Organization and Structure for Sleep Medicine Programs at Academic Institutions: Part 2—Goals and Strategies to Optimize Patient Care, Education, and Discovery

EXECUTIVE SUMMARY

An associated white paper, previous to this one, describes the current institutional infrastructure for academic sleep medicine, its multidisciplinary roots, and related challenges that the field faces in patient care, education, and research. Here we discuss existing approaches to these challenges at some centers, and ideas to maximize the potential that academic sleep medicine has to improve human health, effectiveness of medical care, academic identity, and the likelihood of achieving commonly accepted elements of academic success. Certain features appear to be a recurrent theme for those institutions that have developed existing programs and a recurrent need for others that envision such programs. Key elements identified within this paper include a structure for sleep medicine that includes budgetary responsibility. The institutional reporting structure should recognize sleep medicine as a distinct academic field, with responsibility for defined space, academic appointments, salary control, provision of clinical services across a wide spectrum of sleep-related conditions, and supervision of sleep education. The institutional structure for sleep medicine should permit it to implement research, and also stabilize it with a funds flow that allows reinvestment of those funds into the sleep program.

This paper provides an analysis of some existing programs, notes how several have implemented guiding principles from the Institution of Medicine (IOM) report, and describes in more detail some unique programmatic structures, administrative relationships, and financial solutions. The paper also discusses eroding financial support and possible strategies to prevent pro-grammatic instability from ongoing health care funding changes. Finally, this report considers potential ways to improve efficiency of sleep centers and raise awareness of both recognized and “unrecognized” benefits that a sleep center brings to an institution.

No doubt exists that the field of sleep medicine is undergoing considerable change, and will continue to evolve. Academic sleep centers must reorganize now if this new field is to maximize its potential for fundamental contributions to public health. The Academic Affairs Committee hopes that through identification of the challenges faced, solutions devised by some programs, and creative visions for the future, both this and the preceding white paper can help advance knowledge in the field, training for future clinicians and investigators, and the practice of sleep medicine. This report is endorsed by the Boards of Directors of the American Academy of Sleep Medicine and the Sleep Research Society.

1. CHARTING A COURSE FOR THE FUTURE OF ACADEMIC SLEEP MEDICINE: ADMINISTRATIVE, CLINICAL, RESEARCH, AND EDUCATIONAL GOALS

Many of the challenges for sleep medicine that are inherent in existing academic medical infrastructure were described in the companion white paper. These challenges for the field seem less difficult to identify than the required solutions largely because the organization of sleep in one academic medical center often bears little resemblance to that of another. For example, at the University of Pennsylvania, the organizational model for sleep medicine somewhat resembles that of a cancer center, with considerable administrative autonomy yet involvement of traditional departments, whereas at many other institutions similar cross-departmental constructs cannot serve as cost and revenue centers. At some institutions, such as the University of Michigan, chairs of clinical departments organized along the lines of traditional disciplines have responsibility for academic budgets, whereas at other universities, deans are expected to play a more central role in financial decisions about available resources. At some institutions, such as Veterans' Administration healthcare networks, funding is often tied to clinical need and institutional, regional, state, or national priorities. Depending on the institution, a sleep laboratory may be run by a hospital, a faculty group practice, an affiliated private practice, or a company to which this service has been outsourced.

Given the diversity of existing institutional structures and stakeholders, the Academic Affairs Committee of the American Academy of Sleep Medicine has chosen to recommend, as follows, goals and features that sleep organizational structures should accomplish, rather than recipes by which such goals must be obtained. The specific strategies necessary at each institution will most likely be determined in large part by mechanisms already in place to provide other disciplines with vital opportunities for growth, self-reinvestment, institutional support, and organized forward planning. Availability of these opportunities to sleep medicine will be critical to ensure its development as an academic field that can deliver on the fundamental promise for creating a positive impact on human health and quality of life.

The epidemiology of sleep disorders, their impact, existence of effective intervention, and potential for tangibly improved health should all motivate efforts to improve the infrastructure that supports sleep medicine. This field needs local health-system-based opportunities for growth, self-reinvestment, institutional support, and forward planning. Each of these features may be unavailable to sleep programs at present. Each will be essential, however, to ensure the continued development of sleep medicine as a field with visible identity, recognized importance, key contributions, new opportunities, and size and maturity that warrant a seat at a table often reserved for more traditional fields.

