California Dreaming

If your home sleep testing ambitions have been squashed by Medicare (for now), the grandmother of sleep has a message you need to hear. Grandma’s name is Helen A. Kent, RRT, and she rejects the notion that all insurers are hopelessly bound to follow Medicare’s lead. The proof can be found at Carlsbad, Calif.-based Progressive Medical, where Kent serves as CEO. At Progressive, ambulatory sleep studies are routinely covered by the likes of Cigna, Blue Cross Blue Shield, Adventist Health, HealthNet and almost every IPA in Southern California.

Eschewing the over-pursued trucking companies, Kent even managed to wrangle a contract to test all Bank of America employees for sleep apnea. “People are all going after truckers, so let’s get beyond that,” says Kent with a chuckle. “Go after anybody that employs more than 50 people. Send letters, send emails. First find out who the HR person is, and find out exactly who will say yes or no.”

Whether the non-Medicare business comes from corporate contracts or conventional marketing, the next step is to find the doctors of these younger patients and properly set the stage for home testing. “We get doctors involved before we test anybody,” emphasizes Kent. “We either write to their doctor or call the doctor and tell them that their patient would like to screen for OSA. You must have the doctor’s OK in writing.”

If the answer is yes, Progressive Medical sends the patient home with a Watch-PAT (Itamar Medical) home diagnostic test. The patient comes back the next morning, and results are downloaded and emailed to a doctor who interprets the test. That interpretation is sent to the patient’s physician with a memo.

Kent wastes no time and takes pains to demonstrate the urgency of the situation. Patients avoid the dreaded lab, and physicians appreciate the overall speed and efficiency of the process. If results come back positive for obstructive sleep apnea, Kent can immediately put the patient on auto-titrating therapy because she has made prior arrangements.

“Even before we have that interpretation, we ask the patient’s doctor, ‘If the patient is within the guidelines of OSA, can we put him or her on an auto-titrating therapy to see what their pressure should be?’” explains Kent. “Be proactive. When the patient comes back for titration, we can see from the download on the auto-titrating machine what their 95th percentile is, and what their pressure should be to treat their sleep apnea.”

Unfortunately, Kent says it is not unheard of for patients to wait up to three months just to get in to some sleep labs. After that, it can be another three to four months before clinicians feel the need to reveal what they found. For providers who wish to differentiate themselves, the quickness of home testing can help them stand out. Kent has essentially used this formula for years to treat a growing number of non-Medicare patients successfully.

With these documented results, it’s easy to see why providers routinely seek Kent’s advice. After fielding a host of inquiries, she finally decided last year to formalize her wisdom by way of a new consulting business. Those who look for counsel in this capacity are sure to find strategies for peaceful coexistence with sleep laboratories, a tactic that Kent says is far better than rivalry.

While acknowledging the occasional tension between sleep labs and CPAP providers, Kent adamantly believes there is a better way. Her secret to good vibes is to send a steady stream of patients to trusted sleep labs. “When we get a patient — and we do a great job of screening patients — we know that not every patient is meant for home sleep testing,” says Kent. “We know several sleep labs, and we are their best friend because we provide a lot of patients for them.”

A TWO-WAY STREET

Determining who gets sent over for a full polysomnography depends on a comprehensive intake that takes into account medications and comorbidities. For Medicare, age is of course a consideration, but Kent points out that most Medicare patients usually belong in a lab anyway.

“Pretty soon these labs see all of these patients coming from you — and believe me you have to remind them — and this is where your marketing people come in very handy,” she says. “Marketing people need to be on top of those referrals and going back to that sleep lab and saying ‘Look what we gave you. And we want them back.’”

Calling it nothing less than the “lifeblood of HME,” Kent emphasizes the role of patient facilitator cannot be underestimated. Using your expertise to steer a lab in the right direction can also build trust and a true partnership. For example, if Kent finds a particular comorbidity that indicates the likelihood of complex sleep apnea, she does not hesitate to let lab officials know they should be on the lookout for the ailment.

Since some sleep lab officials occasionally have a short memory, Kent employs two marketing people who make sure the labs are well aware of Progressive Medical’s considerable impact on their business.

“It’s the marketing person’s responsibility to remember these patients, track them and make sure that they are coming back to us,” says Kent. “Our marketers make sure that the sleep labs know how many patients we have sent to them and why we have sent them. You have to keep track of these patients, because if the sleep labs give the patients to somebody else, you have to know about that.

