A lot of interesting talks, discussions, and posters were presented at the annual sleep conference, some related to relatively new scientific knowledge and others related to replication or fine tuning of clinically relevant diagnostic and treatment information. Still other areas covered the future of sleep medicine. From my perspective, an interesting way to look at this information is to monitor trends that seem to hint at coming changes in the field. With this backdrop, there are a number of topics worth highlighting from the conference, including things that may bode well or poorly for sleep medicine specialists and their patients.
Challenges to the Field
It is very clear sleep medicine as a specialty is now in a most vulnerable position. The irony is there are more diagnosed and soon to be diagnosed sleep disorders’ patients than ever before, yet the number of sleep medicine specialists is on the decline. While many academic sleep centers established fellowship programs during the last 15 years to set up a pipeline for new recruits into the field, the number of available spots in these programs has not been filled to maximum for more than 5 years running. Due to so many changes in the treatment practice of sleep apnea (e.g. home sleep tests, HST), regulatory interference piling on administrative loads (e.g. the “unaffordable” care act, i.e. Obamacare), and the persisting economic slump from which the country has never recovered (compared to all other recoveries in the nation’s history), sleep medicine is no longer looking as attractive as it was just a decade ago.
Again, the striking thing is that millions of patients are currently being treated by sleep centers, and millions more individuals are going to be entering the clinical setting with sleep complaints in both the short and long-term. With this type of market strength, it seems almost unimaginable the sleep field could contract or otherwise weaken. But, this current dwindling is exactly what it is occurring; further, there is no clear solution in sight. To be sure, there is likely to be enormous growth in replacement approaches in sleep care for the diagnosis and treatment of OSA/UARS, chief of which include even more reliance on HSTs and auto-PAP devices as well as recruitment of thousands of dentists into the field to prescribe and fit dental devices (oral appliance therapy, OAT). There will even be an uptick in surgical approaches, including the newer hypoglossal nerve stimulation devices that show considerable promise.
With persistent economic woes and burdensome, arbitrary regulatory excess, it is fair to say that some sleep centers will fold up their tents. While centers that remain active are likely to see sufficient caseloads due to all the failed cases emanating from less comprehensive treatment approaches, the wait to be seen at “full-service” sleep centers will likely prove interminable for many patients. While OAT, auto-PAP devices and surgical interventions all can provide substantial benefits to patients, they also require follow-up fine tuning efforts, especially for PAP and OAT approaches, which may not be so easily obtainable in this new era of expedited care that relies less on expertise offered by sleep medicine specialists at sleep medical centers.
The American Academy of Sleep Medicine has been looking closely at these problems for more than 3 years, but there continues to be either a lack of clarity or commitment in sorting out the best pathways forward to solve these problems. However, it is equally fair to report that there is no lack of urgency from the AASM, and they seem to understand the problem is complex and multi-faceted, which likely requires creative solutions. The good news, so to speak, is that as more and more people recognize their need for higher quality care to treat their sleep disorders, a demand will rise in communities throughout the country, which invariably will have some impact on pushing for better services and thus more sleep specialists and sleep center services.
Other elements may also prove major factors in solving these problems. One item discussed was the role of mid-level medical professionals also known as advanced practice professionals (APP) but more commonly known as physician assistants and nurse practitioners. In a related theme, the role of sleep technologists and sleep health educators was also mentioned. In both areas, there was a lot of enthusiastic support for all these types of providers to expand their roles and services in the field, but at the same time there was a notable tension among some attendees at the conference who seemed more reserved or uncertain about how to make the best use of this potential group of providers. It was not clear, however, whether the reluctance stemmed from a perception of a threat to physicians or just the ambiguity regarding how these professionals could assist in the delivery of healthcare in ways that may be needed in light of the coming sleep medical physician shortages.
When sleep technologists and APPs provide services, there are specific coding and billing issues that arise, and it will be very important for the AASM to sort through the regulatory maze of the CPT (Current Procedural Terminology) to determine effective strategies for sleep centers to follow. Various, atypical codes such 94660, 95807, 99212 are widely in use by many facilities and different types of providers, but the AASM in the past has reported information inconsistent with their current use in clinical venues. Clarifying these codes will help sleep centers add more resources to their treatment pathways in their clinics.
Last, there was very little discussion about the potential for cash basis sleep medicine practice, albeit the executive director of the AASM astutely pointed out that high deductible insurance is steering many people into a de facto cash base circumstance. But, it remains unclear whether or not the AASM will develop a cash-based practice model for general use by its members. The emerging aspects of telemedicine may promote such a model as has been discussed previously.