1.1. Budgetary Responsibility

Perhaps the single most important goal is for academic sleep programs to achieve a structure that allows them to act as cost and revenue centers. Such cost centers must be semi-autonomous to the extent that neurology, cardiology, or pediatrics enjoys similar opportunities for self-determination at the given medical institution. Sleep patient care, research, and education functions are currently so widely spread among disparate structures and budgets that few individuals, academic offices, or health system leaders recognize the high impact that this field already delivers. A semi-autonomous financial structure should allow sleep programs to access self-generated financial margins—to an extent commensurate with that afforded other established medical disciplines—and to reinvest those funds toward academic development. Such a structure should offer a defined and recognizable target for institutional rather than more narrow and limited departmental investment. Sleep medicine is now much more than just a subspecialty of any historical parent or traditional department. Institutional investment should be commensurate in size with that directed to other established programs of similar size, productivity, and future potential. A semi-autonomous cost and revenue center structure would diminish the widespread tendency for financial margin generated by sleep services or research to support other traditional “parent” disciplines rather than sleep medicine itself. This practice has inevitably limited development of academic sleep medicine. Such a structure might also allow academic physician salaries to be sufficiently competitive to reduce the current incentive, disproportionate to that in less procedure-oriented fields, for some of the most promising young sleep specialists to forego successful careers in academic settings. If sleep programs in the future incur negative rather than positive margins, such a structure would still permit better evaluation and accountability of the extent to which sleep services merit institutional support, by virtue of clinical, research, and educational contributions to the function of the medical system, success of allied services, academic mission, and overall health of patients served.

1.2. Institutional Reporting Structure that Recognizes Sleep Medicine as a Distinct Academic Field

To follow budgetary responsibilities, the director of the sleep program should report directly to the medical school dean, health center CEO, or other equivalent, extra-departmental, institutional leader. This institutional leader must have a mandate to embody an institutional perspective rather than that of any one particular section, department, or institute, as many major existing disciplines are potential stakeholders in sleep services, research, and education. This individual should have responsibility for institutional-level funding and investment decisions, and have a mandate to support the sleep program in a manner similar to that used for other independent medical disciplines, whether they be organized as departments, centers, or institutes.

1.3. Responsibility for Defined Space

The sleep program should have oversight of assigned space suitable for conduct of its clinical, research, and educational activities. Preferably these activities should be physically contiguous, to foster cross-fertilization between clinical, educational, and research faculty and staff, and between the investigators who focus on preclinical, translational, human, and clinical aims. The director and faculty must have the ability to prioritize use of assigned space according to a logical overall vision for how sleep programmatic strengths can be most effectively enhanced and weaknesses addressed.

1.4. Academic Appointments

The director and senior faculty of the sleep program should have at least shared responsibility for new faculty appointments and promotions of existing faculty. Sleep program faculty should assist with applying criteria for promotion, to a similar extent that traditional departments are given this opportunity. Senior sleep program faculty should participate in evaluation of progress by junior colleagues toward meeting these criteria. In joint appointments, these responsibilities may be shared with traditional department chairs or other faculty. However, the sleep program should at least share the responsibility to contribute to appointment and promotion processes that are fundamental to any academic system. Participation of sleep faculty and use of sleep faculty-defined criteria are necessary because traditional departmental reviews are less likely to appreciate the cross-disciplinary work often performed by sleep faculty without regard to traditional departmental knowledge silos.

1.5. Salaries

Sleep programs should have responsibility for assignment of salaries—or at least the portions of salaries that reflect sleep-related research, educational, and clinical contributions—through the use of autonomous or semiautonomous budgets as described above. Responsibility for overall salaries could be shared with traditional departments when sleep clinicians also provide clinical care unrelated to sleep, or when sleep researchers also receive external support for investigation unrelated to sleep. When shared, the proportion of effort (time) spent in sleep should be compensated through the sleep program, and the proportion spent outside sleep should be compensated from other budgets. For the proportion of effort spent in sleep, a sleep program should offer equivalent compensation for identical sleep services, without regard to background training (in other fields) acquired before sleep medicine. For example, sleep specialists with backgrounds in otolaryngology and family medicine who are equally credentialed in sleep medicine should be compensated in an equivalent manner for interpretation of a sleep study, even though overall compensation may differ because time spent in the operating room is often compensated at higher rates than time spent in a clinic setting. The need to provide similar compensation for equivalent services will become increasingly important as clinicians from backgrounds in widely different fields converge into a new interdisciplinary field of sleep medicine. At the time of this writing, individuals with backgrounds in internal medicine, neurology, psychiatry, pediatrics, otolaryngology, family medicine, and anesthesiology can all, with appropriate sleep fellowship training, qualify to sit for board certification in sleep medicine.

