"please keep me updated about oximeters "
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Ruminations on Home Testing's Emergence in the Market
excerpting from a private conversation i had with a friend (on a no-names basis to protect the identity of the innocent ;-)
"I support the HST as an additional tool. I also see it as an easier way to get more people diagnosed. If the insurance companies use it as a replacement to the PSG instead of an additional tool I see more problems on the horizon for sleep. You have to see that this system is about what is best for the insurance companies, and has very little to do with pt care. I support the HST, but I am not so sure about the Watermark program. If this program were to catch on I believe it would be a step backwards in pt care as far as sleep is concerned. Everything would be done remotely via the primary care physician and Watermark. Under their system not once in the process would the pt talk to an educated sleep anything. I believe that this system would give the DMEs more power while crushing all sleep labs other than hospital based. I understand that the HST may enable more people to get diagnosed. That is huge, but what will be the sacrifice? I wish I knew. What I do know is that it will not fall on Watermark, the physician, or the insurance company. That only leaves one player in this game to take the hit. The patient.
The key to getting more people diagnosed and treated is lowering the price of the REQUIRED test. Not coming up with cheaper versions that only encompass one sleep disorder. I know that 85% of all sleep patients are inflcted with simple apnea. 40% of those have other underlying sleep problems. If the HST and auto titration become gold standard a huge number of people may never get the treatment they need.
It is all about the pts. If you take care of them emotionally, mentally, and physically then they will take care of you financially. There are no shortcuts when we are gambling with lives. "
The key to getting more people diagnosed and treated is lowering the price of the REQUIRED test. Not coming up with cheaper versions that only encompass one sleep disorder. I know that 85% of all sleep patients are inflcted with simple apnea. 40% of those have other underlying sleep problems. If the HST and auto titration become gold standard a huge number of people may never get the treatment they need.
It is all about the pts. If you take care of them emotionally, mentally, and physically then they will take care of you financially. There are no shortcuts when we are gambling with lives. "
Views: 114
Replies to This Discussion
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Permalink Reply by Mike on
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fyi -- i do not necessarily subscribe to these views myself. they are not mine. i am just putting it "out there" for comment/ discussion because it's worth having the dialogue about this critical issue in health care. i'd welcome comments from Watermark and other Home Sleep Test providers.
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Permalink Reply by Banyon on
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My opinion is not too far from your friend's opinions. I do believe a rapid expansion of home testing will do the most good for the most people in the quickest time for the least cost. The target is the 90% or so of sufferers who have sleep apnea without any other sleep problems that would need in-lab sleep studies to diagnose.
But you friend is correct, we don't want to forget the other 10%. We do need to find ways to diagnose the 10% but without slowing down the rapid expansion of home studies and harming the 90%.
Your friend says, "There are no shortcuts when we are gambling with lives."
That's a common homily, but delaying the shortcut of home studies is gambling with the lifes of the 90% that could be properly diagnosed.
Your friend also says, "Under their system not once in the process would the pt talk to an educated sleep anything."
I see the solution here as what we have called the "diabetes model". The health industry provides education - classroom setting would be most efficient- and the patient learns; procures equipment that provides immediate feedback on the efficacy of his therapy; and takes control of his therapy.
The market, however badly restrained by regulation, is still finding ways (home testing) to diagnose more people, more quickly, and at lower cost. That is encouraging when so much of the news is discouraging.
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Permalink Reply by Andrew on
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Home Sleep Testing certainly has it's place in the sleep arena. The BIG question is, Who is interpreting the results? Full polysomnograph is and always will be the gold standard in the industry. There are other sleeping disorders besides Sleep Apnea. It is a very good diagnostic tool for physicians to diagnose and treat their patients. That being said, I believe that it is very important that the person reviewing the results are competent Sleep physicians. Primary care physicians might be able to treat and manage OSA in their patient population. I just think of myself and, Who I would want to treat my OSA. I got it bad baby and since being treated....LIFE IS GOOD!
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Permalink Reply by RockRpsgt on
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I think that the 10% stat placed on people with sleep disorders other than apnea is a little low. That number might cover the apneas as far as OSA and CSA. I think that as sleep knowledge progresses we are going to see a rise in other sleep disorders.
Also "simple OSA" is just a term. Rarely is OSA ever simple as it carries very personalized problems with each individual case. For this reason I believe that 90% is high for the market audience originally targeted. If you calculate the ever growing number of people with cardiac, respiratory, or other medical ailments the number of patients eligible for an HST is growing to drop. Not to mention that the cost for sleep treatment for some of these pts is going to go up when you add the cost of an HST to the PSG, and titration.
I do not have anything against the IDEA of HSTs. I actually have high hopes for the Watermark system. Being able to record sleep is a huge step forward. What I do have a problem against is the monitoring program that they have set up. Right now most sleep labs have trouble with turning around the results when they have all resources on sight. Can you imagine how long this process might take? You pick up the test. Wear the machine for a night or 2. Return the test. Your PCP sends it to a company like Watermark. They score and interpret the test and send it back. Seems like a long way to go to me. Where are they sending the test by the way? What is to say that it is not a completely different country. How many test will have to be scored a day to make it profitable?
