The Changing World of Dental Sleep Medicine

by Dr. Warren Schlott

The practice of sleep medicine and dental sleep medicine is rapidly changing. The Affordable Health Care Act has forced changes in medicine that have consequences for dental sleep medicine. Exploring what “was” and what “is” can be beneficial to the success of a dental sleep practice. For those that can adapt, dental sleep medicine can and will flourish in the future.
Changes in Medicine and Practices
Not so long ago, medicine was dominated by the family doctor who was associated with a hospital. The doctor ran his practice as an independent business. The idea of being an employee was foreign to the physician. However, with the exception of concierge physicians, the independent primary care physician (PCP) is slowly becoming extinct. Primary care physicians are becoming employees of independent practice associations (IPA) or health maintenance organizations (HMO). Financial and “network” issues are the foremost reason physicians are driven this route. Too many physicians exit their education heavily in debt and are unable to fund the opening of a practice. Furthermore, medical insurance companies favor IPA- and HMO-employed physicians over the solo practitioner. To contain costs, insurance companies create “networks” that control the supply of medical patients to the physicians. To gain access to patients, physicians must join the insurance networks. Insurance companies find it easier to negotiate with IPAs and HMOs rather than individuals physicians. Hence, the solo primary care physician finds it nearly impossible to compete with IPAs and HMOs with regard to pricing and more importantly, access to the network. Therefore, most physicians become employees of IPAs or HMOs. This dictates changes in the manner PCPs practice medicine.
Whereas IPAs and HMOs don’t exactly dictate how the doctor is to practice, they create financial incentives that influence PCP’s choices. One carrot IPAs and HMO use is scheduling. Most often the primary care physicians are scheduled to see patients every 15 minutes. Among other items, physician’s bonuses often are affected by the number of patients seen. Because the patient’s first encounter in the treatment/exam room is with a nurse who weighs the patient, takes his or hers’ blood pressure, temperature, determines the patient’s chief compliant, and add chit-chat, the physician is left with only 5-8 minutes to see the patient. During this time the physician is suppose to listen to the patient’s complaints, examine the patient, and give treatment. It is no wonder why family doctors often run behind schedule. Unless the patient complains of sleep disorders it is unlikely the physician will inquire about sleep issues. This is one of the reasons sleep disorders are under diagnosed. With a plethora of other medical problems to address, there is essentially no time in their busy schedule for the PCP to screen for sleep issues. However, this creates a paradox!
PCP, the Sleep Physician, and DMEs in the Real World
In an ideal world, patients with sleep disorders including sleep apnea would be seen by a sleep specialist. The sleep physician would examine, test, and treat the sleep patient. However, in the real world, this is the exception rather than the rule. It has been reported that the number of physicians electing to study sleep disorders and become boarded in sleep is declining. Presumably, this is because other fields of medicine offer more financial rewards. The vast majority of sleep patients are referred for a sleep study by their “too busy” primary care physician only after complaining of sleep problems. The sleep study can be completed at home by the patient (HST), or conducted by a technician in the sleep lab (PSG). Which type of sleep study is often directed by the patient’s insurance company. Because of cost differences between HST and PSG, the trend is to the less expensive home sleep study. Once completed, the studies are then auto scored by computer, or more often by the lab technician. The sleep study is then reviewed by a sleep physician who makes a diagnosis and offers treatment recommendations. Rarely does the sleep physician see the patient to discuss the sleep malady and offer treatment. Most often the sleep physician’s report, including a diagnosis and treatment recommendations is then sent to the PCP. The recommendations for treatment are almost always CPAP, surgery, mandibular advancement device, and weight loss. It is up to the PCP to prescribe the treatment choice. The reality is that the vast majority of primary care physicians have no training and little knowledge about sleep. (When the author has surveyed PCPs, less than 2% claim to have attended a lecture about sleep apnea in or out of school). So what does the PCP do? He or she calls the Durable Medical Equipment (DME) representative selected by the IPA, HMO, or the representative who calls on their office. The doctor knows the DME will treat the patient with CPAP and remove the sleep problem from his or her domain. The DME will follow the sleep physician’s first treatment of choice, CPAP; and thus will provide the patient with a CPAP, hose, mask, and basic instructions. Needless to say, it is in the DME’s financial interest to sell a CPAP unit. Unfortunately, what occurs too often is that once the CPAP is delivered to the patient, the patient has little to no contact with the DME until it’s time for a new hose and mask. Often the patient struggles with CPAP. Sometimes the DME will help with CPAP use, but often the patient’s complaint is ignored. Especially vulnerable to this scenario are Medicare patients and patients with poor insurance plans. The patient may call the PCP for help. Unfortunately, the family doctor cannot offer help because of their lack of knowledge, and other than the DME, the physician has nowhere to turn for aid. Remember, most sleep physicians do not see patients. So the patient is helpless and gives up on treatment for their sleep apnea.