1.6. Clinical Services

Sleep programs must have the ability to organize clinical services that address complaints related to sleep and daytime alertness across a wide spectrum of conditions that must be considered, evaluated, and treated. Sleep programs should be able to organize, coordinate, monitor, and supervise locations at which such services are offered. Sleep programs need administrative ability to offer within their assigned space any necessary subspecialty and multidisciplinary clinic services, such as cognitive behavioral therapy for insomnia, evaluation of surgery or oral appliance options for sleep apnea, and assessment of children or older persons. When specialized equipment or operating rooms are required, the services should be provided at the site of those facilities, but still in close coordination with the sleep program. The sleep program should serve as a single port of entry—for example on internet sites, signage, and institutional brochures—when it comes to institutional services related to sleep and alertness.

1.7. Education

Training of individuals destined to spend most or all of their careers in sleep medicine must evolve. The model of several years in any one of six largely unrelated traditional fields, followed by one year of clinical sleep medicine training, is not optimal to produce academic or clinical practitioners who have the depth and breadth of knowledge to develop the field for the future. Other models could be explored, including a one-year medical internship followed by a multi-year residency specifically in sleep medicine. This format would ensure that each future sleep physician obtains necessary background in internal medicine, pulmonary medicine, neurology, psychiatry, pediatrics, and perhaps other areas, in addition to core competency in sleep medicine itself. This training, in comparison to the current model, would be more likely to produce the highly skilled, dedicated, and research-competent clinical workforce that training programs currently strive to achieve. Other alternatives that expand the depth of knowledge in sleep and sleep research may evolve. Individual clinicians rather than just a community sum total of disparate faculty expertise would be prepared to confront, in a most effective manner, the wide spectrum of disorders that affect sleep and alertness.

The Committee recognizes that considerable time may elapse before a multi-year sleep medicine residency could be planned, approved, funded, and effectuated. In the shorter term, as the field matures, sleep medicine fellowship training could transition into two years instead of one, with some of the additional time spent to enhance knowledge and skills in areas not related to the primary background of the individual trainee. For example, a neurologist could spend time in pulmonary clinics and pulmonary function laboratories, whereas a pulmonologist could spend time in neurology clinics and the EEG laboratory. These newly trained sleep physicians would end up with more similar and versatile expertise. A second goal of the extended training should be to incorporate sleep research. No focused research time is currently included in ACGME-approved 1-year sleep fellowship programs. Additional research exposure may help to address critical shortages of individuals prepared to conduct sleep research.¹ Essentially all internal medicine sub-specialty fellowship training programs are now 2 years or longer. The misconception that sleep medicine is optimally taught in only one year, after highly disparate previous backgrounds, hampers optimal patient care and limits opportunities to identify research interests and potential.

Multidisciplinary and interdepartmental graduate school sleep and biological rhythms training programs should be established. Sufficient faculty already exists at some institutions to accomplish this goal, but they have had no administrative structure in which to organize, plan, and execute this type of program. Establishment of such programs will require investment from institutions themselves and possibly also from the National Institutes of Health. At institutions where independent sleep graduate programs would not be supported by a critical mass of faculty, well-defined sleep-focused tracks should be created within relevant existing graduate programs, again with institutional and possibly National Institutes of Health investment.

Finally, academic sleep programs also should provide training in sleep medicine and sleep science for clinicians, educators, and researchers who do not focus primarily on this field. Sleep programs should have responsibility to teach preclinical medical students, mentor clinical medical students through rotations that expose them to sleep medicine, and educate interns and residents from many sleep-related fields during their clinical training. Graduate courses or classes in sleep and biological rhythms should be integrated into existing graduate programs in a wide range of highly pertinent areas, including but not limited to biology, biochemistry, pharmacology, neuroscience, genetics, and physiology.

1.8. Research

For research stability, indirect dollars received from externally funded grants in sleep and biological rhythms should in part support the sleep program. This funds flow may be facilitated by establishment of sleep programs as autonomous or semiautonomous cost and revenue structures (as above). The reinvestment of such funds in the sleep program should be performed in a visible and standard manner, equivalent to that established for traditional departments, rather than through departments or other entities as intermediaries that may dilute, diminish, fragment, or divert return of such funds to the point that they become unquantifiable. Furthermore, access to sleep-assigned space, and shared access to necessary equipment, facilities, animal housing, and core services, should be available to facilitate collaboration among sleep and rhythms faculty. Sleep researchers will undoubtedly continue for many years to share interests and collaborations with investigators in many traditional clinical and preclinical departments. Locating the sleep program on a central campus as close as possible to a wide variety of other relevant expertise and facilities will facilitate research integration. Similarly, clinical and translational researchers in sleep medicine commonly interact with a wide variety of other departments and centers, and therefore also should be centrally located rather than situated at a satellite location. Off-site locations may seem cost-efficient and attractive for outpatient clinical sleep services, which do not necessarily require proximity to acute care facilities, but off-site faculty locations do not foster the multidisciplinary collaborations that are critical to successful sleep research, education, and clinical functions.

