A Dream Market

If you are not currently participating in the sleep market, you are most likely considering the prospect. There is good reason: The market is growing at approximately 20 percent annually, and opportunities abound for respiratory providers who offer clinically sound and efficiently run programs.

“The sleep market is one of the areas that is growing faster than any other area,” says Bob Messenger, RRT, Invacare’s clinical manager of respiratory products. “From the perspective of evaluating a business going forward, you really need to look at the fact that Medicare is cutting the legs out from under providers in other areas. The one bastion of safety that is left is sleep.”

With the growing need, manufacturers have responded with a new generation of sleep-disordered breathing products designed not only to improve patient compliance but also to enhance providers’ profits.

According to Gretchen Jezerc, respironics’ director of U.S. marketing, sleep-disordered breathing, the company’s new technology is “a way to help people be compliant and successful in their therapy from the beginning, because that’s what really drives everything in terms of the success of a home care provider’s business and the success of the physicians and clinicians in treating the patient.”

Manufacturers note that product enhancements are driven by several factors, competition among them — and that’s good for patients, says Kristin Mastin, director of respiratory marketing for the DeVilbiss Respiratory Products Division of Sunrise Medical.

“The sleep market is a young market, so … each manufacturer is continually trying to offer the latest and greatest solution,” she says.

“Additionally, the industry as a whole is learning more about sleep and sleep disorders, which encourages manufacturers to push the envelope to develop more effective means of providing sleep therapy. These advancements are furthered by continual innovations in the components used in the manufacture of sleep therapy equipment.”

Mastin and others say patient need has a huge impact on sleep product design changes and improvements.

“What drives our newly designed masks and other respiratory products is patient feedback with specific requirements they have for the perfect mask to wear when sleeping,” says Kelly Rudolph, marketing manager for Hans Rudolph.

“The sleep apnea market is a huge market that is growing each day, so, therefore, there are various mask requirements. There isn’t one mask for everyone, so we continually strive to meet all the requirements for a mask that seals better, is more comfortable, more durable and more affordable.”

Messenger adds that consumers want portable systems that fit their lifestyles. “Clearly, what we’re seeing is a movement toward a smaller, lighter, quieter and definitely more aesthetically pleasing product that will fit into people’s home environment,” he says.

To meet patients’ needs today, adds Jezerc, products must focus on comfort, adjustability and “getting it right” the first time.

Respironics’ new My Life series, launched in January with its OptiLife mask, was developed in part to help patients overcome the initial difficulties of therapy. The series offers modular components, simple designs and a wide range of fittings that make it easy for patients — and therapists — to contend with.

The OptiLife, for example, allows side-sleeping without disrupting the seal, based on the premise that patients who are more comfortable with their equipment will be more compliant with their therapy. The mask features headgear with no buckles, and instead of using the nose to support the seal, it uses a chin support band to provide a foundation for the seal, eliminating nasal irritation and pressure.

The flexible headgear and chin band allow the mask to be put on and adjusted with little effort. The mask also comes with pillow cushions in four sizes (petite, small, medium and large) to accommodate a range of patients.

For home care providers, the company says the mask should minimize patient call-backs and “can’t-fit” scenarios, which, in turn, should reduce costs and increase long-term revenue.

Invacare’s Messenger says a good design will allow the use of fewer materials yet still maintain a good feel. “If it’s designed properly, a mask should almost be able to float on a patient’s face with minimum pressure,” he explains.

The company’s Twilight II nasal mask “equally distributes pressure completely around the head,” he says. “By virtue of the way the cushion itself is designed, it does not require the patient to utilize a lot of pressure. They get a comfortable fit, and there are no telltale signs in the morning.”

ResMed’s Mirage Swift II nasal pillows mask, introduced last year, is a lightweight mask that sits at the entrance of the nostrils without covering the nose. The mask has few parts and is designed for easy handling and cleaning.

Fisher & Paykel launched its new Opus nasal pillows mask in February. According to Christian Kiely, the company’s home care product manager, the mask is small, quiet and comfortable, and allows side-sleeping without mask displacement.

