The ethics of hypopnea scoring

Abstract

Study Objectives:

In February of 2023, the American Academy of Sleep Medicine issued a “recommended” way to score hypopneas using 1A criteria (scoring of hypopneas using a ≥ 3% oxygen desaturation from pre-event baseline) that is at odds with the Centers for Medicare & Medicaid Services mandate of scoring hypopneas using a ≥ 4% oxygen desaturation from pre-event baseline. This dichotomy will present an ethical dilemma for sleep medicine providers.

Methods:

We use the principles of medical ethics to discuss the challenges this discrepancy poses for sleep medicine providers.

Results:

Disparate hypopnea scoring undermines beneficent patient care and impairs providers’ duty to deliver just, equitable care, hence violating the principles of justice and beneficence. This primarily affects older adults, the disabled, the “medically needy,” and those living at the federal poverty line dependent on public insurance.

Conclusions:

This discrepancy creates a situation that falls below acceptable levels of health care justice. It is recommended that the American Academy of Sleep Medicine work with the Centers for Medicare & Medicaid Services to develop a scoring policy that consistently promotes individual sleep health regardless of payor.

Citation:

Skolnik C, Attarian H. The ethics of hypopnea scoring. J Clin Sleep Med. 2024;20(4):615–617.

BRIEF SUMMARY

Current Knowledge/Study Rationale: As of February 15 2023 the American Academy of Sleep Medicine has made it mandatory that all hypopneas be scored based on ≥ 3% desaturations. Centers for Medicare and Medicaid Services, however, mandates only ≥ 4% oxygen desaturations be counted as hypopneas. This has created an ethical dilemma because now patients are going to be treated differently based on their insurance plans. We wanted to apply the common principles of medical ethics to argue against a dichotomous definition of this medical finding.

Study Impact: This paper, hopefully, will bring attention to the ethical problems inherent in such duality and be the basis for an advocacy that would result in a single criterion applied to all regardless of payer. Perhaps the AASM can use this, and other papers like this, to argue in front of CMS for a juster and more equitable way to define hypopneas.

INTRODUCTION

In the most recent update to the scoring manual, published on February 15, 2023, the American Academy of Sleep Medicine (AASM) states that the only acceptable and “recommended” way to score hypopneas is to use its 1A criteria (scoring of hypopneas using a ≥ 3% oxygen desaturation from pre-event baseline).¹ The AASM 1B criteria (scoring of hypopneas using a ≥ 4% oxygen desaturation from pre-event baseline) is now optional, albeit not decommissioned from clinical use.¹ On the surface, this appears but a minor change. When considered, however, in the larger context of the Centers for Medicare & Medicaid Services (CMS) mandate that only 1B criteria be used to score hypopneas, providers become faced with an ethical quandary.² We are being obligated to assess sleep-disordered breathing through the lens of an insurance-based, two-tiered diagnostic approach. This change has led to the development of diverging standards of sleep medicine care for the same clinical condition with distinctively different insurance coverage. Therefore, the AASM’s requirement of 1A criteria as a way for centers to maintain accreditation, and CMS’ continued use of 1B criteria to reimburse treatment, has resulted in 2 areas of substantive ethical challenges: First, disparate hypopnea scoring undermines providers’ ability to deliver beneficent patient care; second, dual standards of care in sleep medicine impair providers’ duty to deliver just and equitable care.

From the outset of this recent change, CMS has stringently required that all sleep tests submitted for coverage of obstructive sleep apnea (OSA) treatment use the optional 1B criteria. Meanwhile the rest of private insurers accept 1A to guide diagnosis and management of OSA. Relying on landmark, albeit older, papers to justify their mandate, it is not difficult to surmise why the CMS is insistent on 1B criteria scoring.^3–5 It is used as a strategy for cost containment. Inherent in this discrepancy is the mathematical fact that raising the scoring threshold by 1% leads to a reduction in the absolute number of positive tests. Fewer patients are diagnosed, and ultimately fewer patients are treated, yet this does not mean that the burden of disease is any less. On the contrary, it guarantees that a group of symptomatic patients who may have narrowly crossed the 1A hypopnea threshold can no longer qualify for care based on 1B criteria. In turn, this discrepancy establishes a clinically unfair standard for patients dependent on publicly funded insurance utilizing 1B criteria, because the scope of their illness is not any qualitatively different from that of patients who have hypopneas associated with 3% desaturations and are deemed to have veritable OSA.