2. APPROACHES TO ACHIEVING THE GOALS OF AN ACADEMIC SLEEP PROGRAM

The above goals and key attributes for successful academic sleep programs will undoubtedly be achieved through different structures at different institutions. Whereas an independent department may be most appropriate at one institution, another may achieve the same goals through a sleep institute, division, center, or program. To the knowledge of this committee, no academic medical system in the United. States has yet established an independent department for sleep and circadian rhythms. No academic medical system has developed an ideal approach, one that embodies all the features enumerated in the preceding section. This section therefore discusses some existing examples of administrative approaches that have been developed, and identifies advantages and disadvantages of each. We describe five programs: University of Pennsylvania, Louisiana State University Health Sciences Center (LSUHSC) Shreveport, University of Wisconsin – Madison, Harvard – Brigham and Women's Hospital, and VA Greater Los Angeles Healthcare System. These are convenient examples only and not meant to exclude others. However, one theme that runs through these programs is that clinical activity is critical to success. For a brief summary of these academic programs see Table 1.

Table 1.

Brief summary of selected sleep medicine academic programs

The University of Pennsylvania (based on information from Dr. Allan Pack) has an historical emphasis on Centers for academic program development. The sleep program was one of the first and is based on an academic research and education center model. A center, however, cannot run clinical programs, which are the purview of a department. The sleep program currently has 48 faculty and receives its budget from the Dean. Clinical faculty (11 members) are also members of the center even though their home may be in another department or division.

The clinical program is an independent clinical Division of Sleep Medicine in the Department of Medicine and has its own budget. Management of the Sleep Division's clinical labs is outsourced. All laboratory staff, however, are employees of the University. Clinical faculty have joint appointments with the Division of Sleep Medicine.

Advantages of this organization include: (1) autonomous decision making, (2) independent budgets (Academic Center, Sleep Division, Clinical Sleep Lab), (3) ability to propose and appoint faculty, and (4) a current strong fiscal base from technical margins generated by the clinical sleep program. The program also confronts several challenges: (1) centers are not as robust as departments for ensuring sustainability, (2) the clinical program is under the Chair of Medicine and not fully independent, and (3) placement of sleep trainees in academia, other than pulmonary medicine, remains difficult.

Louisiana State University Health Sciences Center at Shreveport has developed a Division. The guiding philosophy is that the program should demonstrate its importance, beyond providing good sleep medicine, by valued contributions to the broad mission, goals, and objectives of the institution. Multidisciplinary faculty have primary or joint academic appointments in the Division of Sleep Medicine, within the Department of Neurology. Sleep clinical and research faculty FTEs are funded from the State and negotiated between the Sleep Center Director and the Dean specifically for sleep use. Many sleep costs are paid by barter, such that the hospital provides the space, computers, equipment, supplies, and technicians without ongoing direct costs to the Sleep Medicine Division, in exchange for management expertise and a share of technical revenues. The Division aims to provide quality patient care and sleep studies (for both indigent and paying patients); all requested sleep education for technicians, medical, graduate and allied health students, residents, faculty, and community projects; and major general medical school instruction (integrated courses, physical diagnoses, etc.).

An advantage of this system is that the program provides benefits to the institution in addition to bringing in patients and revenue. The “helpful approach/barter” model has effectively opened doors for sleep faculty needing help in faculty development and research activities, among other opportunities, and has reduced requirements for major up-front money. Losses and economic problems are shared. The lab runs typically without out-of-pocket expense to the Division. Indirect costs from grants can return in part to researchers as well as departments. Challenges in this system include: (1) sleep shares its profits and growth, (2) some faculty time is diverted from clinical sleep and research priorities by the other obligations, which also reduces revenue, and (3) growth tends to occur in a slower, steady manner, rather than major visible bursts.

The University of Wisconsin (UW) Center for Sleep Medicine and Sleep Research Program is a university-wide center with the director reporting to the dean of the medical school. The clinical program including faculty is managed by the UW Medical Foundation, which is a faculty practice plan, not by the sleep center. Technical revenue from sleep laboratory supports the technical and administrative staff for the overall Center. Indirect costs from grants run through departments, not the Center, although some funds are provided by the medical school to support the Center's activities.