Kiely says the mask is designed with anatomical silicone pillows and facially contoured, reinforced headgear. A ball-and-socket-styled joint combines with its anchoring system to give stability and freedom of movement, and the Opus comes fully assembled with a variety of pillow sizes.

In other product areas, Mastin adds, the market is moving toward small flow generators that look less like medical equipment and more like small home electronics. “These units are also feature-packed, focusing on patient comfort,” she says.

The new DeVilbiss PAP line, which will be launched later this year, will provide the next generation of remote monitoring, Mastin adds.

Meanwhile, ResMed has introduced its VPAP Adapt SV, an adaptive servo-ventilator designed specifically to treat central sleep apnea (CSA) in all its forms, including complex and mixed sleep apnea.

Running an Efficient Business

Naturally, an HME market that is growing as rapidly as this one spawns high-stakes competition among providers as well. As home care companies increase their presence in the sleep market, experts say they will have to differentiate themselves through efficiency and stellar customer service.

There are a number of aspects of efficiency that must be considered:

• Clinical efficacy If patients are not compliant, a sleep therapy program will most certainly be a disaster. Compliance is directly related to initial success and immediate gratification. Patients whose therapy is effective often feel benefits after the first night of use. Messenger says 80 percent of patients report mask incompatibility as the No. 1 reason for noncompliance. “It is very important for providers to ferret out these issues early in the therapy, because if the patient is non-compliant at the 30-day mark, the window of opportunity has been closed,” he says.
• Diversification Providers will need to diversify their sleep business with both payers and referral sources. It may mean stepping outside their current comfort zone, but it is necessary. “By working with private insurers and expanding their coverage area, there are opportunities for HME providers to enter into the diagnostic component,” says Tom Pontzius, president of VGM Group’s Nationwide Respiratory. “There are numerous ways to partner with sleep labs to expand coverage areas and diversify the existing base of sleep business and expand beyond obstructive sleep apnea.”
• On-site evaluations and set-up As with all areas of HME products and services, delivery costs continue to have a negative impact on profitability. According to Mastin, providers who have chosen to schedule on-site evaluations and product set-ups are discovering that patients are accepting this procedure and are realizing considerable cost-savings. Ron Richard, senior vice president of strategic marketing for ResMed, says on-site procedures can benefit patients by providing increased scheduling flexibility, and can benefit clinicians since they have all of their masks, educational materials and products on hand. “It enables [providers] to improve overall patient satisfaction and engage the patient in selecting the device that matches their lifestyle and needs,” Richard explains. “The patients we have spoken with about this model expressed they felt it was like making an appointment to see their dentist or doctor, so it did not seem to be anything out of the norm for them. “For sleep centers and HME providers,” he continues, “this approach is more efficient from a cost standpoint as it can decrease expenses related to non-reimbursed activities, driving times and appointments that are canceled en route or if the patient is not at home.”
• Patient education When first diagnosed with sleep-disordered breathing, patients are naturally confused about their condition and the requisite treatments, creating a strong need for education. According to Pontzius, patient education is “key in maintaining an efficient approach to patient care. By conducting thorough patient and referral source education, providers will be able to capitalize on their expertise and generate additional revenue,” he adds. Patients need to know the purpose of the therapy and what to expect, notes Jezerc. She encourages providers to make it clear that the prescribed treatment is not “just to make them feel better — it is actually lifesaving.” Since sleep apnea is a chronic condition, disease management programs can enhance patient therapy, according to Richard. “Disease management programs already include monitoring chronic conditions to offset health care costs associated with medical protocols that intervene when appropriate to modify the patient’s behaviors or therapy,” he says. “Early detection and intervention can reduce health care costs and improve outcomes. Sleep is linked to so many chronic conditions. It would seem natural for this disease to become an integral part of an overall patient management program.”
• Inventory management Choosing the right products and the right vendor alliances can have a direct correlation with profitability. Patient choice certainly is a factor to consider, but providers cannot feasibly offer every style of mask. Invacare’s Messenger points out that it may be difficult to streamline inventory — which could mean the patient’s first choice is not available — but doing so is a financially prudent decision. “There have to be 50 to 60 masks out there on the market, and there is no reason for somebody to have to go with the ‘mask of the month,’ so to speak. Providers should try to control their inventory so that they are offering two or three different types of nasal masks and face masks and nasal pillows,” he advises. When selecting which products to carry, it is critical to choose those that are effective and reliable. Choosing a product based only on price can result in long-term loss. Jezerc says the best approach is to determine which products work best for the company’s therapists. Providing a clinically efficient, high-quality mask at the beginning can improve patient satisfaction and should thus decrease costs, adds Rudolph.
• Ongoing supply initiatives Keeping patients informed about the supplies that need to be replaced is not only financially sound, it is essential for ensuring positive clinical outcomes. And follow-up programs that notify patients they are eligible for a new mask or tubing can create a consistent source of revenue.