The good news is that not all is lost. New CPAP units come with a card that monitors patient use. This allows the patient to be monitored via the cloud by DMEs, and hence insurance companies. If the patient is not using their CPAP as prescribed for the first three months, insurance companies are beginning to repossess the CPAP unit. For financial gain, it behooves the DME to help the patient maintain CPAP treatment. The jury is still out if this will change CPAP compliance. Regardless, it appears that treatment for sleep apnea is shifting from the sleep physician to the primary care physician, who just happens to be poorly trained to deal with this malady. So where does this leave dentistry?
Dental Sleep and the PCP
Since the primary care physician is too busy and has little knowledge of sleep apnea, it appears that at the very least, screening for sleep apnea could fall to dentistry. At the very most, dentistry can offer hope for those patients who fail CPAP treatment. However, it is not that simple.
All dental patients should be screened for sleep apnea, just as all dental patients should be screened for oral cancer. Patients can be screened with a written questionnaire such as the Epworth Test, Berlin Questionnaire, or Stop Bang Assessment. However, it’s the author’s opinion that many patients do not truthfully answer the questions. Not many patients will admit to falling asleep while driving. Perhaps a better way to screen patients is to verbally ask questions about how the patient sleeps, and to look for oral signs of sleep apnea. If you suspect that the patient may have sleep apnea, the patient should be referred to their PCP with a report of your findings. Most PCPs will be impressed with you, and perhaps become a referral source. The primary care physician appreciates your referral because a diagnosis of sleep apnea can potentially mean more money, as patient management becomes more complex, and hence can create more insurance reimbursement for each patient visit. If the patient does not have a family doctor, the patient should be directly referred to a sleep lab for a sleep study. There a sleep physician can make a diagnosis and treatment recommendations. There is a trend for dentists to bypass the physician and use a home sleep company. This company provides the dentist with test results, a sleep physician diagnosis, treatment recommendations and perhaps a prescription for oral appliances. The problem is that too many dentists for their own financial gain, treat every patient, even if treatment success chances are slim to none, with an oral appliance. This only reinforces many physicians’ biases against sleep dentistry. If this route is taken, it behooves the dentist to establish a relationship with a local sleep physician and/or DME who can provide CPAP therapy when oral appliance therapy fails. Without local physician oversight, use an of out-of-area sleep physician violates the spirit of the AADSM’s guidelines, and may even violate state medical laws. The author has been audited by insurance companies to check that among other things an appropriate physician prescription for an oral appliance was in the patient chart. Dental appliance treatment for snoring and sleep apnea is becoming more main stream, but there is a long way to go. Many sleep physicians now recognize the benefits of treatment with oral appliances. However, a plethora of sleep physicians still believe that CPAP is the only viable treatment for snoring and sleep apnea. As they are more likely to hear about patient complaints of CPAP, primary care physicians seem to be more enthusiastic than many sleep physicians of oral appliance therapy. Since PCPs appear to be the new directing force for sleep apnea treatment, this is probably a positive for dentistry. Nonetheless, obstacles remain.
Insurance Effects
The Affordable Care Act has changed medical insurance coverage. HMO plans are declining and PPO plans are on the rise. However, this positive is negated by high deductible plans. Gone are the days of $250 deductibles. The trend is to high deductibles, $3000-5000 or higher, or to consumer directed plans. Minimal insurance coverage generally has high deductibles. Unfortunately, these plans generally tend to be held by the lower income population who may have problems meeting the deductible. Consumer directed plans have high deductibles, but are off-set by money set aside in accounts funded by the patient and often matched by the employer. Even though the insurance may offer coverage for oral appliances, until the high deductible is met, many patients are being required to pay cash for services rendered. This is inexpedient, as medical patients, unlike dental patients, still have the mindset that all procedures should be covered by insurance. Being reimbursed for providing treatment for sleep apnea has become more problematic. Adding salt to the wound, regardless of what many are stating, insurance reimbursement for treatment is trending lower. (Dental insurance reimbursement is also drifting lower.) Hence, the practitioner must adapt to the new realities and collect more money from the patient, or cut costs or profits.
