Mar 182012

Sleep docs don't come off looking so hot in this recent NPR story, which paints some of them as opportunistic plunderers of the nation's health care dollars, over-ordering expensive sleep studies to make a buck.

As reporter Jenny Gold points out, the number of sleep studies performed in the U.S. has quadrupled over the past 10 years, with Medicare payments also quadrupling from $62 million spent on polysomnograms in 2001 to $235 million in 2009. A night in a sleep lab costs ~$1,900, and most patients spend two nights (one for diagnosis, one for CPAP titration).

Not only Medicare, but private insurers are paying through the nose, and they're grousing about all their dollars waking up in sleep physicians' bank accounts. A Blue Cross exec is quoted as saying:

We are spending more and more money on sleep testing and treatment, and like anything else in health care, there are unscrupulous people out there who are more than happy to do testing and treatment that might be of questionable value. This might be because of naiveté on the part of the physician, or unfortunately, it could be done for the sake of improving the cash flow of the business.

Oh, snap.

They call out the American Academy of Sleep Medicine, the protector of professional ideals and ethics who also just happens to have offered a seminar to teach physicians the "business of sleep medicine" at a golf resort in Arizona in February, with associated industry partners, of course (one company promoting its wares to sleep docs had promotional images on its site of a physician wearing a white lab coat with pockets stuffed full of dollar bills; the company took the photo down after the NPR piece ran, replacing it with some stock clip art).

The insurers, and groups representing large employers' health plans, argue that not enough patients are being counseled to lose weight as a first-line therapy. But either they don't know what we know, or they're pretending they don't: outside of controlled clinical trials or supervised weight loss programs, patients rarely lose weight in any meaningful amount. Obesity experts have given up on even recommending that people aim for a truly healthy weight -- advising only a "realistic" weight loss goal of 5 - 7% of body weight. In a 200 pound, 5 foot-5-inch woman, that's 10 pounds, which would reduce BMI from 33 to 31: does anyone think that's going to cure sleep apnea? Studies say no: based on the best-quality randomized trials, patients need to lose at least 22 pounds on average to expect a meaningful improvement (~50% reduction) in obstructive sleep apnea. Outside of medically-supervised weight loss programs using very-low-calorie diets or bariatric surgery, that much sustained weight loss is highly unusual.

I'm sure plenty of sleep physicians are cashing in on this profitable sideshow to the nation's obesity epidemic, and I wholeheartedly agree things are becoming ridiculous (with 12 million supposedly undiagnosed with OSA, and with 33% of the population obese and at risk, what's next, complementary CPAP machines for business travelers at the Embassy Suites?). But on the whole, doctors order sleep studies because they're the gold standard test for diagnosing sleep apnea, and order CPAP machines because they're the most effective therapy. With the popular media painting sleep apnea as a cause of everything from sudden death to silent strokes, what else do you expect us to do? If insurers don't like the price tag, or the return on investment in terms of health and reduction in cardiovascular risk, they can do what they do very well: change the game by cutting physician payments and creating  bureaucratic hoops to jump through.

That's exactly what's happening in Massachusetts and Virginia, where polysomnograms now require preauthorization from insurers. Meanwhile, the Centers for Medicare and Medicaid (CMS) have identified sleep studies as a target for special scrutiny, the Department of Justice is going after sleep centers that use unlicensed technicians, and the Office of Inspector General has moved to block new moneymaking ventures between sleep physicians and hospitals.

Home sleep testing with auto-titrating CPAP is probably the answer, but comes with its own limitations, as sleep physicians will be eager to tell you about -- painting a picture of disaster if home testing becomes widespread and primary care physicians misdiagnose and mismanage all the supposed complexities of obstructive sleep apnea and possible coexisting sleep disorders. To which I answer, did a little CPAP ever kill anyone?

Jenny Gold, "The Sleep Apnea Business is Booming, and Insurers Aren't Happy," January 16 2012,

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Insurers sound off to NPR against moneymaking sleep centers