The business of sleep medicine looks particularly challenging right now. Industry participants are experiencing lower reimbursements, more regulation, and greater sleep lab competition. But business challenges can sometimes be the on-ramp to new markets and long-term growth.

The good news is that the US market demand for sleep service continues to grow. Increased public awareness of the benefits of restful sleep for safety, job performance, relationships, and overall health has helped drive this growth. Physicians are becoming more aware of the association between disordered sleep and their own nonsleep medical specialty services. Public awareness of sleep hygiene is penetrating the overall health marketplace.

These signs point to a growing maturation of the sleep medicine industry and the traditional in-lab sleep testing model in particular. Maturation brings with it the opportunity to locate and exploit specialized ancillary services, particularly as growth in the traditional model bogs down.

Instead of moaning the blues about constant changes, industry participants can channel their energy to find niche opportunities and then work them into their existing sleep business as appropriate. Such opportunities include:

  • Oral appliance therapy as a complementary therapy for obstructive sleep apnea;
  • Cardiology/catheterization screenings targeted to cardiologists;
  • Sedation apnea management targeted to anesthesiologists and surgeons;
  • Hospital inpatient sleep care;¦ Diabetes specialty sleep initiatives; and
  • Business and industry sleep safety programs.

Oral appliances can be an alternative to CPAP for the treatment of mild to moderate obstructive sleep apnea. Appliances that advance the jaw, retain the tongue, or lift soft palate tissue during sleep act to lessen or prevent the collapse of a sleeping patient’s upper airway. Dentists with special sleep training can select, design, construct, fit, and adjust the proper device for the patient’s condition.

Oral appliance therapy is becoming a popular alternative to PAP treatment, particularly for patients who refuse or object to using CPAP. Medicare will pay for certain devices as an item of durable medical equipment under the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) fee schedule.

Sleep labs considering an oral appliance program could benefit in a variety of ways. First, labs that follow their patients’ PAP compliance may be able to suggest an alternative treatment for their noncompliant patients. This typically leads to additional testing for the oral device therapy.

The prevalence of disordered sleep in the United States suggests the existence of a large market of persons with undiagnosed sleep apnea. Some persons presenting with symptoms of OSA might refuse sleep testing because they are dead set against the idea of sleeping with PAP as the preferred therapy. Offering the possibility of oral device therapy in lieu of PAP to this pool of recalcitrant patients can lessen patient resistance to sleep testing and initiate treatment for this otherwise invisible patient base. For patients who do not always have access to electrical options to power PAP, oral appliances are an effective adjunct for management of sleep apnea.

Operating an oral appliance program can be tricky. The therapy involves cooperation between the sleep lab, a sleep doctor, and a dentist knowledgeable in sleep medicine. The relationship must be carefully configured legally and ethically to assure that high-quality patient care is always the ultimate goal and outcome. Some sleep labs choose to partner with national sleep dental organizations to provide an oral appliance program as an addition to their sleep service menu.


Studies suggest that approximately one third of general cardiology patients have some degree of OSA.1 Indications of sleep apnea are often seen in the diagnoses of congestive heart failure, refractory hypertension, refractory angina, left ventricular systolic dysfunction, ischemic heart disease, arrhythmia, myocardial infarction, and stroke.2

This association between obstructive sleep apnea and heart disease presents opportunities in sleep. As awareness about sleep disorders grows, cardiology practices are more and more open to incorporating sleep testing into their own practices. Some have coventured with sleep professionals for this purpose, either as part of the practice or as a stand-alone sleep testing entity. Reimbursement and federal fraud and abuse limitations may apply in these settings, so it is always best to review any proposed structure with legal and business counsel.


In 2006, the American Society of Anesthesiologists published Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea.3 The guidelines are intended to assist surgical personnel to recognize symptoms of obstructive sleep apnea so they can manage the patient’s surgical sedation in light of the respiratory challenges present in OSA. The society hopes to reduce the likelihood of adverse perioperative outcomes in OSA patients by identifying the sleep disorder before sedation.

The guidelines state that preoperative evaluation of a patient for potential identification of OSA includes (1) medical record review, (2) patient or family interview, (3) physical examination, (4) sleep studies, and (5) certain preoperative x-rays in selected cases. If a sleep study has been done, the results should be used to determine the perioperative anesthetic management of a patient.

Sleep labs can energize hospitals and other surgical facilities to recognize the importance of preoperative anesthetic management as part of their overall surgical and procedure care plans. Labs can coordinate, manage, and perform programs of standard and ambulatory testing to achieve the level of patient safety management supported by the society’s guidelines.

