1. Changes in Sleep Medicine Presented By: Carolyn Winter-Rosenberg Director of Coding and Compliance American Academy of Sleep Medicine

2. Conflict of Interest Disclosures Speaker: Carolyn Winter-Rosenberg Type of Potential ConflictDetails of Potential Conflict Grant/Research Support Consultant Speakers’ Bureaus Financial support Other 2. I wish to disclose the following potential conflicts of interest: 1. I do not have any potential conflicts of interest to disclose, OR 4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture: X 3. The material presented in this lecture has no relationship with any of these potential conflicts, OR 1. 2. 3.

3. Objectives Review current models of care Drivers of Change in Healthcare and Sleep Impact of recent changes How AASM is addressing these changes

4. Fee For Service (FFS) Model Services are unbundled Cost sharing for most patients Amount of payment varies with private and Government payers.

5. FFS: Advantages Rewards Productivity Transparency: Must report services performed Easy to track utilization of services over time according to the provider, provider type and service.

6. FFS: Disadvantages Volume based No measurement of quality or outcomes Fragmented care Treating illnesses rather than prevention

7. What are the Alternatives? Capitation Accountable Care Organizations and Medical Homes Bundled Payments Pay for Performance

8. Inefficiency Drives Change

10. ACA Changes Alternate payment methods – Shared savings – Financial risk adjustment Integrated delivery systems Evidence based guidelines – Quality metrics – Registries for outcomes research

11. Regulatory changes ACA created uncertainty since specialists are not specifically mentioned in the ACA law; AND: How many new patients will have coverage? Will these new patients seek sleep services? And at what rate will their payers reimburse sleep providers? Medicaid Expansion Many states have expanded their Medicaid program.

12. Sleep Medicine Realities Cuts to codes ► 25% decrease in payment for diagnostic reimbursement from 2009-2012 HSAT utilization Preauthorization

13. Increased Use of HSAT

14. Sleep Medicine At Crossroad

15. Defined Need for Sleep Services 70 million Americans complain of a sleep problem and nearly 60% have a chronic disorder Almost 10% of the total population lives in a rural area and in 28 states, 40% or more of the population is considered rural HHS has identified 6,058 primary care shortage areas, affecting a population of 60 million Americans

16. AASM Response Work with State Sleep Societies Paradigm of Care Shift Embrace home testing Increase sleep/primary care interaction Emphasis on quality markers Emphasis on the Sleep Team Quality Measures for Sleep Telemedicine Federal Initiatives Seniors Sleep AASM PAC

17. Sleep Medicine Changing Over the last few years the landscape of sleep medicine has drastically changed. It is critical for state sleep societies to become more involved with state exchanges, their state department of insurance, and local carriers.

18. AASM's State Sleep Society Management The AASM national office offers state sleep societies free management services. Benefit from the AASM’s expertise and established infrastructure; Over four decades of experience; Equipped to offer basic management services; The AASM’s free management service empowers sleep societies by allowing them to focus more time and resources on your members’ most pressing needs.

19. AASM's State Sleep Society Management Services Offered Filing of Legal/Regulatory Forms Filing of Tax Documents Dues Billing/Processing of Invoices Managing Finances Attending One Event Per Year Publishing a Semi-Annual Electronic Newsletter Recruitment of Membership Maintenance of a Membership Database Emailing of New Member Packet

20. Screening Diagnostic Evaluation The Current Paradigm Testing and Interpretation Treatment Initiation Early Management DME Long Term Management Accredited Sleep Center with Board Certified Sleep Physician (BSCMP) Primary Care Practitioner or Non-Sleep Specialist Only performed by accredited sleep practice (board certified sleep physician and sleep team) Performed by accredited sleep practice and/or primary care provider/non-sleep specialist

21. Screening Diagnostic Evaluation How Does the ACA Change the Paradigm? Testing Treatment Initiation Early Management DME Long Term Management Standards of Practice (CPGs) Accredited Sleep Center with Board Certified Sleep Physician (BSCMP) Primary Care Practitioner or Non- Sleep Specialist Only performed by accredited sleep practice (board certified sleep physician and sleep team) Performed by accredited sleep practice and/or primary care provider/non-sleep specialist Quality Measures Interpretation

