A ReLACSing Blog #8: The Benefits of a Direct Care Practice for Sleep

OK, so I left the title somewhat ambiguous regarding cui bono (to whom is the benefit). Hmmm, does Dr. Berkowski mean the patient’s sleep or his sleep?! Both, thankfully. I detailed in parts alpha and beta how leaving the insurance-driven system would help me sleep better at night by not compromising my ability to provide the best patient care. Here, I will touch on some key examples for how a direct care practice can provide significant advantages to patients beyond a standard fee-for-service sleep clinic. 

Direct specialty care for sleep can provide a rare resource: time with your doctor. There will be no checking the hourglass to see if time has run out with your doctor.

Photo by Nathan Dumlao

In general, time is the largest differentiator, followed by personalization of the doctor-patient relationship. Some of the best treatments including for most sleep disorders are time-intensive activities when done optimally. Let’s say you had diabetes, saw your doctor, and he or she noted your sugar levels were still a little high. What would take more time? (A) Your doctor bumps up your insulin dose a touch and sees you again in three months. (B) Your doctor reviews a food diary with you related to the last week, identifies that you are eating a cup of bran flakes for breakfast, the bran flakes have 38 grams of carbohydrates in one cup (not including the sugar added to make it palatable or the sugar in the milk), and that this may be one source of elevated blood sugars. The doctor goes on to explain to you how carbohydrates are broken down into sugar, causing an elevation in blood sugar levels, which causes a release of insulin, etc. Obviously, telling you to take 5 more units of insulin would be more time-efficient. The latter education and counseling would be better for your health. 

Health system administrators like to use the term “access”, which is a term that matches the best political spin from any government politician. When they say “increase patient access,” this is not actually a term meaning to bring care to more people out of generosity. “Access” means to increase the number of patients on the schedule, thereby leading to more clinic visits and potentially more money-making procedures. Under the current insurance system, this does generate more revenue but not better care for patients. The less time you spend with each patient, the more patient slots you can have and the more revenue. It is simple math…if only patients were numbered parts in a factory assembly line. 

Second to time is the doctor-patient relationship. The 10-minute visit does not lend itself to a deep knowledge of a patient’s medical history, unique health and personal characteristics, goals of treatment, etc. Many patients see a doctor once and maybe again in 3 months for another 10 minutes or are siphoned to any number of physician-extenders because the physician has no return visit slots available. Does this build rapport and strengthen the doctor-patient relationship? These are two areas in which direct care delivers unmatched resources.

For sleep, let us take restless legs syndrome first. In Blog #4, I presented why dopamine agonists are not a good treatment group for RLS. Imagine a patient comes to clinic with worsening RLS due to a dopamine agonist medication. The patient often will not be aware that dopamine agonists cause augmentation, or gradual worsening of the condition over time. It may take just a few minutes to bump up that dose of medication, provide relief for a few more months, only to cause more severe augmentation a few months later. Instead, a patient in this situation needs to be educated on dopamine agonists, how they affect RLS–both good and bad, how they became FDA approved, why they were effective for the first few years, why the dose keeps going up, why the condition seems like it is getting worse, etc. So you’re telling me the condition is not getting worse in spite of this FDA approved drug but because of it? And you want me to taper off this drug, which will cause me to go through withdrawal, but I will be better off several weeks later? This is not a 10 minute visit. Additionally, it takes time to explain how RLS is a condition caused by low levels of iron in the brain, how dietary factors and other health factors affect iron levels, how to check and interpret iron levels, how to supplement iron levels, etc.—not to be done in 10 minutes. That’s not even the involvement to cover other complex factors such as obtaining an iron infusion, controlled substances like opiates which are often needed, and other aspects of sleep that affect RLS significantly. People with significant symptoms of RLS require significant time and education. They require close follow up. They require a physician to get to know them and their health thoroughly. However, many physicians see so many patients in a day that they may not have enough time to keep up to date in order to be aware of augmentation and the clinical guidelines changing several years ago. A direct specialty care clinic like ReLACS Health can provide the necessary time with the patient, follow up visits and availability through various means of communications, the sought-after personalized relationship with the patient, and updated knowledge of changes in the field. This will enable the patient to obtain the best level of care. 

Insomnia may be the most classic area for the time factor. Cognitive and behavioral therapy for insomnia (CBT-I) is the gold standard of treatment for chronic insomnia. There is little debate about its long-term effectiveness, regardless of country, age, other medical conditions, and so on. If this is the undisputed best treatment, then why do so few physicians do CBT-I? Four letters: T-I-M-E. These visits generally take 45-60 minutes and often have to be done weekly or bimonthly for several weeks. How many physicians have a schedule in which they can see one patient several times a month for an hour? As a corollary, in a typical fee-for-service sleep clinic, what do you think generates more revenue for the center: (A) 3 x 20 minute new patient visits, possibly with 1-2 more profitable sleep studies resulting? Or (B) a 60 minute visit with a follow up patient you just saw last week? You know the answer. But CBT-I is the gold standard for treatment! Some centers offer CBT-I, generally performed by clinical psychologists or therapists and often quite well, but these are hard to find compared to the number of patients who have insomnia. Why should a sleep physician out-source the gold standard treatment for one of the 2-3 most common sleep conditions? Again, it takes a few minutes to prescribe a hypnotic (sleeping pill), even though they rarely work for chronic insomnia. Through direct specialty care, ReLACS Health can be a place that does not have to resort to the expediency of the sleeping pill over weekly 55 minute visits for CBT-I. 

We could go on about many of the other sleep disorders. For most people who are referred to a sleep clinic, the sleep study shows sleep apnea and CPAP works out of the box. What happens when you’re struggling to tolerate CPAP? Sure, if you have excessive daytime sleepiness and you take that stimulant, you’ll feel more awake, for a few months maybe. But what if a restructuring of your sleep schedule and habits could address the underlying issue and bring lasting relief from the sleepiness without the medication side effects? What if you’re doing weird things in your sleep and don’t want to take a tranquilizer to get the activity to stop and then be left to struggle with the side effects the next day? Perhaps a behavioral approach to sleep can improve the sleep quality and eliminate the “weird things” (parasomnias) you’re doing when you’re asleep. Behavioral and educational treatments require time and a more personal relationship with the doctor. Direct specialty care is a delivery system that can provide these valuable traits for the true best care practices. ReLACS Health was created with these attributes in mind and has a mission to deliver the level of care its patients deserve. 

-Andy Berkowski, MD 

ReLACS Health