because the push for increased compliance is so strong, the means to gather compliance data is rapidly evolving, according to Mastin.

McCoy of Valley Inspired Products says products will continue to become more technical and interactive. “Sleep screening and testing will help triage patients, and new interactive therapy devices will help adapt a device to the specific patient to meet the individual’s needs,” he says.

Looking ahead, the market for sleep disordered breathing will continue to grow even with reduced payments and changes in coverage. As it evolves, providers must be vigilant to ensure their role is secure.

“We need to transition from a focus on 9.5 percent reductions to how we best show the return on investment of the dollars spent, which may actually lead to expansions of coverage and even increases in home care reimbursement,” says Farrell.

“To achieve this, we will need to get together across industry groups and drive evidence-based medicine decisions with objectively designed and managed economic-clinical trials. The better we execute on this, the more chance we have of rapidly diagnosing and treating the millions on undiagnosed sleep disordered breathing sufferers across the United States and the globe.”

Education and clinical science is the future of sleep therapy, says McCoy.

“If we as an industry don’t do this, the home sleep business will slowly move to a retail business with little to no clinical involvement,” he says.