Sleep Medicine as a Primary Specialty?

[DrLEvanSmith]

Hello everybody!

So, I am a third-year Neurology Resident currently. We get a good amount if exposure to Sleep Medicine, however basically only as an "add-on" to a Neurology practice. Sleep really interests me, but whenever I mention that I may want to pursue it as a primary specialty, my attendings shoot it down saying it's not viable as a solo practice due to decreasing reimbursement for sleep studies, etc. In truth, both the specialty itself as well as the lifestyle I see really appeals to me, but I wanted to let if anyone out there does in fact have a Sleep-only practice, and if they do how much they enjoy it and if it is viable on its own (rather than my needing to essentially "tack it on" to a Neurology practice).

Hope that made sense; thank you everyone!

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[michaelrack]

I used to have a sleep only practice... but the procedural reimbursement really dropped. I don't really like clinic that much and now do mostly inpatient psychiatry. One could still do a sleep only practice, but the reimbursement would probably be less than a neurology cllinic. My guess would be in the 250 to 275 k range.

 

[Bobblehead]

It will be hard to do sleep only due to the reimbursement issues you've been told about. You can certainly focus on sleep in your future neurology group and if you really enjoy the specialty likely your partners will be very happy to have you see all their sleep patients which will drive up the percentage of time that you end up doing sleep vs neurology.

But you should expect and expect to count on your neurology specialization to pay for your time. It can never hurt to be more versatile and if you have any particular areas in neurology you wish to focus on, then make sure you plan accordingly.

 

[Sushirolls]

Sleep as 100% of your practice is doable, there are jobs, but typically its about ~30 across the country on the usual job boards, which means going from neurology where you could practice anywhere to now a more limiting geography specialty.

There are still pockets, more rural, in the country that are ripe for an entrepreneurial sleep doc to open up shop.

Right now I have a sleep doc who is sub leasing from me (I'm psych) and is choosing to make a go of a 100% sleep practice in the midst of heavy saturation. Person didn't want to move after getting the short end from Big Box shops. This person's approach is to rock HST, and doing all admin themselves until growth dictates hiring staff. Has a previous Big Box shop hospital privileges to still refer to for in lab if/when needed. This person is also doing something different, plans to do CBTi themselves and use the 90833 add on codes for those sessions. As a psychiatrist I try to get people to do CBTi but 9 out of 10 times I strike out in referring them ("give me the pill doc"), but this doc is going to get my 1 in 10.

This doc could do well to practice their base specialty and Sleep Medicine, but simply doesn't want to. I'm curious to see how this practice goes.

From what I know of the specialty, I suspect without solid referral base for steady stream of consults, the overhead of in lab and all the employees associated with it, just isn't worth it. I could see the field having sleep docs in the community doing their thing, and either consolidating their in lab to a hospital or a joint venture with other docs to reduce costs, especially as HST tech improves and takes over more of the studies by percentage.

 

[Sushirolls]

Other nuances of the field come with dentistry intrusions, and half the dentists in the community advertising themselves as sleep specialists, and simple google searches over whelms actual attempts to locate a real sleep doc. You also have DME companies looking to expand into also having clinical service lines, or they offer set ups for direct referral from PCP where they simply order the HST, and some where a 'moonlighting' sleep doc is reading those studies on the cheap...

These direct referrals are shunting historic consults away from the sleep medicine specialist to DME type set ups. Natropaths, Dentists, some PCPs are skipping the sleep medicine specialists. The significant advertising of oral appliances by the dental side of things is impacting the field, as we know OA aren't that great for OSA and dentists know that sleep docs are obligated the majority of the time to steer the patients towards the appropriate treatment - CPAP.

Cardiology and PCPs are the biggest referrals to sleep medicine. These days most are in large conglomerate groups associated with big box shops. Big Box Shops are keeping around 1 sleep doc to read studies and the rest of the positions populating with mid-levels. So it can be a tough road to get referrals in the community from sources not associated with Big Box shops. There are only so many independent PCP groups.

Psychiatry should be a huge referral source. I am for sure, and refer constantly, but so many just didn't get the training to understand the importance. And my experiences of trying to educate colleagues to spot it and refer weren't successful. Then there are the PCPs who simply believe only the worst of the worst severe OSA with numerous risk factors are worthy of referrals.

The patients are out there, and OSA is woefully under-treated, and Insomnia with CBTi is woefully undeserved. The issue is how to capture those patients? And is an independent sleep doc willing to do their own CBTi?

 

[Sushirolls]

Now recently learned from Sleep Doc there are small primary care practices where they use a 3rd party DME company to order the HST, and when the results come back they "read" their own sleep study and bill for it. An ARNP informed Sleep Doc they just reference a text book for how to 'interpret the study' and bill for it. They are also getting paid by insurance, too. So they don't even have a need to refer to Sleep Medicine...

So AASM obviously hasn't done a good enough job in putting the lock down on study interpretation and billing, so this also cuts into practice development for a Sleep practice.

 

[Needachange15]

I used to have a sleep only practice... but the procedural reimbursement really dropped. I don't really like clinic that much and now do mostly inpatient psychiatry. One could still do a sleep only practice, but the reimbursement would probably be less than a neurology cllinic. My guess would be in the 250 to 275 k range.

Still better than my FM salary

 

[Sushirolls]

Outpatient E&M based practices also have geographic variability in insurance reimbursement. My current location is good for sleep medicine, per my tenant, but across the border in neighboring state the rates, and also for medicare, are uniformly less.

 

[nexus73]

Sleep as 100% of your practice is doable, there are jobs, but typically its about ~30 across the country on the usual job boards, which means going from neurology where you could practice anywhere to now a more limiting geography specialty.

There are still pockets, more rural, in the country that are ripe for an entrepreneurial sleep doc to open up shop.

Right now I have a sleep doc who is sub leasing from me (I'm psych) and is choosing to make a go of a 100% sleep practice in the midst of heavy saturation. Person didn't want to move after getting the short end from Big Box shops. This person's approach is to rock HST, and doing all admin themselves until growth dictates hiring staff. Has a previous Big Box shop hospital privileges to still refer to for in lab if/when needed. This person is also doing something different, plans to do CBTi themselves and use the 90833 add on codes for those sessions. As a psychiatrist I try to get people to do CBTi but 9 out of 10 times I strike out in referring them ("give me the pill doc"), but this doc is going to get my 1 in 10.

This doc could do well to practice their base specialty and Sleep Medicine, but simply doesn't want to. I'm curious to see how this practice goes.

From what I know of the specialty, I suspect without solid referral base for steady stream of consults, the overhead of in lab and all the employees associated with it, just isn't worth it. I could see the field having sleep docs in the community doing their thing, and either consolidating their in lab to a hospital or a joint venture with other docs to reduce costs, especially as HST tech improves and takes over more of the studies by percentage.

Can non mental health providers bill psychotherapy?

 

[Sushirolls]

90833 is not restricted to Psychiatry with majority of insurance. 1-2 or two might deny. So, yes is the answer.

In the world of Sleep Medicine, good look finding a Neurologist or Pulm or IM or FM base training doc who wants to and is good at doing their own CBTi.