Healthcare Crisis: Sleep Disorders as a Microcosm of the Larger Problem (Part I)

When was the last time you sat down for a medical clinic appointment and asked, “Hey, doc, I was hoping to buy maybe two or three different diagnoses today…by the way, anything on sale?” Of course, the answer is never, because no one walks into a doctor’s office hoping to be given a diagnosis except in the circumstances in which someone is treatment-seeking for a specific complaint(s) for which useful or meaningful answers are desirable. Even then, there is a strong inclination on the part of the patient to not want to hear too much about his or her health problems, because at heart, medical conditions scare people.

If there is some degree of fear among treatment-seeking patients, can you imagine a conversation between a doctor and an individual who is not seeking treatment for any particular condition? These individuals would be even less receptive to new information unless the recommendation was clearly non-threatening, for example, “bananas are a good source of potassium” or “brisk walks improve circulation and well-being.”

In so many ways, the points embedded in the above discussion are actually a major cause of the healthcare crisis we face in our country; some would say it is the major cause, because it can be argued with great evidence that the healthcare crisis has more to do with how patients view health and disease, how they seek or in most cases do not seek treatment for health problems, and the behaviors and other actions they engage in to manage or fail to manage health concerns and problems.

The point here is not to indict humanity; rather, if we are going to enter into an honest discussion about the healthcare crisis, it does not start with health insurance systems or the medical establishment or hospitals or doctors and nurses. It must start with us, the people who are having health problems, and despite the obvious nature of this claim, most discussions about the healthcare crisis do not start with people needing care. Instead, talk starts either with systems in general, like insurance coverage or government mandates, or with healthcare professionals who work in these systems to deliver care. 

Why would it be more important to start with the people receiving the care than all the rest of the players who are involved in delivering the care at so many levels? Why is the grassroots a better place to look at things than starting from the top-down?

The answer is best explained with a detailed description of how sleep apnea would be treated in a fanciful world in which patients really operate like consumers. And, fanciful is a proper adjective, because patients are consumers, yet the real world does not treat them as such. For starters, how would someone with suspected sleep apnea proceed to care in this imaginary world? First and foremost, in this make-believe world of the early 21st century, virtually all patients would complete a home sleep test (HST). But, there is a distinction between an HST in the current environment and one in the fanciful world. In the latter, the technology in a home sleep test would be so advanced that few patients would actually need an in-lab sleep center test. Moreover, a highly advanced telemedicine system would have evolved where sleep technologists and as needed sleep physicians would be ever-present during the home sleep test to problem-solve and coach the patient. The sleep technologist would be available the entire night to address numerous issues that might arise and in fact would be monitoring the test anywhere from 1 to 10,000 miles away. 

Why would all these things emerge in this fanciful world? In part, a world unencumbered by the regulatory or bureaucratic processes of large institutions such as insurance companies, hospitals, or other medical conglomerates would permit innumerable innovations into the healthcare marketplace, because when patients act as intelligent buyers, sellers often arise to meet the new demand. As an example, consider the case of REMZzzzs mask liners: PAP mask manufacturers did not realize many patients needed more comfort to regularly wear the mask, but an inventor solved the problem, and the product has a sizeable market despite its current lack of insurance coverage. 

Thus, in a genuine interaction between consumer and seller, whether for something as simple as a mask liner or as complex as HST, a demand for a higher level of sophistication in testing would eventually be met by innovators who would have discovered the need to measure more elements than currently tested, and these same innovators would rapidly realize that no one wants to spend the night in a sleep lab if the same information can be gathered while sleeping in your own bed—a natural environment, which would seem the most logical place to test any sleep patient. Yet, even now, did you know that HST usually does not measure flow limitations (UARS) or leg jerks and most remarkably, did you know that home sleep tests do not measure sleep?

In this fanciful world, no insurance coverage would be offered for any of these sleep tests, yet the price of the procedure despite its higher quality of data collection would still be less expensive, so much so, you would probably shop at a fanciful store with the name Sleep-Mart. And, after you finished your diagnostic testing, you would return to Sleep-Mart and make plans to try out and then purchase your PAP device, another item that would not be covered by insurance. Again, without the interference of insurance rules and government regulations, the price of the PAP device would be dramatically lower than current levels, probably 50% less or more.

If we now dissect this example, we realize that in the current society in which we live such interactions would be very uncommon, because at minimum few people are willing to forego the use of their insurance coverage in managing healthcare costs. However, more to the point, the people and institutions at the top of the hierarchy in the business of medicine do not believe that the average individual is capable of or willing to act like a savvy consumer. Indeed, they will insist most individuals are unable to rise to the occasion when it comes to healthcare decisions. Thus, in their self-fulfilling prophecy, the top dogs promote the need for institutions like health insurance carriers as well as government regulators to create various rules and mandates about healthcare to serve as the guiding lights for this supposedly wide array of poorly informed patients.

In contrast, if patients could gain a greater degree of control over many health scenarios in which they find themselves, the effects of “smart shopping” would indeed cause the prices of virtually every aspect of healthcare to drop by 30 to 70% or greater, and technology would continually increase the sophistication of many healthcare interventions at a much greater rate of innovation than we currently experience.

Before we go further, I do not believe this lack of attention to patient self-sufficiency is catalyzed by some grand conspiracy of the government-health insurance nexus, albeit these large institutions indirectly stifle patients from attempting to think and act like smart shoppers. Rather, what’s occurring here is a simple “law of nature” typically described as “nature abhors a vacuum.” These institutions arise more so because patients often choose not to act like consumers and instead willingly accept or embrace the top-down model of care. If you want to know why patients accept this model, I believe it is insufficient to declare there are no other choices. True, options are narrow in this day and age, but in my clinical and personal experience, I would suggest that deeper psychological, if not spiritual, issues lie well below the surface when it comes to individual’s decision-making about healthcare problems.

In the next post, I will elaborate on these issues and show how various factors create tremendous inertia in trying to alter healthcare systems. As a hint, ask yourself the following questions: why are so many people unable to lose weight, stop smoking, or reduce their consumption of alcohol? And why do patients believe there are no other options in seeking healthcare?

As a further preview, these posts will highlight a peculiarity of patients in that so many of them may not want there to be another choice. Indeed, patients often fear other choices in healthcare, because it would ultimately lead them to confront their own health concerns and problems in much more direct ways. And, that will be the premise of Part II, namely, people do not want to confront their health problems, by and large, for most of their lives.  

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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