In the last year the challenges facing the field of sleep medicine have been well-documented.1,2,3 In some regions payor policies have hastened the implementation of preauthorization and utilization management for diagnostic sleep testing, which has led to a proliferation of out of center sleep testing (OCST) followed by auto-titrating positive airway pressure (APAP) for patients with suspected obstructive sleep apnea (OSA). Attempts at cost containment have at times heavily incented over-reaching application of the OCST-APAP model of care in a manner not supported by current evidence, such as denial of PSG for patients with a non-diagnostic OCST, application of OCST to patients at lower risk for milder forms of OSA, or use of APAP in patient with forms of central sleep apnea. Such practices often leave patients with suboptimal outcomes and separated from sleep specialty care. Many existing sleep centers have struggled to adapt to these economic realities, the growth of new sleep centers has slowed, and it has become more difficult to recruit young physicians to specialize in sleep medicine.
These changes have been occurring against the backdrop of national health care reform, which has been driven primarily by the ongoing implementation of the Patient Protection and Affordable Care Act (ACA). With the goal of ensuring quality, affordable health care and health insurance coverage for all Americans, the ACA is gradually transforming the practice of medicine in America. This transformation is building on the concept of the patient centered medical home (PCMH), a model that relies on primary care practices to provide comprehensive, patient-centered, coordinated, accessible and high quality care for the large majority of a patient's physical and mental health needs. In support of this model, the ACA contains key provisions that bolster primary care, including funding for primary care training and increased Medicare and Medicaid reimbursements for primary care services.4
The ACA also incentivizes the development of accountable care organizations (ACOs), which are groups of doctors, hospitals, and other health care providers that unite to provide Medicare patients with high quality, coordinated care. The ACA provides funding for the Medicare Shared Savings Program, which enables ACOs that meet certain quality standards to share in any savings they achieve for the Medicare program. Currently an estimated 18.2 million lives are covered by more than 600 public and private ACOs, most of which are either physician-led or hospital-sponsored entities.5,6 With the ACA accelerating care consolidation, it is no surprise that many physician practices are being bought by hospitals and an increased number of hospital mergers are occurring.7,8
A frequent focus of both the PCMH and ACOs is payment reform. The traditional fee-for-service payment model, which rewards consumption and utilization rather than quality and value, is incompatible with the prevailing emphasis on cost-effectiveness. However, there is growing recognition that the fiscal impact of the PCMH is limited, as primary care services account for only six percent of total health care spending; the medical home will succeed only if it is located in a “Patient-Centered Medical Neighborhood,” where specialists provide quality, coordinated care, particularly for patients with complex and chronic diseases.9,10 Coordination of care between and among specialists and primary care providers, especially for patients with chronic or complex diseases, will be a key to effective, efficient, and affordable care. Therefore, the National Committee for Quality Assurance (NCQA) now offers Patient-Centered Specialty Practice Recognition to promote “streamlined referral processes and care coordination with referring clinicians, timely patient and caregiver-focused care management and continuous clinical quality improvement.”11 Furthermore, the CMS Innovation Center is exploring the feasibility of a bundled payment model to include care managed by specialist practitioners. Global payment systems that promote high-value care, eliminate low-value services, and improve care coordination and integration will require changes to the traditional models of specialty care delivery.12
After evaluating the impact that all of these changes are having on the sleep field and the care of patient with sleep diseases, the American Academy of Sleep Medicine (AASM) Board of Directors affirmed that the best sleep care paradigm promotes comprehensive, integrated care management for patients with sleep diseases through collaborative relationships with primary care providers and non-sleep specialists. This care paradigm was discussed during a summit of sleep medicine stakeholders and thought leaders who gathered in Chicago last November, and subsequently with attendees of the AASM's Sleep Medicine Trends course in Phoenix this past February. A detailed report from the summit is expected to be submitted for publication later this year. The paradigm of care promotes the Institute for Healthcare Improvement's Triple Aim for optimizing health system performance by improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care.13
The integrated care paradigm for sleep medicine highlights the expertise of board certified sleep medicine physicians and the value realized when patient management is conducted at an AASM accredited sleep center.14 Specifically, the development of care standards, evaluation and diagnostic testing of patients with comorbid conditions, interpretation of all polysomnograms and OCST studies, provision of durable medical equipment (DME), and monitoring of outcomes of therapy are facets of patient management that should fall under the purview of sleep specialists and accredited centers. Coordination and delivery of ongoing patient care may be managed either by sleep specialists, primary care providers, or non-sleep specialists, depending on the terms of well-aligned and defined collaborative relationships.
To support this care paradigm for sleep medicine, the AASM recently made a significant investment in the establishment of the Welltrinsic Sleep Network (www.welltrinsic.com), a national network connecting board certified sleep medicine physicians and accredited sleep centers to deliver high-quality, integrated care. Recognizing that the continued consolidation of patient care systems and the creation of new physician payment models require a unified specialty on a national scale, the AASM Board of Directors determined that the formation and success of this network is essential for the long-term viability of the sleep medicine specialty and to ensure patient access to sleep specialty care in the changing landscape of the U.S. health care system.
As an independent corporation, Welltrinsic will negotiate contracts for sleep medicine services with insurance companies, sleep benefit management groups, ACOs, managed care groups, health care systems and large employers to ensure that patients receive high-quality, cost-effective care from network members. Through a partnership with Somnoware, the network also will equip members with a unified data platform that enables sleep specialists to streamline patient management while collecting and reporting outcome data, paving the way for a successful transition from a fee-for-service payment model to value-based care. In addition, the network also will provide other innovative services, such as an online platform to assist in cost-effective delivery of cognitive behavioral therapy for insomnia (CBT-I), and a telehealth system to keep members on the cutting edge of sleep medicine. Welltrinsic Sleep Network will also offer a variety of practice management consultative services for sleep physicians and practices.
Information about the Welltrinsic Sleep Network will be communicated to sleep professionals over the coming months, and the network's website (www.welltrinsic.com) is a primary source for membership and further details.
As the U.S. health care system continues to evolve, the AASM is committed to advancing sleep medicine. One important way to do this is by helping to ensure that the value of care provided by sleep specialists is enhanced and accessible to all patients. Through a model of care that promotes collaborative relationships with primary care and other specialty providers and a network that unifies sleep specialists across the country, board certified sleep medicine physicians and accredited sleep centers will continue to lead the way in improving sleep health and providing high quality patient centered care.