Sleep apnea is on the rise in the US, as the obesity epidemic puts more people at risk of the condition. And tests for sleep apnea are big business, having helped an industry of thousands of sleep clinics sprout up across the country. But the first randomized trial on the subject adds to the growing evidence that at-home testing may be just as good as the laboratory kind, and at a cheaper cost.
That’s great news for insurers, but it might spell more pain for for-profit sleep centers around the country.
Obstructive sleep apnea is what happens when muscles in the throat relax too much, temporarily cutting off airflow during sleep. The new study, published Monday in Annals of Internal Medicine, followed nearly 400 patients with suspected sleep apnea at seven Australian academic hospitals. After screening out patients who had cardiovascular, lung, or neurological diseases, scientists randomized patients to either receive full laboratory sleep testing or home testing (though the researchers simulated the at-home test in a lab).
The researchers found that the proportion of patients diagnosed with obstructive sleep apnea was roughly equivalent across the groups.
Other studies in recent years have pointed the same direction. In-lab testing is still considered the gold standard for diagnosing sleep apnea, but American College of Physicians guidelines say that portable sleep monitors can be used if lab-based testing isn’t available, as long as the patient doesn’t have other serious illnesses. Insurance guidelines in many cases encourage home monitoring as the first-line test for sleep apnea.
And that has been putting pressure on the sleep testing industry. According to the American Academy of Sleep Medicine, the number of accredited sleep clinics peaked at the end of 2014, when there were 2,597, but has decreased slightly since then. “I think the switch from in-lab to at-home sleep testing has been particularly difficult for private sleep clinics,” said Dr. Lawrence J. Epstein, a sleep specialist at Brigham and Women’s Hospital who ran a private group of sleep centers in Massachusetts until it shut down in 2013. “If they weren’t proactive about how to manage their costs better very quickly, a lot of them ran into trouble.”
Sleep centers receive between $500 to $600 for an in-lab test; home sleep tests only bring in around $150 to $230. A 2015 economic analysis of sleep apnea testing showed that providers actually lost money on at-home sleep tests.
And the amount insurance companies will pay for any kind of sleep test — especially in-lab testing — has been going down over time, said Glenn Becker, the CEO and president of the International Institute of Sleep, a Florida-based sleep clinic group.
“Eight years ago, our fee schedule was 45 percent higher. Over the last eight years, they have totally crushed our fee schedule. They’re making it very very hard.”
“I’m not against home sleep testing,” Becker said. “But as far as [home sleep tests] are concerned, I think they should be strictly be used in cases when someone can’t get to a facility or is homebound or in emergency cases.”
While Medicaid and insurers in some parts of the country have embraced at-home testing, it’s not fully adopted. A comptroller for a sleep center group in Massachusetts reported that about two-thirds of the company’s tests were now done at home, while Becker said 90 percent of his company’s tests were still done in a lab.
Epstein considers the industry in the midst of a technological disruption — one that may not be over yet.
“I think there has been some readjustment now, but that has been one of the problems that came about with the disruption that has come from new technology — which happens in every industry, right?” Epstein said.