Further complicating matters is the fact that many insurance companies have their own requirements that must be met before payment is rendered. Whereas, most insurance companies require a copy of the sleep study, some need documentation that the patient failed CPAP therapy before payment is made. Others demand a prescription for an oral appliance from a physician. Still others require a copy of a paid lab slip demonstrating that a FDA approved appliance was used. And some insurance companies want all of the above. Reimbursement is becoming more complicated.
Sleep Dentistry Treatment Options
Unfortunately, medicine and sleep dentistry do not have the perfect treatment for snoring and sleep apnea. CPAP effectively treats most, but not all, sleep apnea. However, its effectiveness is off-set with severe compliance issues. Oral appliances have higher compliance, but cannot effectively treat all sleep apnea. Surgical procedures for sleep apnea are becoming more of an adjunct to other therapies, than a treatment per se. Neural stimulation holds promise, but still is in its infancy. These facts create a quandary for which treatment to use. Guidelines suggest using oral appliances for mild sleep apnea, for patients who have mostly hypopneas as opposed to apneas, or for patients who fail CPAP therapy. But what do you do when oral appliances don’t effectively treat sleep apnea, but the patient won’t wear CPAP?
A developing trend is to use combinations of therapies when oral appliances by themselves fail to sufficiently treat apneas. For example, oral appliances can be combined with positional therapy for individuals who have moderate to severe “positional” sleep apnea. Good results have been obtained with this combination. An example of this treatment would be use of an oral appliance and “Night Shift”. Rumor has it, that a major manufacturer of oral appliances may soon routinely provide a positional aid with their appliances. Another option is to combine CPAP with oral appliance therapy. An example of this is the CPAP Pro. This combination removes straps from the head and neck that were once required to hold the nasal pillow in place. Combination of oral appliance and CPAP routinely reduces air pressures by about 25-50%. The author’s experience is that patients readily accept this treatment protocol, and this may be the answer for those severe apnea patients who don’t tolerate “stand alone” CPAP. From a health and business perspective, this treatment protocol makes everyone a winner. The patient wins because they are getting treatment and become healthier. The DME wins because the patient remains on CPAP, and semi-annual hoses and masks sales can be made. The dentist wins by making an oral appliance. Unfortunately, most physicians including sleep physicians are not aware of this mode of treatment. Another alternative treatment is to provide the sleep patient with a custom CPAP mask. The custom mask removes straps and pressure points from the face. It is more stable than a standard mask, and it often leads to a reduction of pressures. Physicians and DMEs are unaware that such a product exists. Because of these facts, and because of matters previously discussed, new strategies are required to develop a dental sleep practice.
Dental Sleep Practice Development
The easiest method to start a dental sleep practice is to screen the dental practice patients. Statistically, about 30% of these patients will have sleep apnea. With an ongoing patient relationship, it is easy an first step to convert these patients to dental sleep patients. Treating these patients allows the dentist to develop skills with oral appliance therapy. With confidence the dentist can then move to develop outside patient referrals. Since the beginning of dental sleep practices, it has been gospel to associate with a sleep physician(s) and/or sleep lab(s) for their help in referring patients to the dentist for oral appliance therapy. However, with the primary care physician becoming the “de facto general” of sleep apnea treatment, it would be prudent for the sleep dentist to develop relationships with PCP. This does not mean relationships with sleep physicians, sleep labs, and other medical specialists should be abandoned. They can be sources of patients, but remember most labs and many sleep physicians own part or all of a DME. Hence, they have financial incentive to place all patients on CPAP. Unless you refer a great number of patients to them, oral appliance therapy is secondary to them. On the other hand, the PCP has little or no financial incentive with regards to CPAP or oral appliance therapy. Their goal is to have the patient satisfactorily treated without regard to treatment method. Thus, the new norm should be to target the primary care physicians for help with developing the sleep practice. Unfortunately, as stated earlier, most PCPs do not routinely screen for sleep apnea. Therefore, to develop a healthy dental sleep practice, a great number of referring PCPs are required. Remember, most PCPs only refer for sleep testing for only after the patient complains of sleeping problems. To overcome this issue, it may be wiser to become a provider for an IPA or HMO group with their large group of PCPs. Practitioners of IPAs and HMOs only refer to the “network” sleep dentist. However, becoming a member sleep dentist of an IPA or HMO is easier said than done.