“Through the use of follow-up programs and maintaining contact with their patients, mask and accessory reorders will help in the increase of profits as it relates to revenues,” says Nationwide Respiratory’s Pontzius.

ResMed’s Richard adds that there are a variety of ways follow-up programs can be effective, and points out they can offer additional bonuses.

“Providers are looking at various ways to increase their revenue based on follow-up programs utilizing automated call systems, postcards and e-mail notices to make sure the patients replace their masks and accessories,” Richard says.

“These programs also can be used to answer questions about their therapy, which improves patient satisfaction and documents outcomes, so [providers] are in compliance with accreditation programs.”

Such resupply programs offer a significant, yet often under-utilized, opportunity for providers.

Currently this is an untapped market, says Respironics’ Jezerc. She advises providers to create a comprehensive patient database, even if it means starting with new patients. Then, existing patients can be added as time allows.

According to the experts, the market for treating sleep-disordered breathing does not appear to be slowing down. Providers who create beneficial partnerships with payers, referral sources and manufacturers are looking at an incredible opportunity.

Utilize Manufacturer Support Programs To Increase Success

If you haven’t already, take advantage of manufacturer support to increase your success in providing products and services that treat sleep-disordered breathing. Many offer programs that address both patient and referral source education, marketing and operations.

Fisher & Paykel recently launched a new patient education program called Vigor8. “This program was designed for those who live with obstructive sleep apnea and those that care for them,” explains Christian Kiely, home care product manager. “We feel this tool is uniquely positioned to drive home care provider efficiencies, particularly in the areas of patient set-up, follow-up and education.”

Invacare offers educational programs designed to help clinicians become better sleep therapy providers by helping them understand the technology that exists today and what is appropriate for their patients, notes Bob Messenger, RRT, clinical manager of respiratory products.

“We have also put together some tools to help providers who aren’t currently in the sleep market to evaluate that market so that they have a good understanding of the requirements.”

According to Messenger, the company also can help providers develop relationships and create programs to meet the needs of “non-traditional sources” for sleep referrals. He adds that Invacare offers team selling opportunities and has clinical specialists in the field who are specifically focused on this area.

“Our goal is to help the provider become a more effective and efficient provider of sleep therapy,” he says.

Mick Farrell, vice president of marketing for ResMed, says the company provides opportunities for providers to enhance their growth, including programs for marketing to cardiovascular clinicians, primary care physician practices and diabetes educators, as well as those in emerging areas like occupational health.

The company can help improve profitability with “mask guarantee programs, follow-up programs that include free mask and accessories replacment, email services for patients using MyResMed.com and patient awareness through HealthySleep.com to help drive undiagnosed patients into the sleep lab and through to the HME provider,” he says.

ResMed also offers clinical services such as continuing education programs and clinical protocols for new areas.

“We promote superb patient care by defending the value and essential place of HME sleep therapy services through our Internet policies,” says Farrell. “This is important because better patient education of the risks of cardiovascular disease in untreated OSA and the quality-of-life improvements from effective OSA aftercare result in better long-term patient outcomes.”