METHODS

We use the bioethical principles of justice and beneficence to discuss the impact of the sanctioned implementation of divergent diagnostic standards predicated solely on insurance status. This is generally a proxy for socioeconomic status and age.

RESULTS

Providers become limited in their duty to bring about the “improvements in physical or psychological health that medicine can achieve” for every patient when they are denied the tools to adequately diagnose and treat their patients in general, and OSA in particular.⁶ Consequently, providers’ inability to employ uniform OSA diagnostic criteria introduces an inherent unfairness in the care of patients who face more rigorous hypopnea criteria. In cases of mild OSA, where skirting the hypopnea threshold could make or break a symptomatic patient’s opportunity to be treated, providers have had to consciously accept that a swath of their patient population will simply be ineligible for OSA care per 1B criteria.

Due to this dichotomy, a level of moral distress has been introduced into the sleep medicine community. Providers unable to treat symptomatic patients who fail to meet 1B criteria but may well have met 1A criteria face a moral struggle in that they know what diagnosis and care these patients need but are “unable to provide it due to constraints that are beyond [their] control.”⁷ In cases where providers know the “right” thing to do, but face diagnostic barriers that make it impossible to pursue the correct diagnosis, moral distress ensues. Inevitably, this external imposition can undermine the provision of beneficent patient care, making sleep medicine providers feel complicit in a process that ultimately harms their own moral psyche.

DISCUSSION

Limiting OSA care by way of 1B criteria hits particular groups of patients; it applies to all our patients dependent on Medicaid and Medicare, meaning older adults, the disabled, the “medically needy,” and those living at the federal poverty line.⁸ Leaving patients with public insurance beholden to more restrictive hypopnea criteria establishes a regressive process of resource allocation for OSA care. Downstream treatment sequelae, which largely affect our nation’s most vulnerable patients, means that care is more difficult to obtain for those who already face significant psychosocial and economic barriers to obtaining needed medical care. It is widely accepted that treating OSA improves patients’ quality of life as well as cardiovascular outcomes, such that the approach of the CMS should be to promote policies that bolster OSA care for these at-risk groups, not make care more limited. Therefore, the current allocation of care afforded by 1B criteria fails to meet acceptable levels of health care justice. The AASM’s new policy roll-out does not consistently promote individual health, because only some are given a “fair opportunity” to obtain an OSA diagnosis.⁹

Further complicating this issue is the requirement by the AASM that all facilities it accredits comply with this ruling by December 31, 2023. Even though compliance with the AASM 1A is “recommended,” it is a de facto mandate and not simply a voluntarily adopted recommendation. The reason for this is that if laboratories and centers do not follow the recommendation, they will lose the academy’s accreditation, which is a death knell to any self-respecting sleep center. Therefore, even from an accreditation standpoint, the only solution to this incongruity is to reinforce dual standards of care at the institutional level. That way, facilities remain compliant with both mandates while these clinical ethical dilemmas become entrenched in operational sleep medicine care.

In conclusion, by moving to 1A criteria at large, yet using 1B criteria for selectively insured patients, sleep medicine providers are potentially being pushed into morally harmful and clinically unethical territory. A better option might be to simply allow us to treat patients individually based on their specific needs and symptoms. We hope that the AASM, being the guardian of high sleep medicine standards, negotiates with the CMS and convinces it to change its requirements based on recent clinical data.¹⁰ Then, it can rightfully mandate that all sleep centers follow a single rule. If these negotiations were to prove fruitless, then as an organization advocating for and protecting sleep medicine providers and patients alike, the AASM should come out with a creative balance that promotes national sleep health equity and its providers ability to deliver ethical sleep medicine care.

DISCLOSURE STATEMENT

Both authors have seen and approved the manuscript. Work for this study was performed at Northwestern University. The authors declare no conflict of interest.

ABBREVIATIONS

AASM

American Academy of Sleep Medicine

CMS

Centers for Medicare & Medicaid Services

OSA

obstructive sleep apnea