Do you know of any sleep wellness programs supported by a treatment plan for nutrition, weight loss, exercise, hypertension and diabetes management?

I have been treating sleep apnea patients for many years, but feel strongly in this day of an epidemic of obesity, as healthcare providers we need to extend our level of service to include sleep wellness supported by a treatment plan for nutrition, weight loss, exercise, hypertension and diabetes management. Are there any programs like this? I would really like to coordinate my efforts with them.

You are speaking about the wave of the future, now lapping upon the shores of sleep medicine. The extent to which sleep professionals embrace your proposed model of care will likely determine the viability of sleep medicine in the coming years. In contrast, it cannot go without saying that the government, insurance carriers, and even a fair proportion of our patients want the structure of sleep medicine practices to devolve into something much simpler, easier, and cheaper, due in large part to the twin and equally dubious propositions of allegedly too much profit embedded within sleep lab reimbursements and of allegedly minimal loss in the quality of care with the ambulatory testing model.

While both presumptions have emerged from very weak evidence that tends to examine only classic, uncomplicated sleep apnea patients, this glaring lack of generalizability has not inhibited attacks on the current model of sleep medical centers. Thus, new business models for sleep centers are likely to traverse two discernible paths, one that scraps the sleep lab altogether and conducts all “testing” in the home and one that expands services to deal with the complexities observed in the substantial majority (not the minority) of sleep apnea patients.

We will focus on the latter model, but as an aside it is worth mentioning that the most likely endgame for the home testing model is one that largely dispenses with sleep medical professionals or transforms them into part-time consultants, serving a variety of operations that will emerge in places such as Wal-Mart, primary care clinics, doc-in-the-box urgent cares, Walgreens and perhaps embedded within occupational health clinics in medium to large business entities. Common sense makes it difficult to imagine how these scenarios preserve the vision of a “sleep medical center,” but who knows, maybe your friendly neighborhood Wal-Sleep will prove effective and efficient.

Among those who wish to continue to practice sleep medicine in a form similar to our current models, the questioner has thrown down the gauntlet, but it remains to be seen how sleep medical centers will respond to the challenge. Depending upon one’s background in medicine, certain options are available for expansions. I trained or worked in internal medicine, emergency medicine, and addiction medicine, and was mentored for nearly 20 years by both academic and clinical psychiatrists while I was training, researching, and practicing sleep medicine. It was an easy transition, then, to leave the university environment to open a private, community-based sleep center that specializes in the care of sleep disorders in mental health patients, which has further expanded into the realm of educating mental health professionals on how to assess and treat sleep disorders in their complex patients.

A huge market is developing for this particular expansion into mental health, because the fields of psychology and psychiatry remain behind in the clinical application of evidence-based treatments for sleep disorders. Moreover, both fields will most likely incorporate extensive training additions for sleep medical education into their current internships and residencies. Based on our experience with the nexus between sleep and mental health, we assume all residential psychiatric facilities will eventually operate their own sleep laboratories and clinics and that all outpatient mental health clinics will collaborate in extreme proximity to a sleep clinic or lab or both. This niche alone will require the services of several thousand highly skilled sleep specialists, including both physicians and behavioral sleep medicine professionals as well as sleep technologists and sleep health educators/coaches. While it is conceivable the “silo effect” will provoke many in the fields of psychology and psychiatry to resist the inevitable marriage between sleep and mental health, such a response will only increase patient demand for services—higher quality services—from outside, expert sleep health professionals who learn to serve this unique and broad area of healthcare.

Another obvious attempt at niche building would occur in the realm described by the questioner in so far as all these elements (obesity, nutrition, weight loss, exercise, hypertension, and diabetes) co-occur so frequently that a highly skilled specialist with a penchant for working in the realm of mind-body medicine could easily attract a large caseload of patients who currently must exhaust themselves by traveling here and there to see too many doctors at too many appointments. However, this expansion usually requires additional personnel and attentive use of a business model that at least sustains itself or preferably turns a profit.

A key point in moving ahead is to first determine whether you anticipate insurance coverage or not for some of these services. Many physicians make a great deal of profit operating weight loss clinics, not only because patients are motivated to pay out of pocket, but also because dietary products sold to these patients (e.g. Optifast, Medifast, or Nutri-systems) create profit as well. Most advanced obesity centers seem to use a full range of personnel including nutritionists, counselors, and coaches along with their medical professionals. To my knowledge several sleep centers around the country are already engaging in the implementation of obesity treatment programs, and advertisements from weight loss enterprises seem to be on the increase in attempting to link up with sleep centers. I know Classic SleepCare is also currently developing a weight loss program to combine with its CPAP compliance model.

Thinking back over my medical career and the constant refrain that “doctors make poor business men or women,” I believe it is important to bear in mind how you achieved success in your sleep medicine practice and ask yourself whether such insights can guide your next steps. For example, most of us achieved a good portion of our financial success by the procedure of sleep testing, and for some the sale of durable medical equipment was another way to generate a profitable revenue stream. So, what procedures or products come to mind that could fit naturally into your new niche?

If you want to start an exercise coaching program as part of your obesity platform, do you want to include exercise testing procedures as well as offer weight loss products? If you want to work with dietary or nutrition components, would you be comfortable learning about the pros and cons of numerous vitamin, mineral, and herbal supplements sufficiently, so to sell them at your facility? Or, suppose your long-term goal is to generate a Sleep Wellness program that caters to that portion of the population that proves eager to buy and use monitoring devices to track progress and reinforce new behaviors; would the combination of your clinical consulting services combined with the revenue generated from the sale or use of sleep tracking devices prove adequate to sustain this niche program?

My sense is the questioner has posed a very timely if not urgent topic. I believe those who expand their sleep center operations to accommodate the greater complexity inherent in the majority of our patients will see not only increased satisfaction from outcomes that lead to healthier and happier sleepers but also increased security by producing a more viable business model.

I would close, however, by reiterating that some or many of these expansions must be organized and implemented without any expectation for insurance reimbursement. Despite the recent attempt by the government to markedly expand its influence over health insurance systems, it seems plausible that a more likely scenario in the years ahead is the implosion of specific parts of health insurance. In their place, we are likely to see more nimble and flexible systems for managing non-catastrophic illness in which health clinics develop direct relationships between doctors and patients without the “middle man.” As the Internet and the accompanying wealth of information expand, savvy patients will lead a revolution to greatly facilitate this necessary change in healthcare delivery. Over time, both costs and pricing will decrease, which I think could create vast opportunities for patient-friendly Sleep Wellness programs and other sleep niche clinics such as Sleep-Obesity centers that will achieve financial success and deliver higher quality care.

For additional reading, see Dr Wickwire’s piece in the March issue of Sleep Review:

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

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