There are many things that can be done to drop the price of sleep studies. Most have not even been attempted yet. The AASM and CMS both agree that an AHI>5 is treatable. Let's start treating people if they are above this number. This would decrease the number of 2nd studies by almost two thirds. The PSG is and has been made as a portable machine. These same machines could be used to perform the studies in home. This would drop the cost to the test provider making it easier for them to lower the price. There are options that have not been considered.
My last argument is simple. With the current plans for the HST "false positives" will go up. I predict that they will rise almost 25%.
Please keep in mind that these opinions are my own. I view the HST as another wrench in my toolbox.
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Rock Hinkle said, "Where are they sending the test by the way? What is to say that it is not a completely different country."
That is the first thing that came to my mind.
It is just as easy to email the files to India as across the hall. They should be scored in India or whatever country has the best comparative advantage of quality and cost. No use tying up our expensive resources doing this.
Scoring those tests all day long must be boring. Let a low-wage country give the jobs to people who will really appreciate them and improve their lives with the wages.
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I work for a home sleep testing provider and know that Watermark does have an option to have studies read by boarded sleep physicians. It is all web based, so there is no delay in sending the studies from place to place as mentioned above. Primary care docs can read their own if they want to under the Watermark model, and it will be up to the insurers to control who reads the studies to establish the rules.There are other providers such as Sleep Solutions that encourage PCPs to read their own studies and make money doing so.
The risk of "false positives" on HST is actually quite low. Data shows that there are more false negatives, which is why it is only used to rule in OSA and if results are negative further evaluation by a sleep specialist or a lab study are recommended.
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Permalink Reply by Mary Z on
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Exactly what are we talking about with autotitration? Would it be a wide range of numbers and the machine counted on to find the pressure that got apneas <5? When I had a pressure range on auto, the machine rarely went up to the max pressure even though I was having significant apnea events.
Is there a place for the company reps in this -perhaps giving inservices on the machine. A little self adjusting could be included, sort of like an insulin sliding scale though not day to day, dose to dose changes, a period of one week, two, four? Let these reps have more contact with their patients. I know they do come to AWAKE Meetings for those of you with more organized programs.
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Scoring those tests all day long must be boring. Let a low-wage country give the jobs to people who will really appreciate them and improve their lives with the wages.
How does this help anything Banyon? Growing up in a union family I can not support shipping more jobs over seas. It seams to me that it does not matter who it hurts as long as things are cheaper. if this happens remember "you get what you pay for".
Sending all of those jobs to Mexico has really boosted our economy. For the record I really appreciate my job.
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Permalink Reply by 99 on
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this is short sighted thinking
there should be laws about trasfering any data across any boarders
banks, hospitals, insurances,etc
Banyon said:Rock Hinkle said, "Where are they sending the test by the way? What is to say that it is not a completely different country."
That is the first thing that came to my mind.
It is just as easy to email the files to India as across the hall. They should be scored in India or whatever country has the best comparative advantage of quality and cost. No use tying up our expensive resources doing this.
Scoring those tests all day long must be boring. Let a low-wage country give the jobs to people who will really appreciate them and improve their lives with the wages.
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There is a quite clear direct correlation between the relative wealth of a country and the amount of international trade it conducts. This is both true historically and true in today's snapshot as the wealthiest countries are those who have had the most international trade for the longest time.
In the eighties I visited a production plant in which there was one huge room with 900 women working at sewing machines. Today those jobs are gone to Asia and Latin America because the clothes are cheaper and American consumers like lower prices. Also, American women don't want to sit at sewing machines 40 hours per week making your clothes. They have moved on to better jobs.
Buy your clothes from Asia and pay American women to provide your healthcare, legal services and high-tech batteries. Women like these jobs better than sewing and the jobs also pay better.
As far as "you get what you pay for", each person should make his own decisions on what he will pay for.
I have used two Indian (East) MDs and one Chinese MD. They both met my quality requirements. I voluntarily paid for them.
If people that support Unions want to purchase "Made in USA" only, that is fine with me and I support their freedom to do so. But I also support every individual's right to buy from foreign suppliers if they so choose.
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There is a difference between scoring sleep studies and sewing clothes. As well there is a huge difference between buying foriegn made products and supporting the shipping of good jobs over seas. As far as I know there are many men and woman who still would like to have the opportunity to score the studies in question. I would gather that their are quite a few unemployed people that would love the opportunity to sew clothes.
I am sure that both of your docs were perfectly qualified. I would also bet that they were american citizens. Now if you want to put things into perspective let your next doc be in India. You entire appointment could be done over an internet cam.
I wonder how things would change if we started talking about sending Banyons job overseas. How about the jobs of your kids, grandkids.
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The two best jobs I ever had and the great career I enjoyed were ended by industry moving to Asia and Latin America. I do sometimes reminisce about the times we had, but I would no more change that history than I would wish computers would go away. Most of my former colleagues feel the same.
The consumers of the products we produced are able to buy in even more variety and higher quality at lower cost today. That leaves them happy and with more money in their pockets.
Some of us do have principles that go beyond only thinking of our situation in life.
My kids are preparing themselves to compete in a global market and are excited about it.
I know you are a busy guy, but you should plan some vacation trips overseas to see what is going on outside America. Start saving your money to visit India and China.
So would you deny individuals their rights to buy cars from Korea, electronics from China, clothes from Vietnam, lumber from Canada, caviar from Russia and wine from Italy?
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