The advantages of this organization are: (1) some of the profit from the technical revenues are given back to the Sleep Center for research and development, (2) key administrative and research staff are provided by the Center, and (3) all departments have equal access for research studies, since the Center is not located within any single department. Challenges include: (1) there is no ability to hire faculty (clinical or research) and limited ability to control clinical assignments, (2) development of new initiatives is slow and cumbersome, due to a need to interact with multiple departments and administrative entities, (3) there is limited authority to “assign” teaching or other needed functions to faculty, (4) the sleep laboratory is an independent diagnostic testing facility (IDTF) rather than hospital-based because it is run by a faculty practice plan, (5) no durable medical equipment (DME) is supplied by the Center, and (6) continued profitability of the sleep laboratory will be critical for continued success of this center model.

The Sleep Medicine Division of the Brigham and Women's Hospital (BWH) and Harvard Medical School is in the Department of Medicine. Until early 2013, sleep clinics were outsourced through Sleep Health Centers (SHC). Financial and administrative duties were performed by SHC. Payment from SHC to BWH (for clinic and PSGs) was used to pay faculty and fellows.

Advantages of BWH/SHC relationship included: (1) ability to support talented junior faculty until NIH funding could be established, (2) exposure of clinical trainees to a broad range of faculty with varied expertise, (3) technicians were hired and trained by SHC personnel, and (4) academic faculty could focus on patient care, teaching, and research. Challenges of the SHC/BWH relationship included: (1) priorities of business and academics were not always fully compatible, (2) funding was vulnerable to the Massachusetts reduction in authorization for polysomnography, and to a sudden increase in home sleep testing (HST), as there was no other clinical revenue, and (3) reluctance by some physicians to send patients to a “company” separated geographically from the main Brigham hospital. The vulnerability of this model was highlighted recently by the closure of SHC, which left BWH without a functioning clinical sleep disorders center.

The Veterans' Administration (VA) Greater Los Angeles Healthcare System (GLA) Program is a closed system with funding dependent primarily on patient care needs and VA priorities. GLA has a long and strong history of research funding and the leadership is committed to supporting both research and clinical activities. The VA is supporting “emerging specialties,” and sleep was designated as one of these specialties, with funds provided for fellowship training based on a proposal by the medical center and approval by the region. Currently, GLA plus Olive Medical Center of Los Angeles County run a one-year sleep medicine training program for 4 fellows, with GLA as the administrative center. The program is accredited under Internal Medicine from Cedars Sinai Medical Center (CSMC).

Advantages of the program include: (1) funding for faculty, fellows and technical staff generally depends on current and future need rather than revenue; (2) as the program is administered within Pulmonary Medicine, resources and staff such as sleep technicians can be shared between Pulmonary and Sleep (allowing, for example, the sleep clinic to be staffed by respiratory therapists); (3) DME is provided by the VA through cooperation between Sleep and Prosthetics but essentially controlled by Sleep; (4) control of recruitment of faculty and fellows lies primarily within the Sleep Section of Pulmonary, although final approval and funding are the responsibilities of the Department of Medicine and Chief of Staff; (5) the VA has an independent research funding mechanism in addition to other traditional sources such as the NIH; (6) funded faculty have protected time to do research; (7) the program has a great deal of stability and potential for growth; (8) the VA encourages cooperation with other institutions with exchanges that allow expansion of clinical opportunities and under some circumstances improved opportunities for research funding; and (9) the VA allows trainees to obtain part of their training, if not available at the VA, at other institutions (e.g., pediatrics). Challenges within this system include: (1) funding for new or replacement faculty is competitive with other Divisions and Departments; (2) the Section is within Pulmonary, and priorities for Pulmonary and Critical Care may conflict with those for Sleep; (3) cooperation with allied institutions may change as leadership of those institutions changes; and (4) future growth may be limited without expansion and funding from non-VA institutions.

3. STRATEGIES FOR FINANCIAL VIABILITY

The changes in the current health care climate have brought the field of sleep medicine new and evolving challenges that raise questions about the long term financial solvency of sleep programs across the nation. In just the last few years we have seen a significant reduction in reimbursement for the primary revenue generating procedure (in-laboratory attended PSG) that sleep programs have relied upon as a major source of income and growth. Additional financial stress has occurred in areas where third-party payers have demanded out-of-center testing (portable monitoring [PM]) as the first-line diagnostic test for suspected sleep disordered breathing, and low reimbursement for PM threatens the traditional financial model. These realities have created a need to reevaluate the financial structure of sleep programs, develop new strategies for support of academic sleep centers, and raise awareness among institutional leadership about the value of identifying and treating sleep disorders. This section will discuss ideas and strategies to help improve the long-term financial outlook for academic sleep programs in the United States.

