Fifteen Patients Who Can Be Helped by Medicare: Insurance Policy Changes in the Coverage of CPAP Therapy for Obstructive Sleep Apnea.

Insurance coverage policies define the diagnostic criteria and adherence requirements for patients to qualify for initial and ongoing therapy with continuous positive airway pressure (CPAP) treatment, the most complete therapy for obstructive sleep apnea. Unfortunately, a number of patients who use CPAP and benefit from treatment fail to meet these requirements. We present 15 patients who fail to meet Centers for Medicare and Medicaid Services' (CMS) criteria, highlighting policies that do not support patient care. Finally, we review expert panel recommendations to improve CMS policies, and we suggest ways that physicians can better support CPAP access within the current regulatory restrictions.

Optimal NIV Medicare Access Promotion: Patients With Central Sleep Apnea: A Technical Expert Panel Report From the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society.

This document summarizes suggestions of the central sleep apnea (CSA) Technical Expert Panel working group. This paper shares our vision for bringing the right device to the right patient at the right time. For patients with CSA, current coverage criteria do not align with guideline treatment recommendations. For example, CPAP and oxygen therapy are recommended but not covered for CSA. On the other hand, bilevel positive airway pressure (BPAP) without a backup rate may be a covered therapy for OSA, but it may worsen CSA. Narrow coverage criteria that require near elimination of obstructive breathing events on CPAP or BPAP in the spontaneous mode, even if at poorly tolerated pressure levels, may preclude therapy with BPAP with backup rate or adaptive servoventilation, even when those devices provide demonstrably better therapy. CSA is a dynamic disorder that may require different treatments over time, sometimes switching from one device to another; an example is switching from BPAP with backup rate to an adaptive servoventilation with automatic end-expiratory pressure adjustments, which may not be covered. To address these challenges, we suggest several changes to the coverage determinations, including: (1) a single simplified initial and continuing coverage definition of CSA that aligns with OSA; (2) removal of hypoventilation terminology from coverage criteria for CSA; (3) all effective therapies for CSA should be covered, including oxygen and all PAP devices with or without backup rates or servo-mechanisms; and (4) patients shown to have a suboptimal response to one PAP device should be allowed to add oxygen or change to another PAP device with different capabilities if shown to be effective with testing.

MACRA and the future of value-based care.

The passage of Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015 (MACRA) heralded a fundamental shift from volume-based to value-based payment for health care services in the United States. Beginning in 2019, neurologists will participate in 1 of 2 Medicare pathways: the Merit-Based Incentive Payment System or Alternative Payment Models. Both options represent an important change from the current fee-for-service payment models, and neurologists will need to be prepared well in advance of the MACRA launch. This article reviews the background, structure, uncertainties, and implications of MACRA on the practice of neurology, with recommendations for preparation.

Is Physician Work in Procedure and Test Codes More Highly Valued Than That in Evaluation and Management Codes?

OBJECTIVES: To determine whether the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule confers higher value for physician work in procedure and test codes than in Evaluation and Management (E/M) codes. BACKGROUND: Medicare Payment Advisory Commission previously demonstrated that time for medical services is the dominant element in valuing physician work in the CMS Physician Fee Schedule. In contrast, a more recent analysis suggests that more relative value units (RVUs) per unit time are issued for work in procedure codes than in E/M codes. Both prior analyses had important limitations for evaluating a possible systematic differential valuation of medical services. METHODS: Data regarding RVUs, physician work times (minutes), and claims were obtained for all active level I Current Procedural Terminology (CPT) codes from 2011 CMS files. Linear regression was used to assess the associations of work time components and CPT category with work RVUs, including a model that weighted codes by the number of claims. RESULTS: Included in the analysis were 6522 CPT codes (87 E/M codes, 6435 procedure/test codes). Compared with E/M codes, procedure/test codes did not have a significant difference in work RVUs adjusting for time (-0.631; 95% confidence interval, -1.427 to 0.166). The analysis also did not indicate a work RVU advantage specifically for Surgical CPT codes compared with E/M adjusting for time (-0.760; 95% confidence interval, -1.560 to 0.040). This pattern was not altered after weighting codes by the number of claims, indicating that an increase in RVUs per minute was not concentrated in a small number of highly utilized procedure codes. CONCLUSIONS: We did not find evidence of a systematic higher valuation of physician work in procedure/test codes than in E/M codes in the CMS RVU system.

