Ditch the Doughnuts and Focus on the Science

It is a rocky road ahead for those in the respiratory sector of the HME industry. As a grim reminder, here is what we are facing: a 9.5 percent payment cut from CMS for many product lines, capitated reimbursement on an average 25 percent of oxygen patients, even more outrageous oxygen payment policy proposals and the ever changing PAP policies!

We have been hearing for years the more you can break your dependence on Medicare, the better you will be. While we realize other payers often follow the lead of CMS, it remains worthy advice.

Breaking that dependence is one reason why growing your sleep business should become a well-thought-out and deliberate process for 2009.

When considering steps to grow business, our first tendency is often to look to the sales department. With that as a logical first step, survey your company and ask “What is it the sales team does?” Other than the obvious answer “They sell things,” you are likely to hear that they take in doughnuts, mugs, pens and conduct lunch-and-learn sessions for doctors’ offices and other referral sources.

Unfortunately, if we are painfully honest, we might get that same response when we pose a similar question to the physician office: “What is it your HME does for you?”

Consider the following: At last year’s American Association of Sleep Medicine conference, a physician walked up to the microphone and stated to the presenting panel, “You have to get the DMEs out of this. They don’t have a clue.”

A different physician has noted an editorial in the journal Chest, published by the American College of Chest Physicians, that discussed “the marginal job that DME providers often do in managing patients. This is a common impression of sleep physicians who are really taking care of patients.”

And during a recent state association meeting, yet another physician said to the audience, “I know we have clinical people present, but there are also DME folks here.”

It is apparent from these examples that many in the physician community do not see us as a part of the continuum of patient care. While that may frustrate us as providers — and perhaps even evoke anger for some — if we want to change that perception, we need to investigate the causes.

One of them is that our industry has a reputation for fraud. Seldom does a week go by without news of a provider accused of conducting business in a questionable manner. Additionally, every one of us knows a story of someone breaking the rules within our own service area. Our referral sources read of and hear these same stories.

There is also the perception of too many sales and not enough science. The perception is that for many providers, the goal is to move more blowers, sell lots of masks and don’t forget those hoses, filters, battery packs and AC adapters.

Understand the Science

In order to grow your sleep business, consider changing your own attitude about what the medicine of sleep is all about. Start with understanding the science that exists within the medicine, apply that knowledge to increase measurable patient outcomes and then increase your credibility as a trusted health care team member.

Start by making sure team members (beyond the respiratory therapists) understand the acronyms and measures commonly used in sleep medicine. These include AHI, RDI, ESS, CSR, Comp S.A., CSA, N.H., REM and the Berlin Questionnaire, or BQ. (Respectfully, these are the Apnea Hypopnea Index, Respiratory Disturbance Index, Epworth Sleepiness Scale, Cheyne Stokes Respirations, Complex Sleep Apnea, Nocturnal Hypoventilation and Rapid Eye Movement. The Berlin Questionnaire is a scale for sleep apnea.)

Educate yourself and your staff on the significance of the many comorbidities associated with sleep disordered breathing. All too often when there is overlap in health care, we focus on what we believe to be the primary problem only to learn there is potentially another disease process taking center stage. We miss the mark, so to speak.

As an example, 35 percent of all patients with hypertension are also impacted with sleep disordered breathing. Add to that 50 percent of patients with congestive heart failure (one of the most common diagnoses for hospital admissions), followed by 30 percent of those with coronary artery disease and a full 80 percent of those with drug-resistant hypertension. If you ask the question “Do you know anyone with high blood pressure?” the answer will almost always be “Yes.” Yet, few people have been assessed for their potential SDB.

Treatment of SDB/OSA has been associated with a fall in blood pressure of 10 mm HG, which in itself may not sound that impressive until you realize that a drop in mean blood pressure of 10 mm HG would be predicted to reduce the CHD risk by 37 percent and stoke risk by 56 percent.

HME providers can play a key role in identification of these risks by being involved in community education and screening events. A study done by Peppard et al in 2000 (New England Journal of Medicine) revealed there was an ability to determine the likelihood of cardiovascular morbidity based off of AHI. Think of it as identifying those who are future heart and stroke patients who are now undiagnosed SDB patients.

Be Aware of Comorbidities

There has also been an increased effort to raise awareness of the link between both obesity and type 2 diabetes with SDB. HME providers can take the information a step further by showing data that may hit home a bit more succinctly. This would include sharing facts such as: CPAP lowers blood glucose levels as well as increasing insulin sensitivity. Some patients have shown improvement in as little as 48 hours after implementation of therapy.

Obesity remains the single most important risk factor, however. Studies show 77 percent of those with morbid obesity (body mass index > 30) have SDB. A mere 10 percent increase in body mass has been shown to create a 500 percent increase in the risk for developing OSA. The good news is that chronic CPAP use has been shown to reduce total body fat. For many, that could be the note of encouragement they have been seeking.

In addition to the comorbidities related to heart disease, diabetes and obesity, there are several other disease entities or conditions not so readily recognized.

Canadian researcher Dr. David Dancey and colleagues sought to compare the rate and severity of sleep apnea in pre- and postmenopausal women. They looked at the records of nearly 2,000 women who had been assessed at a sleep clinic. Those who were younger than 45 were assumed to be premenopausal, and those older than 55 were assumed to be postmenopausal.

The researchers found among women 55 and up, 48 percent had sleep apnea compared to 22 percent in the younger group. Contributing factors are thought to include age, muscle tone, weight gain and progesterone. Consider, then, that some reports show it may take up to 10 years for women to be accurately diagnosed, and again we are missing the mark.

While thinking about the effects of hormones, let’s not forget serotonin. Most of us realize serotonin has a direct effect on our mood, behavior and thoughts. What you may not know is the effect serotonin has on the sleep-wakefulness cycle and upper airway muscle tone control during sleep.

Psychiatrists with an interest in sleep medicine realized this effect long ago and proposed that many patients who had been treated for depression were not really depressed at all but sleep deprived. One study suggests that people with depression are five times more likely to have SDB than non-depressed people.

Remember, sedative antidepressants may actually exacerbate OSA, with a possibility of decreasing muscle tone in the upper airway and blunting the arousal response (waking up) to apneic events.

Go for the Goal

So, when looking for your next group of patients, consider:

• Looking through the eyes and ears of a diabetic case manager;
• Following up on your own COPD patients who may have nocturnal hypoventilation;
• Partnering with mental health professionals;
• Presenting at weight-loss groups or women’s organizations;
• Educating at Better Breathers groups regarding the crossover effects of COPD and SDB;
• Local industry (for instance, 28 percent of truck drivers are at risk); and
• Special interest/support groups for neuromuscular and neurological patients.

The best practice an HME can pursue is to become passionate about the goal of increasing awareness. Early recognition and intervention drives improved health care.

With more than 25 years of respiratory experience in both institutional and home care settings, Kelly J. Riley, CRT, RCP, is director, National Respiratory Network, for The MED Group, Lubbock, Texas. Previously, she served as COO for At Home Medical (formerly Via Christi at Home) in Ponca City, Okla. You can reach her at [email protected].