By Joseph Krainin, M.D., FAASM, President & Founder, Singular Sleep LLC
DECEMBER 1, 2016 – A recent survey from the Missouri Telehealth Network reported a 90% patient satisfaction rate with the quality of care received by telemedicine. Our internal reviews have been consistent with this finding, showing an overwhelming satisfaction rate. Patients cite convenience and short appointment wait times as major benefits. Many patients have had sleep telemedicine consultation with me due to inability to take time off from work to travel to a sleep clinic or an unacceptably long wait time to see a sleep doctor. Our goal is to offer patients appointment availability within two to three business days of their initial contact.
A typical consultation involves reviewing the sleep study report, counseling regarding the pathophysiology of sleep apnea and its medical co-morbidities, and then formulating a treatment plan. In most cases, I will prescribe auto-titrating positive airway pressure (PAP), e.g., auto-CPAP (APAP) or bilevel (“BiPAP”). PAP is the gold standard treatment for sleep disordered breathing. However, I offer alternatives to PAP when appropriate.
When PAP is prescribed, the patient has the option of purchasing the equipment through Singular Sleep or taking the prescription to another DME of his choosing for fulfillment. Singular Sleep is a licensed home medical equipment supplier and offers extremely competitive pricing, generally at or near Internet “minimum advertised pricing” (MAP), which is the lowest cash price allowable by the manufacturer. Brick-and-mortar DMEs often charge cash-pay patients a 300-400% markup for the same equipment.
Besides price, purchasing the equipment through Singular Sleep provides several other advantages. By retaining control over DME dispensation, I am able to ensure that the patient gets the best equipment at the optimal settings for his condition. Insurers will commonly deny newer, more advanced forms of PAP without the patient having first failed older, less expensive (and often less tolerable) equipment. Over the last several years, insurers have widely adopted a rental policy under which, in order to keep the equipment after a trial period, patients must demonstrate PAP compliance meeting the insurer’s arbitrary guidelines. PAP can take weeks to months to fully habituate to, and the patient risks having to undergo another sleep study to re-qualify for PAP should she not meet usage goals. Another advantage of patients obtaining equipment from Singular Sleep is that we are able to troubleshoot it for them. Patients commonly have questions and minor problems with their equipment during initiation of therapy. For patients who purchase their equipment through Singular Sleep, our trained equipment specialists are available to address issues that arise at no additional cost.
Also, when we dispense PAP, we register the device in our electronic database which enables us to seamlessly retrieve compliance reports. PAP devices have internal SD cards that record important data, such as usage patterns, excessive system leak, estimated residual abnormal breathing events, and average pressures. A sleep medicine physician needs to periodically review this data to ensure that sleep apnea is being treated effectively. Machine settings may need to be adjusted based on findings from the compliance report. I typically recommend that patients have a follow up consultation with me after one to two months of use, at which time I will obtain and review and compliance report and then adjust PAP settings as needed. Follow up consultations are typically $99.
While the majority of our DPC referrals are for sleep apnea, our model is effective for management of most other sleep disorders. Ten to fifteen of adults report insomnia that is chronic, severe, or both. I recommend that DPC providers refer chronic insomniacs to a sleep specialist for evaluation for an underlying sleep disorder; insomnia is often a symptom of sleep apnea, periodic limb movement disorder (PLMD), or another primary sleep disorder. Even when the diagnosis is primary insomnia, pharmacological management of the disorder carries with it issues of tolerance and dependence and, in some complex patients, referral to a sleep specialist is advisable. Numerous studies have shown that, when compared to drug treatments, long-term outcomes are superior with cognitive behavioral therapy for insomnia (CBT-I). Having been trained in this modality during sleep medicine fellowship at University of Michigan, I offer it in my practice and it is an excellent option for patients who prefer drug-free insomnia treatment.
Up to ten percent of the U.S. population may have restless legs syndrome (RLS). Evidence for long-term adverse effects from traditional dopamine agonist (DA) therapy with agents like Mirapex and Requip has been increasing and thus, best practices for managing this disorder are evolving rapidly. Many sleep medicine physicians believe the tipping point has been reached in indicating that risks outweigh benefits for DAs in RLS and there are several emerging treatments that increasingly are being utilized by specialists in the field . A thorough workup to rule out secondary causes of RLS is now standard of care. When appropriate, DPC providers should consider referring RLS patients to a sleep medicine physician.
Circadian rhythm disorders are prevalent, particularly at the extremes of the adult age cohorts. Teenagers and those in their early-to-mid 20s are predisposed to delayed sleep-wake phase disorder, i.e. the tendency to go to bed and wake up extremely late. Advanced sleep-wake phase disorder is common in elderlies and is characterized by a shift to markedly early bed and wake times. Both of these disorders can cause disruption in quality of life and daytime function, and are eminently treatable.
As out-of-pocket health care costs continue to rise for non-Medicare/Medicaid patients, access to affordable specialty services will become increasingly important for DPC practices. Sleep disorders are common in DPC clinics, and diagnosis and treatment of these problems by traditional pathways often involves substantial patient expense and delays in treatment. Singular Sleep offers an alternative model to a traditional sleep center: Our direct pay, cost-effective, and efficient practice is synergistic with the needs of DPC practices.
Joseph Krainin, M.D., FAASM is a board certified sleep medicine physician and neurologist and the founder of Singular Sleep. He is a fellow of the American Academy of Sleep Medicine and licensed to practice medicine in 30 states.
Contact: Singular Sleep, LLC