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The challenge
Inspire therapy is an alternative to CPAP therapy for obstructive sleep apnea (OSA) that uses hypoglossal nerve stimulation (HGNS) via an implanted device to open the patient’s airway. Until Inspire became FDA-approved in 2014, the surgical options for OSA were limited to more complex surgeries with higher complication rates. But while Inspire improves outcomes for many CPAP-intolerant patients, it has a unique set of administrative considerations. Before launching an Inspire therapy program, ENTs and their partners must determine if the procedure is operationally and financially sustainable for their region and site of service. ENTs may need to establish or strengthen relationships with area sleep medicine clinics to help identify new patients and ensure efficient long-term care for Inspire patients.1
The organization
The ENT & Allergy Centers of Texas (ENTTX) is a private practice with 12 providers and four advanced practice providers (APPs). Among other services, ENTTX provides balloon sinuplasty, sinus surgery, and the Inspire procedure to the Dallas-Fort Worth area and Northern Texas. Several physicians from ENTTX also founded and continue to own a local ambulatory surgery center (ASC). This co-ownership partnership makes it easier for both organizations to make decisions that positively affect patient outcomes and increase efficiency.
The approach
Before their Inspire therapy program launched in 2019, ENTTX and the ASC worked together to determine whether the implant procedure would meet the needs of OSA patients in their region, would be reimbursed by insurance companies, and was safe to perform in an ASC setting. Also, ENTTX connected with area sleep medicine clinics to establish comprehensive care pathways and ensure care for all OSA patients, whether they choose Inspire or not.
The result
Both ENTTX and the ASC found that offering Inspire therapy was a good fit. ENTTX determined that the Inspire procedure is feasible to perform in an ASC setting, is reimbursed by insurance, generates high patient satisfaction rates, and requires equipment that’s available in most ASCs.
ENTTX performs the majority of its Inspire procedures in the ASC. Since launching the program, the care team at the ASC has worked to refine their processes and improve the implant procedure’s efficiency. Due to these efforts, Inspire recognized ENTTX as a Care Team of Excellence for their commitment to patient experience and clinical results.2 To accommodate high patient demand, the ASC is in the process of expanding the number of operating rooms, and ENTTX is planning to train more surgeons to perform the Inspire implant procedure.
How ENTTX and an ASC built a thriving Inspire program
To improve access to Inspire therapy for OSA patients, ENTTX fostered relationships with area sleep medicine clinics and leveraged their co-ownership partnership with an ASC to improve workflow efficiency.
1. Create a strategic partnership with a local ASC
The ENT & Allergy Centers of Texas (ENTTX) has been partnered with a local ASC since 2012. Because several ENTTX physicians are also partner-managers at the ASC, both organizations can more easily make decisions that improve patient outcomes and increase workflow efficiency.1
The ASC setting creates opportunities to improve efficiency because it provides the same surgical team every time, while area hospitals tend to have inconsistent surgical staffing. That consistency means the surgical team is so familiar with the Inspire procedure that they can safely build efficiencies into the process to improve patient experiences.
The majority of ENTTX procedures are done in the ASC, but some patients with complex comorbidities or conflicting insurance coverage may require a hospital setting. Because most OSA patients have comorbid health conditions, dedicated nurses at the ASC handle all preprocedure clearances and work with schedulers at other practices to make sure all patients have had the right tests, so they can evaluate whether the ASC setting is right for each patient.
Although a partnership with an ASC isn’t feasible or desirable for every provider organization, aligning organizational practices with each ASC’s interests can still be beneficial. Efficiencies, like shortening procedure and pre-procedural clearance time, may make it more likely for ASC administrations to see the implant procedure as value-added.
“There’s something to be said for having the same staff every day at the ASC, where the scrub tech, circulating nurse, and anesthesiologist are all familiar with the procedure. It really helps.”
2. Demonstrate the business case for Inspire at an ASC
Before launching the Inspire program in 2019, ENTTX worked with the ASC to determine whether the procedure would be clinically and financially viable long-term.
ENTTX and the ASC first assessed the clinical relevancy of the Inspire procedure for the region, including whether the procedure would help improve the quality of life for patients with OSA, who often go untreated or undertreated. Importantly, both organizations evaluated whether their patient base was vulnerable to intraoperative complications or complex post-operative care that goes beyond the capacity of most ASCs. On the business side, the ASC reviewed insurance coverage and reimbursement in relation to the cost of the Inspire device, pre-authorization requirements, and equipment needed for the procedure.2
ENTTX and the ASC made the business case that Inspire therapy will be a net benefit for patients, surgeons, and ASCs in their region. Similar analysis will make it much easier for ASCs in different partnership configurations to decide whether offering Inspire is right for them.
Questions ASCs ask themselves before offering a new program or procedure
Clinical
Is the procedure clinically relevant to the patient population? Will it improve access to care and quality of life?
- Studies have estimated that 30 million people in the U.S. have OSA, but 80% remain undiagnosed and untreated.3 On top of that, only 50-75% of patients who are diagnosed with OSA adhere to CPAP therapy.3 Since 2018, Collin County has had a population of more than 1 million people.4 The ASC inferred that a sizable number of patients would need help with OSA. Inspire therapy is an FDA-approved option with the potential to improve those patients’ quality of life.
Are patients in the region good candidates for receiving the procedure at an ASC, accounting for age, comorbidities, and the potential for intraoperative or post-operative complications?
