Maintaining Defined Scopes of Practice
There are specific Medical and Dental Licensing Laws and Practice Acts, which dictate the scope of practice for physicians and dentists (http://www.aasmnet.org/resources/pdf/AADSMJointOSApolicy.pdf). As per individual state law, laws only a licensed physician can make a diagnosis and treatment plan for sleep disordered breathing. Similarly, a dentist’s scope of practice includes evaluating the candidacy of patients for oral appliance therapy as well as construction and fitting of the appliances. The proposed “care-under-one-roof model” will be structured within the practice parameters established by the AASM.4 Updated practice parameters are currently being prepared by the AASM for publication.32
Responsibilities of sleep physician specialist:
Assess patients with sleep related complaints.
Order appropriate diagnostic tests and diagnose obstructive sleep apnea.
Discuss treatment options with the patient based on practice parameters and standard of care guidelines.
Counsel on behavioral therapy, sleep hygiene, weight loss, and driving precautions.
Manage concomitant sleep disorders which often accompany OSA, such as restless legs syndrome (RLS)/periodic limb movement disorder (PLMD), circadian rhythm disorders, and insomnia.
Follow and document comorbid conditions and impact of treatment on hypertension, diabetes, heart failure, arrhythmia, and neurocognitive function.
Engage in active consultation with staff dental sleep expert on treatment plan.
Participate in periodic multidisciplinary rounds and conferences.
Provide follow up sleep testing after OSA therapy has been instituted.
Provide ongoing and routine follow up patient care.
Responsibilities of staff dental sleep expert:
Evaluate patients for dental sleep medicine therapies.
Discuss treatment options (mandibular advancement splints, combination MAS/PAP therapy, tongue retaining device, maxillofacial surgery, etc.).
Manage coexistent dental disorders, such as bruxism.
Counsel on dental hygiene and daily maintenance of oral appliances.
Follow up patients every 4-6 weeks until treatment efficacy and patient adherence to therapy have been established.
Review compliance and manage potential complications or adverse effects of therapy.
Maintain communication with sleep physician specialist for outcome measures monitoring.
Assess the need for change in treatment, or repeat PSG for either retitration or resolution of sleep disordered breathing.
Establish protocols at the sleep disorders center on oral device titration, technician training, consent procedure, off hour call coverage issues.
Participate in periodic multidisciplinary rounds and conferences.
Provide ongoing and routine patient follow up care.
Sustainability of the integrated care-under-one-roof model would depend on development of a business model that can successfully address the financial challenges faced by many dentists today who provide oral appliance therapy. Ideally, the sleep clinic administration would negotiate contracts with medical insurance companies for the dental providers in much the same way the physicians are enrolled to deliver contracted services and are credentialed as providers. The clinic office would ideally handle preauthorization and file insurance claims for the dental component of the patient’s evaluation and treatment. A single, unified electronic medical record (EMR) system would be used by all providers. Financial sustainability would be made possible, in part, by the efficiency of care delivery and the quantity of care delivered. The dental sleep expert may be able to bill for his services provided to the patient at the sleep disorders center even if seen on the same day as the sleep specialist, as services provided are different and performed by two different specialists.
The care-under-one-roof model raises legal concerns that would need to be addressed to comply with individual state and federal laws. For example, dentists in some states are bound by a “corporate practice” doctrine, which prevents non dentists from owning any part of the dental practice. Moreover, compliance with the federal Stark laws also require that the referring physician have no financial interest in any business that provides positive airway pressure (CPAP provider) or oral appliance (dentist), as both are viewed as durable medical equipment (DME) providers by the Centers for Medicare and Medicaid Services. However, several large hospitals and institutions now have DME services and can provide integrated care-under-one-roof with appropriate safeguards. Due to these limitations, we believe that this model is best suited initially for use in an academic/institutional setting with a community based model evolving from the experience of these centers.
Community-Based Non-Academic Model
Although the above model is proposed with academic institutions in mind, this model can be adapted for nonacademic centers. We propose that this collaboration take place in AASM-accredited sleep disorders centers. Board certified sleep physicians at the center should form alliance with dedicated dental practitioners who have adequate training in sleep medicine and are motivated to serve this population. The dental expert should have scheduled clinic hours at the sleep center where a comprehensive dental evaluation may be performed. Dentist “chair” is a small investment which the sleep center or the dentist has to make (a refurbished chair can be obtained for around $3,000.00). The use of radiographs is essential to the treatment decision (http://www.aadsm.org/PDFs/TreatmentProtocolOAT.pdf), but these can be obtained from the patients’ general dentists. Many dentists have digital offices and therefore are able to email the radiographs upon patients’ permission. This will all be done in conjunction with a comprehensive dental exam, periodontal screening, muscle evaluation, TMJ evaluation, and review of medical history.
From a business perspective, the sleep center charges the dental sleep expert for renting space and equipment. The dental sleep expert, by his presence and expertise, determines which patients are good candidates for OA. The dentist utilizes the center’s expertise to titrate patients either by OCST or in lab titration, and in long term follow up.
Oral appliances for OSA are considered durable medical equipment, so several models out in the real world can exist. Under one model, the sleep center provides DME, and the dentist is contracted to provide under the DME services of that group. This model allows the DME company to bill on behalf of the dentist for those services. Other models have the dentist with their own DME, then provide services and bill for their services. The advantage of the dentist contracting under the sleep center DME is that most of these DME companies already have insurance contracts in place to provide CPAP, another DME item. It is then easy for the contracts to be extended to oral appliances.
While the reimbursement for OA is varied, it is a covered benefit to most patients with private insurance. Medicare has also come on board in reimbursing for these appliances with fairly strict coverage and mandating delivery by a dentist.
We feel this model will not only improve patient care and comfort, but it is also financially viable and professionally satisfying.
Integrating oral appliance therapy into the delivery of care for obstructive sleep apnea syndrome has been a challenge and few effective models exist so far. It is imperative that the sleep medicine community develops a realistic and effective model of this underutilized but promising treatment modality. We believe that the best structure is to integrate dental sleep medicine with the sleep disorders program is via a care-under-one-roof concept. Training, communication, education, marketing, and evaluating outcome data are vital. Such centers of excellence at academic institutions are best suited to lay this foundation. These institutional centers can provide care in their community as well as serve as a model of integrated care delivery for sleep medicine throughout the country in nonacademically based sleep centers.