Sleep medicine practice adaptations.

Sleep medicine has been a rapidly growing field for the last 15 years. Medicare and private payer insurers continually examine testing and treatment closely to monitor potential fraudulent practices. In this article, we explore responses by some practitioners to adapt to policy changes. In addition, we offer advice to clinicians on how to review their customary office procedures and involve patients in overcoming administrative obstacles to the diagnostic and therapeutic course agreed upon by a doctor and patient.

Treating sleep disorders in neurology practice.

Neurologists treat many people with unrecognized sleep disorders. This review recommends that new and established patients routinely complete standard sleep questionnaires as an aid to clinical history. Because there is high prevalence of treatable primary sleep disorders among neurologic patients, routine diagnostic sleep testing is indicated for patients with stroke, neuromuscular disease, dementia, REM behavioral disorder, atypical or treatment-refractory insomnia, and chronic and unexplained fatigue or sleepiness. As local and national regulatory momentum favors increasing care coordination and integration, neurologists should develop a clinical pathway to diagnose and treat sleep disorders within the practice or through a collegial expert network.

Physician work intensity among medical specialties: emerging evidence on its magnitude and composition.

BACKGROUND: Similarities and differences in physician work intensity among specialties are poorly understood but have implications for quality of care, patient safety, practice organization and management, and payment. OBJECTIVE: To determine the magnitude and important dimensions of physician work intensity for 4 specialties. RESEARCH DESIGN: Cross-sectional assessment of work intensity associated with actual patient care in the examination room or operating room. SUBJECTS: A convenience sample of 45 family physicians, 20 general internists, 22 neurologists, and 21 surgeons, located in Kansas, Kentucky, Maryland, Ohio, and Virginia. MEASURES: Work intensity measures included the National Aeronautics and Space Administration-Task Load Index (NASA-TLX), Subjective Work Assessment Technique (SWAT), and Multiple Resource Questionnaire. Stress was measured by the Dundee Stress State Questionnaire. RESULTS: Physicians reported similar magnitude of work intensity on the NASA-TLX and Multiple Resource Questionnaire. On the SWAT, general internists reported work intensity similar to surgeons but significantly lower than family physicians and neurologists (P=0.035). Surgeons reported significantly higher levels of task engagement on the stress measure than the other specialties (P=0.019), significantly higher intensity on physical demand (P < 0.001), and significantly lower intensity on the performance dimensions of the NASA-TLX than the other specialties (P=0.003). Surgeons reported the lowest intensity for temporal demand of all specialties, being significantly lower than either family physicians or neurologists (P=0.014). Family physicians reported the highest intensity on the time dimension of the SWAT, being significantly higher than either general internists or surgeons (P=0.008). CONCLUSIONS: Level of physician work intensity seems to be similar among specialties.

Clinical work intensity among physician specialties: how might we assess it? What do we find?