“Why not show them how many patients you have given them?” continues Kent. “That makes the labs think a little differently about HME since we are actually doing the referring, instead of them doing the referring to us. If you can facilitate, you are much more proactive and you have higher prestige in the industry.”

While the friendly relationships have spawned a healthy home testing business among younger patients, Kent does outfit plenty of CPAPs for Medicare patients. As for all providers, that process got a little tougher thanks to November 2008 Medicare guidelines.

“We have had to change the way that we monitor, making sure that the patient has had a pre-visit before his test — a face-to-face with his diagnosing doctor,” says Kent. “After the sleep lab test, we must make sure patients are compliant with our therapy. Then we have to make sure that patients have another face-to-face.”

As has been the case with past rules, the onus falls squarely on providers to get crucial notes from doctors after the patient’s second face-to-face evaluation. Specifically, CMS is looking for physician notes that are typically written up between day 31 and day 90. So far, Kent has not had a problem getting the notes, a success she attributes to clear communication.

“We have to educate our physicians now and tell them that this is a new way of doing sleep if they want their patients to be treated,” she adds. “We have to do all of these things for CMS, and these are all added burdens.”

Not surprisingly, Kent was disappointed with last year’s CMS ruling that essentially banned provider involvement in home sleep testing for Medicare patients. Instead of expanding sleep testing availability for the Medicare population, Kent laments that the ban instead closes a lot of doors.

“The physician that does the home sleep test must be certified in sleep medicine by the American Board of Sleep Medicine, and the test must be provided by that physician,” reasons Kent. “What’s in it for this doctor who obviously works for a sleep lab? Why would he take this patient and send him home with a home sleep testing device where he is going to get paid less? Why would he do that when he could bring them into his lab? Follow the money.”

EYE ON OPPORTUNITY

Progressive Medical sports a black, red and charcoal gray decor spread across an ample 3,500-sq.-ft. facility. Three offices, two rooms with beds, a 1,200-sq.-ft. warehouse, and one conference room round out the spacious digs. Keeping the office running efficiently is a high priority that Kent says allows her and staff members to better care for patients.

Attending trade shows and taking full advantage of membership in the Waterloo, Iowa-based VGM Group have helped Progressive Medical evolve into a high-tech operation. Largely thanks to VGM’s endorsement, Kent uses both Brightree and MedFORCE software to maximize billing and filing efficiency.

“Everything is at our fingertips,” enthuses Kent. “There is no more looking for papers and files. Going paperless and streamlining our billing are two of the best things we ever did.”

Fairly brimming with confidence, it’s hard not to take away a bit of optimism when Kent shares her enthusiasm for the sleep industry. That contagious confidence is one reason new clients have flowed steadily to Progressive’s consulting business.

Nurturing the new venture without neglecting the core business has admittedly been a challenge, but the extra work is consistent with Kent’s philosophy of keeping several irons in the fire. “Every business has to have a baby in the incubator along with a mature business plan,” says Kent. “You can’t just depend on one item or one product for your sole income.”

Keeping one eye on legislative and business trends while running day-to-day operations is never easy, but Kent attends Medtrade and keeps up with regulatory matters through membership in both the American Association for Homecare and the California Association of Medical Product Suppliers. Never one to mince words, Kent believes that both these organizations need to be squeakier wheels, an admittedly difficult task in a crowded legislative agenda.

For legislators, clinicians and patients alike, Kent says the key to awareness is more education. Yes, the numbers of undiagnosed people are still vast, but one misconception that Kent seeks to address is the notion that most OSA sufferers can be identified by body type.

“There is no stereotype for people who have sleep apnea,” stresses Kent. “I have been wrong many times. When you are talking about the average healthy person walking the street, there is no physical type where you can say that person has got it for sure.”

Fortunately for the legions of undiagnosed patients, the comfort levels of CPAP masks have improved dramatically even over the relatively short span of the last five years. Kent remembers the bulky heavy masks that so recently gave way to light, form-fitting marvels. It’s now a rarity that Kent comes across a person she can’t fit. If she does, she goes to a nasal unit first and continues the analysis from there. Retail accessories include snore pillows and mask cleaner wipes, which Kent estimates at about 15 percent of her current revenue.

Finding the delicate balance between comfort and function is a challenge not unlike the many business obstacles that Kent has managed to overcome. In the end, her optimism inspires trust in patients and referral sources alike. “If they block this gate, find another way around it,” says Kent.

“That’s what we have always done as long as I have been in this industry. You can’t sit and take it. You must find a different avenue. If you don’t, you are not going to be in business.”