Hospital patients recovering from surgical procedures may show symptoms of undiagnosed OSA in the recovery room. Initiation of PAP therapy by auto-titrating machines or otherwise may be indicated.

Sleep labs can offer hospitals and other surgical facilities PAP expertise in such cases. Hospitals may see the need to outsource this service or initiate portable postoperative sleep testing to promote the patient’s quick recovery and discharge.


In 2008, HealthGrades published information on hospital patient safety data reported by the Agency for Healthcare Research and Quality. Of the 41 million Medicare admissions to nonfederal hospitals in 2004–2006, one specific safety concern is evident: the incidence for respiratory failure. Failure to proactively assess and monitor respiratory failure of hospital inpatients can result in increased costs associated with at-risk patients. These patients require a higher level of care, such as in critical care units, and they have added costs with a longer length of stay. Sleep labs can assist hospitals in developing and integrating protocols to monitor patients for detection of sleep apnea to reduce the cost of care associated with respiratory failure.


The International Diabetes Federation reports that up to 40% of people with OSA will have diabetes, but the incidence of new diabetes in people with OSA is not known.

In people who have diabetes, the prevalence of OSA may be up to 23%, and the prevalence of some form of sleep-disordered breathing in diabetes patients may be as high as 58%.4-7 Sleep labs can direct their educational resources to diabetes educators and local diabetes coalitions to provide sleep apnea information. The sleep lab can also offer its clinical resources to integrate sleep apnea testing and therapy into the patient’s blood glucose management program.


Safety-sensitive industries such as commercial trucking, railroads, aviation, shipping, public transportation, nuclear power, and others have long recognized the safety risks posed by sleepy employees. Government regulations dictate hours of service and other rules promoting periods of rest for these workers. Some trucking companies are also taking steps to ensure that their commercial drivers are either free from obstructive sleep apnea or compliant on their OSA therapy if they do have the disease.

Existing sleep programs can offer these employers sleep testing, PAP therapy, and compliance monitoring on a negotiated fee basis. These contracts typically provide for direct payment from the employer to the sleep provider so there is no burdensome impact from Medicare or insurance coverage rules. Legal review of state laws governing health care providers and insurance rules may be necessary depending on how the arrangements with the employers are structured.

The seeds for building success for your sleep business can be found in these new and somewhat surprising directions. These opportunities, and others such as weight loss clinics, home testing ventures with primary care physicians, pain clinic services, and nongovernment CPAP services, are available now and new ones are sure to appear. Keep looking as the landscape changes, and take appropriate action to adapt your business for continued success.

Duane M. Johnson, PhD, is a senior partner and cofounder of Sleep Center Management Institute ( He has a PhD in psychology and has been in Practice Management Advisory Service for over 30 years. Dr Johnson is one of America’s most respected practice management consultants and has consulted with thousands of physicians over his professional career. Daniel B. Brown, Esq, is the managing shareholder of Brown, Dresevic, Gustafson, Iwrey, Kalmowitz and Pendleton, The Health Law Partners, LLC, Atlanta. The authors can be reached at [email protected].

  1. Peker Y, Hedner J, Norum J, Kraiczi H, Carlson J. Increased incidence of cardiovascular disease in middle-aged men with obstructive sleep apnea: a 7-year follow-up. Am J Respir Crit Care Med. 2002;166:159-165.
  2. Gottlieb DJ, Yenokyan G, Newman AB, et al. Prospective study of obstructive sleep apnea and incident coronary heart disease and heart failure: the Sleep HeartHealth Study. Circulation, 2010;122:352-360.
  3. Gross JB, Bachenberg KL, Benumof JL, et al, American Society of Anesthesiologists Task Force on Perioperative Management. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2006;104:1081–1093.
  4. Bradley TF, Floras JS. Sleep Apnea: Implications in Cardiovascular and Cerebrovascular Disease (Lung Biology in Health and Disease, June 15, 2000).
  5. Meslier N, Gagnadoux F, Giraud P, et al. Impaired glucose-insulin metabolism in males with obstructive sleep apnea syndrome. Eur Respir J. 2003;22:156-160.
  6. West SD, Nicoll DJ, Stradling JR. Prevalence of obstructive sleep apnea in men with type 2 diabetes. Thorax. 2006;61:945-950.
  7. Resnick HE, Redline S, Shahar E, et al. Diabetes and sleep disturbances: findings from the Sleep Heart Health Study. Diabetes Care. 2003;26:702-709.