Medical reimbursement drives sleep therapy in a new direction

David Gergen and Marty Russo

Medical reimbursement drives sleep therapy in a new direction

One inescapable conclusion one would have to make about OSA therapy is that CPAP has dominated the scene for over 30 years. The current DME climate has reimbursement so low that it is difficult to get CPAP supplies locally in many areas. Often internet suppliers are the only option. CMS has changed its billing practices many times in the last 3 years resulting in consolidation of care providers and has really begun to affect compliance rates with CPAP.

Dr Colin Sullivan the inventor of CPAP had this to say in an interview with the National Sleep Foundation entitled Past Present and Future of CPAP

“Nasal CPAP use is now so common that I have to make myself go back to the beginning to answer this question. At the time of the first experiment, nasal CPAP as a treatment looked like a useful rescue therapy to give us time to find a surgical cure. So, yes I must say that I am indeed surprised that nasal CPAP is now the front-line therapy for sleep apnea. I recall that in the early days,patients would use the treatment as it had such a dramatic effect on their daytime function – their personal feedback was the key to CPAP’s continuing acceptance. We now know sleep apnea can cause all of the common vascular diseases, so we are asking people with less severe symptoms to use CPAP to prevent having a heart attack or stroke. However, the comfort of the systems has improved. I often ask my patients to think of CPAP like reading glasses. They are a nuisance but you can’t do without them. Unlike other therapies, they don’t have to worry about drug side effects.”

It is often reported that CPAP compliance rates have dropped significantly in mild to moderate sleep apnea patients. The use of oral appliances for this subsection of diagnosed patients makes all the difference in compliance. Often combination therapy is a good choice for patients with sleep apnea and who have an active lifestyle or simply have a very high pressure on their CPAP.

Gergens Orthodontic Lab reports a change in reimbursement by CMS that seems to indicate that Oral Appliance Therapy (OAT) has achieved the first line therapy status with Medicare. Read the article below and let me know what you think.-ed

CMS Bets on Oral Appliance Therapy a blog post Gergensortho.com

A running discussion for the last 6 years here at Gergens Orthodontic Lab has been the CPAP as Gold standard of sleep therapy vs Oral Appliance therapy debate. These discussions usually go for hours and have gone on for years. The strongest debate has been between David Gergen President of Gergens Orthodontic Lab and executive director of American Sleep and Breathing Academy (ASBA) and Randy Clare from ASBA. Back and forth compliance vs treatment efficacy. David Gergen has been back and forth to Washington working with congressman Marty Russo trying to get some traction within the federal government on this issue.

The key point of distinction of course is what drives medical care in the United States is reimbursement. The story for CPAP in the reimbursment arena since competitive bidding became an issue has slowly restricted access to care and fed a consolidation of providers. Fewer providers to provide care and the care they can afford to provide is less personal which results in lower compliance rates which results in lower reimbursement. January 1 2016 CMS cut CPAP reimbursement by 25%. Will this affect a diagnosed OSA patients ability to get great care of course it will.

On the other side of the ledger Oral Appliance therapy has not been a focus for CMS. The OAT program has been way underfunded. This has made access to oral devices for sleep apnea difficult for medicare patients. Dentists were not finding it easy to provide care for these patients because reimbursement was so low. January 1 2016 CMS raised reimbursement for OAT to $3700 in jurisdiction B (see attached EOB) If you don’t know your jurisdiction for medicare I have also added a map for your use.

I expect that this will increase access to care significantly. I feel it indicates a trend and perhaps insurers are ready to consider higher compliance rates and better return on sleep therapy dollars. After all the dental team sees the patient at minimum every six months which is a much better way to manage a lifelong condition with severe health implications.