3.1. Identifying New Activities for Income

3.1.1. Portable Monitoring

With the potential for PM to move to the forefront of diagnostic sleep testing, one strategy to mitigate the anticipated decline in revenue from loss of PSG testing is to increase testing volumes. Since sleep disordered breathing remains markedly under-diagnosed, aggressive screening, especially of high risk populations, may improve testing volumes. Screening patient populations with a high prevalence of sleep disordered breathing and where PM might be expected to perform reasonably well as a mass screening tool, such as type 2 diabetics, elective surgery patients (especially bariatric surgery candidates), and patients with cardiac disease (excluding advanced heart failure) could improve patient care and also create demand. Collaboration with leadership in these different areas (i.e., endocrinology, presurgical services, cardiology) would help to establish a steady patient-referral base needed to maintain volumes. However, in conjunction with this, it behooves academic programs to insist upon adequate quality oversight of this type of testing strategy so that inappropriate and unnecessary testing is not performed, and to ensure that patients receive appropriate treatment. Lack of quality oversight is a major risk in the current PM testing arena.

A fully implemented PM testing program could yield additional benefits of lower overhead (fewer personnel needed, less space required) as well as a more rapid turnaround time for testing if the program is highly efficient. Efficiency could be marketed to referring physicians and institutional leadership, as quicker diagnosis and treatment of sleep apnea will lead to overall health care savings. In addition, increased diagnostic testing volumes for sleep apnea and specific guidelines for moving to in-laboratory testing need to be validated and could help to maintain some of the in-laboratory PSG testing volume. Some high-risk patients will not meet criteria for PM testing; other high-risk patients will have negative PM tests and thus require in-lab PSG; and patients with positive PM results will require treatment (sometimes titrated or assessed by in-lab PSG). Academic sleep laboratories may be in an ideal position to assess symptomatic patients whose PM studies elsewhere do not clarify their problems, or whose treatments do not resolve their symptoms.

3.1.2. Contracting with Third-Party Payers

Academic institutions often offer expertise and comprehensive services in sleep medicine. Maintaining high quality standards such as those set forth by the AASM, coupled with efficient service, could enable academic sleep centers to market themselves as a source for low-cost, high-quality care. These qualities should make academic sleep centers particularly attractive for third-party payers. For example, an academic sleep center might be in an ideal position to partner with a trucking company to screen and treat their commercial drivers.

3.1.3. Integrating New Technologies

Academic sleep centers stand at the forefront of innovation and should be able to offer the most advanced technologies in assessment and treatment for sleep disorders. Partnerships with local biomedical firms could offer sleep centers early access to novel technologies that can be marketed as a unique service in the area. In addition, use of certain technologies in the appropriate setting, such as CO₂ monitoring for patients with neuro-muscular disease, hypoventilation due to potent narcotics, or COPD, will help to maintain in-laboratory testing volumes, as technologies such as this are currently not available for out-of-center testing. Expansion of pediatric sleep services, an area where PM is not currently validated or approved, can also help to sustain in-laboratory testing volumes. Recently, actigraphy has gained more widespread clinical use and is no longer considered just a research tool. Embracing this technology and its use in appropriate patients seems reasonable, though at this time insurer coverage is variable.

3.1.4. Revisiting Durable Medical Equipment (DME) services in Academic Sleep Centers

In the past, Stark laws have prevented sleep centers from running their own DME services. This exclusion is currently being reevaluated. If such laws are altered to improve the effectiveness with which patients receive needed equipment, an additional benefit could be an additional revenue stream for academic sleep centers. Generally, a major investment by an institution is required but the improved service and long-term financial rewards are likely to be worth the investment.

3.1.5. Other Activities

Sleep and sleep disorders influence many aspects of health and healthcare. Sleep programs should be able to integrate with other programs in the hospital to offer additional opportunities beyond the traditional services in sleep medicine. This may include activities such as offering weight loss programs within the sleep center, prolonged EEG monitoring (i.e., ambulatory or continuous EEG monitoring) in the sleep laboratory, or integrated and enhanced behavioral sleep medicine services at the sleep clinic.

Academic sleep programs should partner with other specialties in their institutions to enhance therapies that can be offered within the sleep centers themselves. As an example, collaboration with ENT and dental services can lead to an expansion of alternative therapies for OSA, such as oral appliances (e.g., mandibular advancement devices) and nasal resistive valves. Many non-CPAP therapies require follow-up testing for confirmation of effectiveness, which again could help to maintain testing volumes while enhancing quality care.