- ENTTX did an internal evaluation of OSA patients to determine whether they were likely to need additional intraoperative or post-operative care. They found that 80% of patients could receive implant surgery at the ASC, and 20% had comorbidities that required a hospital setting.1
Are area surgeons interested in offering the procedure and willing to become credentialed in the Inspire skill set?
- The ASC knew that ENTTX had already trained two interested surgeons to do the Inspire procedure. Now, because patient demand is high, ENTTX plans to train and credential several more surgeons on staff in the Inspire therapy.
Has the procedure improved clinical outcomes?
- Clinical data has shown that HGNS implants are a safe and effective treatment for adults with moderate or severe OSA who can’t tolerate CPAP therapy.5
Administrative
Will the procedure be covered by insurance? Are there processes in place to obtain pre-authorization?
- Inspire therapy is covered by most U.S. insurance providers when patients meet eligibility requirements. ENTTX and the ASC were also able to connect with Inspire’s in-house team, which is dedicated to resolving issues with reimbursement and prior authorization, to clarify eligibility questions.
Does the ASC have the right equipment for the procedure?
- Like similar organizations, the ASC already had most of the equipment needed for the Inspire procedure and didn’t have to invest a lot of capital to do the procedure. Required equipment includes a sterile sleeve or bag, finer right-angled forceps or a hemostat, a narrow malleable ribbon retractor, and a nerve monitoring and stimulation system.
What training and support is available for the program or procedure?
- An Inspire representative was available to help ENTTX and the ASC access training and credentialing programs for the procedure, as well as insurance reimbursement and prior authorization support.
3. Foster trusting relationships with sleep medicine clinics
ENTTX took care to develop relationships with area sleep medicine clinics and create a comprehensive care pathway for OSA patients. Sleep clinics are essential to the Inspire treatment plan: They handle sleep studies, monitor or adjust the Inspire implant, and treat and manage OSA patients who aren’t eligible for Inspire therapy. Surgeons from ENTTX visited sleep medicine clinics in person to emphasize the importance of sleep medicine to the Inspire care pathway and answer questions or concerns.1
To help build a comprehensive care pathway, ENTTX partnered with area sleep medicine clinics. When patients are already established at a sleep medicine clinic, ENTTX sends them to their original sleep care provider for sleep studies, Inspire follow-up care, or further care when ineligible for Inspire. When patients aren’t yet established with a sleep medicine clinic, ENTTX sends them to another sleep clinic in the area. ENTTX screens patients using the STOP-Bang score and sends patients who meet the criteria for OSA to a sleep medicine clinic for evaluation.
ENTTX has also developed a co-management process with another sleep medicine clinic, Dream Sleep, to improve outcomes for some patients who don’t already have a sleep care provider.
A consistent flow of OSA patients is beneficial for ENTs, ASCs, and sleep clinics in the region, particularly for private practices that must generate their own referrals.
How we know it’s working
As a result of ENTTX’s efforts to build and strengthen partnerships, Inspire therapy has changed the sleep apnea treatment landscape in the region. In addition to the following outcomes, ENTTX and the ASC have substantially increased patient access to the Inspire therapy and are in the process of expanding the number of available implant surgeons and ORs.
Median apnea-hypopnea index (AHI) of ENTTX patients using Inspire (as compared to a 35.4 AHI pre-implant).6
Implant procedures performed at the ASC since the Inspire program was launched in 2019.
Of implant procedures performed in the ASC.
1 Note: Unless otherwise specified, all information in this case study came from Advisory Board interviews with officials from The ENT & Allergy Centers of Texas.
2 ENTTX recognized as an Inspire Care Team of Excellence. The ENT & Allergy Centers of Texas. Date unknown.
3 American Academy of Sleep Medicine. Hidden health crisis costing America billions: Underdiagnosing and undertreating obstructive sleep apnea draining health care system. American Academy of Sleep Medicine, 2016.
4 Neilsberg. Collin County, TX population by year. Neilsberg, August 1, 2024.
5 Costantino A, et al. Hypoglossal nerve stimulation long-term clinical outcomes: a systematic review and meta-analysis. Sleep Breath. August 15, 2019.
6 The apnea-hypopnea index (AHI) measures how often people with sleep apnea stop breathing in their sleep per hour. A score of 15 events indicates moderate sleep apnea, and a score above 30 per hour indicates severe sleep apnea.
Inspire Medical Systems, Inc., is a medical innovation company committed to the safe, effective, and reliable treatment of obstructive sleep apnea in order to improve patient lives.
Inspire® therapy is a solution for people with obstructive sleep apnea who have tried and struggled with CPAP. The Inspire® implant works inside the body to treat the root cause of OSA, enabling patients to breathe regularly and sleep soundly. Learn more at inspiresleep.com.
This report is sponsored by Inspire, an Advisory Board member organization. Representatives of Inspire helped select the topics and issues addressed. Advisory Board experts wrote the report, maintained final editorial approval, and conducted the underlying research independently and objectively. Advisory Board does not endorse any company, organization, product or brand mentioned herein.
To learn more, view our editorial guidelines.
This report is sponsored by Inspire. Advisory Board experts wrote the report, maintained final editorial approval, and conducted the underlying research independently and objectively.
Posted on August 27, 2024
Updated on September 27, 2024
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