Chapter 3: Understanding Organizational Movement

I. Strategic Planning

A strategic plan is a document that outlines an organization’s goals, vision, and mission, along with a timeline, measured in years, for each goal. Strategic plan documents are beneficial in guiding any organization, including individual families, toward success. A strategic plan should also include a design for achieving each goal. What makes a strategic plan effective? Effective steps to developing a strategic plan include identifying the issues within an organization, asking the right questions, and implementing the best solutions. The need for a strategy or a plan would not exist if areas in need of improvement did not exist. As Ralph “Waldo” Emerson said, "Our strength grows out of our weakness." Discovering areas that need improvement and focusing on those areas until each goal is achieved is critical in sleep medicine, healthcare, and in life. How can strategic planning and identifying areas for improvement in the sleep lab be achieved? Through assessment, measurement, implementation, analysis, and repetition of these practices.

II. Assessments, Measurement, And Outcomes

This section will focus on subjective data collected; this is the typical form of information gathered from employees and patients within the sleep center. Assessment is the organized and methodological collection, examination, and use of data. During a single shift, sleep technologists can ask patients to complete Epworth Sleepiness Scales (ESS), sleep history questionnaires (SHQ), patient satisfaction surveys (PSS), and more. These are all forms of subjective patient assessments, meaning that responses are based on how well or poorly patients believe they sleeps, or how well or poorly they have been told they sleep. It is not an objective measurement or history. Once the sleep study has been completed, the data collected from the polysomnography will transmit the objective data, showing whether the patient snores, kicks, or any other measure of sleep quality, reflecting or contradicting patient suspicions. Employees may be asked to take surveys, participate in focus group conversations, or be interviewed by leadership for their subjective opinions on topics to help develop key strategies. Once assessments are gathered, they can be measured.

Measurement happens when all the subjective data collected can be assigned to numbered groups (e.g., the average number of patients with ESS higher than 10; the engagement rates on PSS; or the annual number of reported sleep quality improvement from SHQ follow-ups). All measurements must be securely defined by a qualified number. Metrics are the tools used to collect information which is turned into measurable data. Keeping metrics or surveys consistent in format and wording assists in creating measurement reliability. This means that data collected over time will remain consistent. Even changing the font or colors on a survey can skew the validity/accuracy of the assessment, yielding incorrect outcomes. Yielding correct outcomes is vital because they provide results used to strengthen areas requiring improvement. A targeted strategy can then be made to create a desired outcome that yields improvement.

Health Insurance & Reimbursement

Health insurance is an agreement written in the form of a contract between an insurance entity and either an individual person or employer. This legally binding agreement states that a person will receive health benefits from necessary providers as long as the individual or employer pays the fees outlined by the insurance company. If the fees are not paid to the insuring company, the company is not obligated to cover any medical benefits from the date of the last payment received. Fees include, but are not limited to, monthly premiums, deductibles, and co-insurance.

Insurance premiums are the amount the individual pays out of pocket — typically every pay period or monthly – to the insurance company. Deductibles are the amount one may have to pay to the healthcare provider prior to payment by insurance. Co-insurance is a percentage that each person pays after he or she has met the deductible. Deductibles and co-insurance are commonly seen with PPO (Preferred Provider Organization) insurance plans. These plans help with healthcare cost sharing and allow people to see healthcare providers whenever and wherever they would like. However, the cost is generally higher than a Health Maintenance Organization (HMO) plan. An HMO plan has the same insurance premium standards as a PPO, but it usually does not come with deductibles or co-insurance. HMOs do have co-payment fees, or a predetermined fee to see a provider. HMO plans require patients to have an assigned primary care provider to perform all screenings and provide referrals to specialists, if needed.

Insurance companies can be private companies, or they can be government funded companies. Medicare, Medicaid, and the Veterans Administration are the three government owned health insurance providers. The Health Insurance Marketplace is a government funded marketplace where individuals who may not be insured, employed, or eligible for private or government insurance, can find affordable, and, at times, no cost, healthcare insurance coverage. Sleep studies and visits within sleep centers are often paid for by insurance companies. The cost of sleep procedures varies by center, city, and state, making it difficult for patients to decide where to make appointments.

In the context of the sleep lab, reimbursement refers to the amount of payment that the insurance company will pay the sleep center for a service. Reimbursement may affect the amount each patient may have to pay for his or her service. In recent years, the American Academy of Sleep Medicine has been advocating in Washington D.C. for better reimbursement and additional measures of sleep health reform. Each type of sleep service is billed with procedure codes and each insurance company decides how much of the cost it pays for each procedure.

Procedure Coding

The International Classification of Diseases and related health problems (ICD) is responsible for the creation of coding procedures for diagnostic services. The current ICD-10 is the most updated version of classifications and descriptions of diagnoses. Diagnoses from the ICD are indications for diagnostic procedures, paired with Current Procedural Terminology (CPT) billing codes. CPT codes are assigned to each study and describe what was done or used during that study. G ccodes are used to bill for HSAT’s (Home Sleep Apnea Tests) and are considerably cheaper for insurance companies. The lower cost drives insurance companies to push for more HSAT testing, even though these tests not as accurate as full polysomnography studies. It is important that sleep technologists understand billing codes to ensure insurance companies are properly billed. Table A-1 shows the CPT and G codes for sleep studies, provided by the AASM.

1. What is the purpose of a strategic plan?

3. Is the PSQ-III a form of measurement or is it a metric?
4. What is the difference between assessment and measurement of quality improvement?

5. State the difference between managed care plans and list pros and cons for each.

6. What role does insurance play in cost control and what role do all sleep center employees play in cost control?
7. Is accessibility of care a form of an outcome or is it an assessment?
8. A 5-year-old patient is having an in-lab sleep study. The technologist applies EEG, ECH, leg, EMG, nasal pressure, thermistor, pulse oximetry, and respiratory effort belts. Four hours in the study, they apply CPAP to the patient. What is the proper billing code be for this study in 2022?