Health Reform Hits Sleep: Speakers encourage specialists to get involved in initiatives

Minneapolis, Minn.—As in all of medicine, the future of sleep medicine will be defined in part by changes evolving under the health care reform law and by the need to slow the unsustainable cost of medical care, experts said here last month at a session at SLEEP 2011, the 25th Annual Meeting of the Associated Professional Sleep Societies,

Patrick Strollo, MD, medical director of the University of Pittsburgh Medical Center Sleep Medicine Center and past president of the American Academy of Sleep Medicine (AASM), outlined steps being taken by the academy to meet the challenges of the changing health care landscape. One step is a soon-to-be published white paper titled “The Future of Sleep Medicine Initiative.” The session was, in part, a forum to gather input from audience members on issues to be included in the white paper.

Sam Fleishman, MD, medical director at Cape Fear Valley Sleep Center and Behavioral Health in Fayetteville, N.C., and president-elect of AASM, gave a brief overview on the tools that the working group identified as providing value to the acute and chronic management of patients with sleep disorders. These tools include actigraphy, portable monitoring, transcutaneous C02 monitoring, nasal endoscopy, neurocognitive testing, ambulatory blood pressure monitoring, high density electroencephalography (EEG) analysis, phenotyping obstructive sleep apnea (OSA) and circadian rhythm testing.

Clete Kushida, MD, PhD, professor of psychiatry and behavioral science at the Sleep Center in Stanford Hospital and Clinics in Stanford, Calif., said an of c interest involves intermediate measures and biomarkers that provide some assessment of cardiovascular risk for OSA patients. Among the reasons to look at outcomes measures, he said, is to help provide information on the pathophysiological stresses relevant to sleep-disordered breathing as well as to look at the heterogeneity among patients who have sleep-disordered breathing and different cardiovascular profiles.

New Care Models

Michael Coppola, MD, associate clinical professor of medicine at Tufts University School of Medicine in Boston, talked about two structural changes happening in clinical practice. One is the patient-centered medical home (PCMH), a model of care provided by physician practices and designed to strengthen the physician/patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care. The second includes accountable care organizations (ACOs), which are defined by the Centers for Medicare and Medicaid Services as organizations of health care providers that agree to be accountable for quality, cost and overall care of Medicare beneficiaries.

Both of these organizations reflect the evolving nature of medical practice, which is increasingly integrated and provides a more multidisciplinary approach to taking care of patients. From 2009-2010, more than 7,600 clinicians at more than 1,500 practices nationwide earned PCMH recognition by the National Committee for Quality Assurance, Dr. Coppola noted.

According to Dr. Coppola, specialists will likely become involved in PCMHs by assuming what he called a “neighbor role” (PCMH-N). This arrangement can take the form of a pre-consultation exchange with the PCMH in which the sleep specialist provides his or her expertise on the management of a patient, with no further involvement; a formal consultation with the PCMH in which the sleep specialist recommends diagnostic and treatment measures and co-manages the patient; or a relationship in which the sleep specialist acts as co-manager, diagnosing and treating a patient and then referring the patient for regular follow-up with a primary care physician while continuing to see the patient.

Dr. Coppola also encouraged sleep specialists to participate in ACOs, “as opposed to being a downstream vendor in the ACOs that are already in existence or developing in your area.” He cited examples of organizations that have adopted an ACO model, including Advocate Health Care, Geisinger Health System, Kaiser Permanente, Harvard Vanguard Medical Associates and Blue Cross Blue Shield of Massachusetts, which he said has converted over 25 percent of its commercial business to an ACO model.

Involvement in an ACO, he added, would allow sleep specialists to participate in the higher value delivered by an ACO through quality improvement of care with shared savings. However, he also pointed out the challenges to adapting to this new model of care. In this type of organization, the sleep specialist would no longer be an independent provider delivering fragmented care to a patient, but would instead act as an interdependent team provider who coordinates the care of a specific population, such as patients with obstructive sleep apnea. Payment would change from the current system of reward for volume to reward for value. According to Dr. Coppola, dollars spent on reducing the impact of negative medical conditions, such as diabetes, high blood pressure and heart diseases, would be valued the most.

“We need to get involved now,” he said, “and proactively redefine the field [of sleep medicine] in the next three years.”