22. The Sleep Team BCSMP APRN Sleep Technologists Office Staff Center Managers Physicians Assistants

23. AASM Quality Measures Under the leadership of Dr. Tim Morgenthaler, the AASM charged a task force with multiple subgroups to determine outcomes metrics Adult OSA Pediatric OSA Insomnia RLS Narcolepsy Accepted papers (6) published in March in JCSM

24. AASM Quality Measures Adult OSA Improve disease detection and categorization Assessing quality of life Counseling on weight management Counseling on hypertension Work of the task force included delineating outcomes can be captured in EHR need to approach EHR providers (in process)

25. Telemedicine

26. Telemedicine - Why Sleep? BCSMPs: ~ 7,500 Persons in US with: OSA: ~ 18,000,000 RLS: ~ 30,000,000 Insomnia: ~ 30,000,000 Ratio: 10,400 : 1

28. Telemedicine - Why Now? Emphasis on Patient Management Influx of New Patients Reaching Rural Populations Patient Directed Care Collaborative Care (e.g., ACOs)

29. Telemedicine – AASM AASM Telehealth Protocol Task Force The protocol will provide guidance on how to conduct: E-Visits, the use of store-and-forward technology, maintaining quality care in the treatment of telehealth patients.

30. Telemedicine – Sleep Technologist Responsibilities Patient Education According to the Physician’s Care Plan; In-Center Testing for the Complex Patient; HSAT Program Coordination and Patient Set-Up; Facilitate PAP Set-Up And Long Term Management

31. Training/Certification New responsibilities require more training and possibly new certification opportunities: Addressing the needs of more complex patients (ASV and bi-level titrations) Familiarity with HSAT and telemedicine DME set up and education Consider CAAHEP programs

32. Education and Credentialing Requirements for the Technologist AAST recently adopted a position addressing individuals performing sleep testing procedures and patient care service

33. Future Success for Sleep Requires: A highly trained sleep team under the direction of a BCSMP Collaborative relationships with primary care Monitoring of outcomes and focus on quality Incorporation of new technologies to reach more patients and provide them with better care

34. Advocacy

35. Seniors Sleep

36. Welcome to Medicare Newly Enrolled Medicare Beneficiaries: Welcome to Medicare Visit During First 12 Months of Medicare The Welcome to Medicare visit is the covered wellness service during that time period Once in a lifetime benefit

37. Expand Medicare Benefit Legislation that will: Expand the Welcome to Medicare benefit to include a sleep apnea screening to identify individuals with a high pre-test probability of OSA. The purpose is to increase preventive sleep care for individuals entering the Medicare program. Seniors Sleep

38. Why Add a Sleep Question to the Program? Obstructive sleep apnea (OSA): By the Numbers Who has OSA 20-30% of Medicare beneficiaries have OSA. 30% of obese adults have OSA Comorbid Conditions of OSA 75% of adults with type 2 diabetes have OSA 30-40% of adults with high blood pressure also have OSA OSA increases the risk of ischemic stroke by 3 times in men

39. Obstructive sleep apnea (OSA): By the Numbers Costs $3.4 billion: the additional annual medical costs of untreated moderate-to-severe OSA in middle-aged adults Benefits of OSA Treatment Reduces the risk of heart attacks by 49% Reduces the risk of stroke by 31% Relieves sleep apnea symptoms, such as excessive daytime sleepiness

40. Identify Beneficiaries with Moderate-to- Severe OSA The screening will be a simple and clinically validated questionnaire, such as STOP-Bang or Berlin. Adding OSA screening to the Welcome to Medicare benefit will promote wellness, identify at-risk patients, and remove barriers for newly enrolled Medicare beneficiaries to receive preventive sleep care. Seniors Sleep

41. Reduce Federal Healthcare Costs Seniors Sleep

42. Seniors Sleep – Next Steps AASM staff meeting with the new members of the 114 th Congress; Obtain additional cosponsors in the House and lead sponsors in the Senate; and Encourage members to contact their Congressional representatives to inform them of sleep illnesses and the Senior Sleep bill.

43. AASM PAC

44. Contact Carolyn Winter-Rosenberg, Director of Coding and Compliance, for more information: Cwinter-rosenberg@aasmnet.org Health policy issues: policy@aasmnet.orgpolicy@aasmnet.org Medical coding issues: coding@aasmnet.org