Lower Reimbursement, Greater Regulation Threaten to Shutter Sleep Centers

This model of sleep testing raises many questions about the efficacy of the treatment offered through a PCP office. Who prescribes the CPAP machine for patients diagnosed with sleep apnea—the PCP or the interpreting physician? Who in the office has the necessary knowledge, experience and time to train patients diagnosed with sleep apnea on CPAP machines? Who troubleshoots for patients having equipment problems? What is the impact on compliance, already low for CPAP use, in cases where patients do not have access to a qualified sleep professional? Ultimately, the question is whether or not a PCP can treat sleep apnea effectively.

An Australian study published in March of this year compared PCP management of sleep apnea to that of sleep centers (JAMA. 2013;309:997-1004). Re-

searchers concluded that patients treated by a PCP experienced outcomes relatively equivalent to those seen in sleep center patients. However, a closer look at the participating PCP offices revealed that their nurse practitioners had received intensive training in testing for and treating sleep disorders. In fact, one nurse had 20 years of experience in sleep medicine. Would typical PCP offices that do not employ staff with this level of expertise still be able to deliver results that approach those achieved in a sleep center?

The Burden of Increased Regulation

Another blow, new regulations, comes with a cost for compliance. There are three types of regulations affecting centers’ bottom lines:

• Accreditation. Previously, sleep centers did not have to be accredited, but most states now require accreditation from either The Joint Commission or the American Academy of Sleep Medicine. Accreditation will most likely be mandatory in all states within the year.
• Credentialed staff. Professionals employed in sleep centers are now required to demonstrate competencies in diagnostics and treatments through exams, CE credits and peer review.
• Proof of effectiveness. Centers must demonstrate that they are effective through patient compliance and improvement data.

Kathryn Hansen, executive director of the Kentucky Sleep Society and a sleep center management consultant, says that these changes should come as no surprise. The use of sleep testing has become almost epidemic as more and more physicians, nurse practitioners and physician assistants recognize the effects of sleep disorders on overall health. “While the increased recognition of sleep dysfunction is good,” she said, “we cannot continue to incur more costs and increase availability of our services without more regulation as we have seen in other specialties, including cardiology, pulmonology and home health care.”