In January, Respironics launched its Lasting Impressions program, which is aimed at boosting providers’ success. According to Gretchen Jezerc, the company’s director of U.S. marketing, sleep-disordered breathing, the program offers materials to help providers’ sales and marketing employees target their referral sources effectively, and it provides talking points about the benefits they can offer.

“It includes materials for helping encourage physicians, primary care physicians and cardiologists to screen and refer patients because of the compelling facts about the prevalence of OSA among other comorbidity conditions such as heart disease and diabetes,” Jezerc says.

Respironics also offers educational materials for providers as well as additional sales and marketing materials to enhance patient success and referrals. The company’s “Are You Sleeping” screening device is designed to assist providers in the initial screening of patients with sleep-disordered breathing.

Sunrise Medical offers free educational courses for both respiratory therapists and sleep technicians. The company also offers remote CPAP utilization monitoring as well as parameter adjustments.

“This allows providers to monitor CPAP adherence and adjust the prescribed pressure or settings from their office,” says Kristin Mastin, director of respiratory marketing for the company’s DeVilbiss Respiratory Products Division.

Monitoring Home Diagnostics

Currently, the vast majority of patients at risk for sleep-disordered breathing are diagnosed in a sleep lab. But going forward, this could change, some manufacturers say.

“There are already pockets of certain providers and certain insurance companies that are using [a home-based] model, placing people on an auto CPAP device and having that device do the titration from home,” explains Respironics’ Gretchen Jezerc, director of U.S. marketing, sleep-disordered breathing. She says many Veterans Administration programs are already working within this model as are some payers. Jezerc advises providers to keep an eye out to ensure they are prepared to embrace this model with the appropriate products and services that it would require.

Ron Richard, senior vice president of strategic marketing for ResMed, adds that reimbursement is going to play a vital role in this area.

“Payment for diagnostic-attended polysomnograms is decreasing across the nation [but] there is a fixed cost for these tests associated with overhead and technicians,” he notes. “At some point, only the sickest patients will be studied in overnight attended sleep centers, thus enabling the physician to spend time evaluating and getting the patients on the right therapy.”

Richard adds that if fewer patients are studied in sleep labs, then a shift in studies will occur somewhere else.

“Most likely, these studies will occur in the home,” he says. “Perhaps what is more important is the need then to provide technology that will also tie the portable study to a means of home titration so therapy can be initiated.”

Types of Sleep-Disordered Breathing Conditions

There are over 80 known sleep disorders. Common sleep disorders include:

• Circadian Rhythm Disorders
• Excessive Sleepiness
• Insomnia
• Narcolepsy
• Obstructive Sleep Apnea
• Parasomnias
• Periodic Limb Movement Disorder
• Restless Legs Syndrome

Source: National Jewish Medical and Research Center

Effects of OSA

• Unrefreshing, fragmented sleep
• Severe daytime sleepiness
• Morning headaches
• Fluctuating oxygen levels
• Increased heart rate
• Chronic elevation in daytime blood pressure
• Increased risk of stroke
• Higher rate of death due to heart disease
• Impaired glucose tolerance and insulin resistance
• Impaired concentration
• Mood changes
• Increased risk of being involved in a deadly motor vehicle accident
• Disturbed sleep of the bed partner

Source: American Academy of Sleep Medicine

Experts Interviewed:

Mick Farrell, vice president of marketing, and Ron Richard, senior vice president of strategic marketing, ResMed Corp., Poway, Calif.; Gretchen Jezerc, director of U.S. marketing, sleep-disordered breathing, Respironics, Murrysville, Pa.; Christian Kiely, home care product manager, Fisher & Paykel Healthcare, Irvine, Calif.; Kristin Mastin, director of respiratory marketing, DeVilbiss Respiratory Products Division, Sunrise Medical, Longmont, Colo.; Bob Messenger, RRT, clinical manager of respiratory products, Invacare Corp., Elyria, Ohio; Tom Pontzius, president, Nationwide Respiratory, VGM Group, Waterloo, Iowa; and Kelly Rudolph, marketing manager, Hans Rudolph, Inc., Kansas City, Mo.