Most if not all such groups, limit the number of sleep dentist providers (generally one) to a given geographic region. To become a provider of the IPA or HMO requires knowing the medical director or the managing business person who is in charge of network membership. The sleep dentist must convince this person that you benefit the group with your hire. Once a dentist becomes a member, the work is not done. To receive referrals from PCPs requires that the dentist educate them about sleep apnea and oral appliance therapy. This is best accomplished during the group’s business meetings. Often the IPA or HMO will provide the dentist an hour for education. It is the author’s experience that most physicians do not want to meet after their long day’s work, so lunch meetings work best. Expect PCPs to be enthusiastic to learn that sleep dentist can be of great service to their patients. (Remember they are the ones hearing patient complaints). It is reasonable to expect referrals, but it takes to time to build physician confidence. One key to winning physician acceptance is to be a Medicare provider. Physicians accept Medicare and expect the sleep dentist to treat their Medicare patients. Hence the sleep dentist should become a Medicare provider. Also, it helps to provide the physician with written SOAP notes, letters, and /or e-mails detailing the dentist’s finding and treatment. Programs such as Dental Writer can simplify this task. It is also recommended that the dentist, not the patient, make adjustments or titrations to the appliance. This allows the dentist to “stay on top” of the patient. Be sure to follow-up with a sleep study to verify results. If conditions warrant, add positional therapy or CPAP. If the dentist chooses to use combination therapy, he or she must be familiar with the various types of positional devices and methods. They also should be familiar with CPAP machines and hoses. Patients will ask questions and the answers needed to be known. It is wise to notify the PCP or sleep physician if you choose to add combination therapy or revert to a custom mask. The physician uanderstands that treatment doesn’t always cure or manage the disease. They appreciate the dentist’s efforts to manage a condition they know little about.
There are some who advocate placing your employee in the physician’s office to screen for snoring and sleep apnea. Most IPAs and HMOs will not allow this, and even if they did, it would be an expensive proposition. Regardless, the PCP would have to concur with the findings of your employee, refer the patient for a sleep study, and then if conditions warrant (mild sleep apnea) refer the patient to you for treatment. It seems more prudent and less expensive to just develop a large referring base of PCPs and other physicians and let them handle the leg work.
It is possible to market to the public at large, by-passing the physician. Again, there are issues to overcome. The dentist cannot diagnosis sleep apnea, and for insurance to pay for oral appliance treatment, insurance companies are most often requiring a prescription for oral appliance therapy from a physician. These issues can be overcome by having a referral base of PCPs and sleep physicians, and simply sending the patients to them once you have screened the patient. Newspaper ads are relatively inexpensive. A simple message in the ad will generate responses, but most will be Medicare patients. Younger people as a rule don’t generally read newspapers. They receive their news via the internet. A presence on the internet is prudent. However, to have a successful presence there must be key words on the web-site, and because of competition a service that places you at the top of searches is a must.
In metropolitan areas this can and will likely costs thousands of dollars monthly. Radio is the most expensive advertising and can bring exceptional results. The problem is that in many metropolitan areas, radio can cover large areas. Since many patients are unwilling to drive great distances, multiple office locations are necessary. In addition, radio ads must be heard multiple times before a person reacts. This means the ad must play for weeks, but more likely months before a return on investment is reached. Other than network television, TV is generally less expensive than radio. There is an upfront cost of thousands of dollars for producing an ad, but running the ad on cable TV is quite reasonable. The trick is to pick shows that draw the audience you want to see your advertisement. Again, like radio, repetition of showings is required before potential patients respond. All in all, marketing to the public can produce results, but it is more expensive than developing physician referrals.
The medical field is rapidly changing and having effects on dental sleep medicine. Instead of targeting sleep physicians and sleep labs for patient referrals, the sleep dentist should concentrate on primary care physicians and indirectly IPAs and HMOs. The dental sleep dentist will need to develop communication skills with these groups. Marketing to the public can be effective, but is more expensive than developing a referring network. Insurance companies are becoming more responsive to oral appliance therapy, but requirements for reimbursement are becoming more stringent. The sleep dentist should be familiar with positional therapy and know the ins and out of CPAP therapy so that combinations of therapies can be considered to enhance oral appliance efficacy.

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