Healthcare has been changing radically for the past 10 if not 20 years with a continuous regression in time spent between patient and doctor. If you are not familiar with the time crunches frequently publicized, consider this scenario: many primary care physicians working under the management of large hospitals or other large institutions are literally on the clock to see the average patient in follow-up for six minutes of actual face-to-face contact time. Stop and think about your own list of medical complaints or problems and ask yourself how much you could cover with your doctor in 360 seconds?
This trend is worsening for many reasons and unquestionably will sabotage quality of care in many healthcare venues. For our purposes, I want to focus on clinic appointments for sleep disorders’ patients and how these changes in healthcare may or may not be affected by time constraints.
In a typical sleep apnea patient without serious co-occurring medical conditions and who adapts easily to the PAP device, follow-up appointments can be completed in 15 minutes or less. The 15-minute appt, by the way, is a very common billing code for follow-up in virtually all medical clinics. Note that 15 min is 250% longer than the recently enacted 6 minute appointments in primary care. Thus, if I ask you to imagine conducting a solid 15 minute discussion with your physician, it is much easier to believe many of your conditions and treatment steps could be covered. A quarter of an hour feels a lot longer than one-tenth of an hour!
But, now I want you to imagine a complex sleep disorders’ patient who not only suffers from sleep apnea for which he can barely use his PAP device, but also he reports insomnia and nightmares that further compromise his capacity to either sleep at all during the night or use the PAP device or both. In this instance, we have a patient who needs at least twice (30 min) as much as the average follow-up appointment of 15 minutes and probably needs more like three (45 min) or four (60 min) times as much contact with the sleep specialist.
Will such a patient receive this measure of care? Can the sleep specialist create a schedule to spend more time with complex patients? Can the sleep specialist do anything to organize the clinic to accommodate the time spectrum needed to treat easy as well as more difficult patients?
The answer is affirmative to all three questions with one major caveat, which is that the physician must first and foremost recognize that some patients are clearly more complex than others. This statement might seem very obvious, but it is not so for many physicians who may not set up their clinical appointments to offer shorter and longer time periods. Indeed, many docs may be forced by administrators to limit the time spent with all patients. While it is true most physicians offer distinct time frames based on a new patient intake appointment vs an established patient follow-up appointment, once a complicated or difficult patient emerges and needs more attention, the staff must recognize this special circumstance, and the doctor running the clinic still needs to determine how much additional time will be given for this case.
In my own experience working nearly 20 years ago as the medical director of a university sleep disorders center, my appointment intervals were governed by administrators who had gauged with small flexibility the amount of time available to fill so many slots with so many patients each day. When I left the university and opened my own sleep center nearly 15 years ago, I immediately addressed this problem in a unique way. By creating an online intake system to gain detailed backgrounds about the medical, psychiatric, and sleep histories of the patient beforehand, we learned to predict with great accuracy who needed more contact time. Indeed, in the first few years of operation as we tested out our theory on expanded clinics, I would regularly see complex patients for appointments lasting more than two hours. After working in this style for roughly 5 years, I determined that the lengthier appointments were needed for some patients, particularly those with psychological barriers to PAP therapy or those with severe psychological insomnia; whereas, other difficult patients actually did better by only having to swallow and digest morsels of sleep information instead of the whole enchilada.
Around this time, we became increasingly perplexed about the role of DMEs in helping or as was often the case not helping patients learn to use PAP therapy. Although we were leaders in the field at looking at sleep apnea as a chronic medical condition, it was uplifting to say the least to meet the folks at Classic Sleepcare, because of their highly focused operations toward sleep and sleep apnea patients. The standard lack of focus on sleep at the majority of DME companies continues to plague the field of sleep medicine, especially so because of the diminishing time frames being offered for clinic appointments.
Which brings up the question of how many appointments. Again, as described in an earlier post on phases of adaptation to PAP, even more critical than the length of time spent with a patient may be the frequency of contact points. Some patients clearly need regular visits as much as weekly or bimonthly in the early initiation of PAP therapy. I sense this point is lost on many sleep center operations. In fact, recently, I was asked to review a research paper that was looking at insomnia patients who use PAP therapy. As you would surmise, such patients require more time and attention to learn to use PAP, yet in the system described, it took three months on average for the sleep apnea patient to return to the sleep center after initiating PAP. Three months! And, as best as I could understand about this time frame, it seemed to be governed exclusively in accordance with an insurer’s policy on follow-up and thereby had nothing to do with the sleep center’s clinical program.
You can see with this sort of trend how the role of a DME company could be the critical factor in helping someone to use the PAP device. The DME should be able to find ways to meet regularly with patients by phone or in person to troubleshoot early barriers that often force patients to give-up without ever having really given PAP much of a chance.
For these reasons, I continue to see the Classic Sleepcare service model as the most sophisticated and efficient one I have encountered among any others that attempt to serve sleep apnea patients. Long-term, if the pressures on healthcare clinics continue to reduce doctor-patient contact time, more DMEs will be called upon to take up this slack.