Academic centers are also beginning to embrace the concept of the patient-centered home as a chronic care model. As most sleep disorders are chronic and many require ongoing follow-up or monitoring by a sleep provider, academic sleep centers should integrate themselves into these programs to assure quality sleep care.² This would, at the same time, enhance patient volumes. As most academic centers today have large primary care networks, building a good relationship with the primary care providers can improve cooperation, increase referrals, and improve patient care.

Telemedicine is another evolving area of healthcare that offers opportunities for provision of care to underserved areas and for enhanced revenue. Insufficient numbers of sleep providers exist to handle the large burden of sleep disorders in society; offering telemedicine services to underserved (i.e. rural) regions could serve as a new source of patients and income.

3.2. Improving the Efficiency of the Sleep Center

As reimbursement for procedures has declined substantially in the last few years, sleep centers must maintain efficient operations to keep overhead low, improve patient throughput, and stay financially solvent. Some strategies to lower overhead expenses might include reduction of space costs by renting sleep-capable facilities such as hotels for diagnostic testing, and limitation of personnel expenses, for example, through use of PM programs. Using the same facility for both sleep testing and clinics has been successful in some locales and may be cost-effective. For example, many centers now have rooms that can dually function as clinic rooms during the daytime and sleep testing rooms at night, although this model cannot be used in facilities designated as IDTFs. Increasing access to clinics by utilizing mid-level healthcare providers (i.e., sleep-trained nurse practitioners and physician assistants) can increase throughput to help with management of larger volumes of sleep patients. Training sleep fellows, aside from the academic rewards of having a training program, can also help to improve access and efficiency of patient care. Finally, on-site DME services, if allowable, would improve the efficiency of patient care and lead to less “wasted clinic time” when DME services are not provided in a timely fashion by outside DME providers.

3.3. Research and Other Funds

Further research in sleep medicine is clearly needed, as is increased funding at a national level to support this.¹ The academic sleep community should advocate at the NIH, other federal funding agencies, Congress, and public arenas more aggressively for establishment of specific funding opportunities for sleep medicine, to include a nationally supported sleep research network. Numerous examples exist, focused on public health problems that are no greater than those posed by sleep disorders. The academic sleep community can assist this advocacy by identifying the specific opportunities within sleep research that will offer the most compelling impact, as compared to many other unrelated health research priorities in an extremely competitive research funding environment.

The structure of research support at academic sleep centers varies greatly, with some being well supported by federal funding while others receive little support or remuneration for their efforts. Ideally, structures should be in place to allow a percentage of the indirect costs for research funding in sleep to benefit the sleep program in ways that grow the academic endeavors of the program. Establishment of a Sleep Center, Section, Division, Department, or other structure—whatever is necessary and appropriate for the given institution—can be successful as long as it provides the necessary administrative and financial integrity that is envisioned by the IOM, created for other academic fields at the specific institution, and critical to the future of academic sleep medicine.

Industry-supported clinical trials can also provide an adjunctive source of income for academic sleep centers to support their academic missions, although industry has also decreased research funding. For centers with the appropriate infrastructure, marketing the center as a standardized scoring center for clinical trials, or even for clinical work, can provide additional revenue. Although industry has traditionally favored not using academic sleep centers for industry-sponsored clinical trials due to IRB and other issues, some centers have adjusted to expedite the process. Having dedicated individuals with research expertise in the sleep center is needed for the operation to be efficient.

Universities hosting academic sleep programs should be approached to provide support for sleep centers through foundations that already exist. Endowments for fellowship support, including salary cost of sleep trainees, could enhance the stability of sleep training even in these times of GME/IME potential cuts in funds and slots. Few centers have endowed faculty positions in sleep medicine, and these should be sought. Fund raising should not be limited to the Universities themselves; local public and patient support groups for sleep disorders (e.g., OSA, RLS, and narcolepsy) can be approached to lobby for fund raising for research at the local sleep center. Educational courses hosted by academic sleep centers, targeted towards primary care providers or other groups caring for patient populations with a high prevalence of sleep disorders, can be an additional source of revenue for a sleep program.

3.4. Raising Awareness of the “Unrecognized Benefits” of Having a Sleep Center

Given the current evolving environment of health care, it is difficult to predict the level of profitability of sleep programs. As such, it becomes imperative for academic sleep centers to impress upon institutional leaders the vital role and “unrecognized benefits” of having an academic sleep center as part of their operations. Additional outcomes research should be targeted, to quantify benefits and cost savings.² Examples might include:

• Identifying and treating sleep disorders saves health care costs: Numerous studies have shown that once sleep apnea is identified and adequately treated, health costs and health care utilization decrease.