BACKGROUND: The level of work intensity associated with patient encounters has implications for quality of care, patient safety, practice management, and reimbursement. The utility of available instruments for clinical work intensity assessment is unknown. OBJECTIVE: We assessed, in the clinical setting, the performance of existing measures of work intensity that are valid for nonclinical contexts. RESEARCH DESIGN: A cross-sectional, multimeasure design involving work intensity assessments for the last patient encounter and for an entire half-day clinic session. SUBJECTS: A convenience sample of 14 providers from the following 4 specialties: family medicine, general internal medicine, neurology, and surgery. MEASURES: Perceived clinical work intensity was measured by the following 3 instruments: National Aeronautic and Space Administration-Task Load Index, Subjective Workload Assessment Technique, and Multiple Resources Questionnaire; stress was measured by the Dundee Stress State Questionnaire. Convergent validity was assessed by correlation among the instruments. RESULTS: For the last patient encounter, there was a moderate to high correlation between the work intensity instruments' scores (Pearson's r ranged from 0.41 to 0.73) and low to moderate correlation with the distress subscale of the Dundee Stress State Questionnaire (Pearson's r ranged from -0.11 to 0.46), reflecting their stress dimension. Provider personality was associated with reported levels of work intensity and stress. Similar results were obtained when the entire clinic session was the unit of reference. CONCLUSION: Existing measures of work intensity and stress appear to be valid for use in the clinical setting to generate evidence on perceived intensity and stress experienced by providers in the performance of medical services.

Temporal and subjective work demands in office-based patient care: an exploration of the dimensions of physician work intensity.

BACKGROUND: Physician work intensity (WI) during office-based patient care affects quality of care and patient safety as well as physician job-satisfaction and reimbursement. Existing, brief work intensity measures have been used in physician studies, but their validity in clinical settings has not been established. OBJECTIVES: Document and describe subjective and temporal WI dimensions for physicians in office-based clinical settings. Examine these in relation to the measurement procedures and dimensions of the SWAT and NASA-TLX intensity measures. DESIGN: A focused ethnographic study using interviews and direct observations. PARTICIPANTS: Five family physicians, 5 general internists, 5 neurologists, and 4 surgeons. METHODS: Through interviews, each physician was asked to describe low and high intensity work responsibilities, patients, and events. To document time and task allotments, physicians were observed during a routine workday. Notes and transcripts were analyzed using the editing method in which categories are obtained from the data. RESULTS: WI factors identified by physicians matched dimensions assessed by standard, generic instruments of work intensity. Physicians also reported WI factors outside of the direct patient encounter. Across specialties, physician time spent in direct contact with patients averaged 61% for office-based services. CONCLUSIONS: Brief work intensity measures such as the SWAT and NASA-TLX can be used to assess WI in the office-based clinical setting. However, because these measures define the physician work "task" in terms of effort in the presence of the patient (ie, intraservice time), substantial physician effort dedicated to pre- and postservice activities is not captured.

Obstructive sleep apnea syndrome: are we missing an at-risk population?

STUDY OBJECTIVES: While age and body-mass index (BMI) are well-established risk factors for obstructive sleep apnea syndrome (OSAS), this disorder occurs across a wide spectrum of ages and weights. Preconceptions regarding "classic" patients with OSAS may lead to underdiagnosis in at-risk populations, particularly younger nonoverweight individuals. We hypothesized that the severity of OSAS is independent of age and BMI in a younger less-obese population. METHODS: Prospective study of consecutive patients diagnosed with OSAS. Active-duty military, National Guardsmen, and civilians were compared to determine if age and BMI correlated with disease severity. RESULTS: Two hundred seventy subjects (120 active-duty, 80 National Guardsmen, 70 civilians) were included. Active-duty military members were significantly younger and less overweight than both National Guardsmen and civilians. Of the civilians, 64.3% and, of National Guardsmen, 48.8% were obese, whereas only 19.2% of active-duty had a BMI > or = 30 kg/m2 (p < .001). However, the prevalence of severe disease did not differ between groups. Disease severity showed no correlation with BMI among active-duty subjects (r = 0.09, p = .33). Of the active-duty subjects, 37.5% had severe disease, as compared with 42.5% of National Guard and 45.7% of civilian subjects (p = .18 and .09, respectively). BMI did not differ between active-duty subjects with severe disease and those with mild to moderate OSAS (26.7 kg/m2 versus 26.9 kg/m2, p = .40). There was a low but significant correlation between age and AHI (r = 0.21, p = .02) among all subjects. CONCLUSIONS: OSAS occurs in young nonobese individuals and should be considered in patients reporting excessive daytime sleepiness, regardless of age or BMI.