• Identifying and treating sleep disorders improves comorbidities: Studies have indicated benefit, from identification and treatment of sleep apnea, on cardiovascular disease (hypertension, arrhythmias, heart failure, and stroke) and diabetes. Addressing sleep apnea also likely improves symptoms associated with psychiatric illness. These improvements can decrease long-term health-care costs.

• Identifying and treating sleep disorders improves quality of life: This too has been shown in a number of randomized trials.

• Identifying and treating sleep disorders may help to reduce readmission rates: Prevention of unnecessary readmission is a major priority for hospitals. If institutional leaders can be convinced that treatment of patients with sleep apnea prevents readmission, they may be more willing to support sleep center programs. For example, patients with decompensated heart failure have both high risk for readmission and high frequency of undiagnosed sleep apnea; for such patients, Sleep Centers may be able to improve patient health and hospital readmission rates simultaneously.

• Identifying and treating sleep apnea is increasingly important to surgical services: Growing data highlight the risk patients with sleep apnea face when undergoing surgery, especially if sleep apnea is unexpected or undiagnosed.

• Hospitals employ a large number of individuals with sleep disorders: Identifying and treating these disorders could improve employee performance and safety.

• Hospitals employ a large number of individuals who perform shift work: An on-site sleep center is needed to help optimize shift working employee's productivity and quality of life.

Another consideration is to approach hospital and university leadership to request that institutions support the vital role of academic sleep centers by reimbursing them based on such outcomes as:

• Decreased health-care costs resulting from their effective management of patients with sleep disorders.

• Referrals to high revenue generating departments (e.g., surgical specialties) for management of patients with sleep disorders. This idea could require somewhat of a paradigm shift in how resources are allocated at a given academic institution.

4. THE ROLE OF THE AASM AND OTHER SOCIETIES

The AASM and other societies that have a vested interest in sleep medicine should continue to provide education on dealing with financial issues of this field. Academic institutions traditionally have not been knowledgeable about financial and legal aspects of providing sleep services—there is a deficit in skills in this area at many academic sleep centers.

5. CONCLUSION

The field of sleep medicine is undergoing considerable change that will have impact on both academic and nonacademic sleep centers. Academic sleep centers must be prepared to evolve and meet these new challenges with innovative strategies. Programs need to work within their institutions to help gather and disseminate data on the health impact of sleep disorders, and to highlight the benefit of effective diagnosis and treatment.³ An academic sleep program should further the mission of its institution and provide clear added value through a new sleep medicine administrative structure that includes responsibility for effective patient care, clinical resources, finances, faculty and trainee recruitment, research resources, and sleep policy, education, and curriculum. Academic sleep centers will need to reorganize, not only to ensure survival, but hopefully to grow and fulfill the fundamental promise this field has to augment human health and well-being in ways that are most likely profound, yet still seldom realized.

CITATION

Chesson Jr AL; Chervin RD; Benca RM; Greenough GP; O'Hearn DJ; Auckley DH; Littner M; Mullington JM; Malhotra A; Berry RB; Malhotra RK; Schulman DA. Organization and structure for sleep medicine programs at academic institutions: part 2—goals and strategies to optimize patient care, education, and discovery. SLEEP 2013;36(6):803-811.

DISCLOSURE STATEMENT

Dr. Chervin receives educational grants from Philips Respironics Inc., Fisher Paykel Inc.; receives honoraria as section editor for UpToDate; receives fees for technology licensed by the University of Michigan to Zansors Inc.; is an advisory board member for the non-profit Sweet Dreamzzz Inc.; is named in patents owned by the University of Michigan for signal analysis diagnostic algorithms and hardware relevant to the assessment and treatment of sleep disorders; and serves on the Boards of Directors of the American Academy of Sleep Medicine, American Board of Sleep Medicine, American Sleep Medicine Foundation, and the International Pediatric Sleep Association. Dr. Benca has consulted for Sanofi-Aventis and Merck. Dr. Auckley has received research support from Teva and equipment for research from ResMed. Dr. Littner has participated in speaking engagements and consulted for Forest Pharmaceuticals. Dr. Atul Malhotra is a consultant for Philips Respironics, SHC, SGS, Apnicure, Apnex, and Pfizer. Dr. Berry has received research support from Dymedix, Inc. The other authors have indicated no financial conflicts of interest.