We kicked off 2024 with an engrossing conversation with Abhinav Singh, MD- sleep vigilante and clinician with 14 years of experience at the Indiana Sleep Center. He's not only an excellent clinician, but also a TEDx speaker (What would you do for $13.5 million?), educator, and author of the book "Sleep to Heal". He is a sleep consultant for the professional basketball team - Indiana Pacers as well as a medical review panelist at the National Sleep Foundation.

In this conversation, we delve into the clinical and financial implications of Home Sleep Tests (HSTs) proliferating the field of sleep medicine, maintaining price transparency with patients and about the rewards of being truly patient-centric.

Listen to the full episode here

Transcript of the full episode:

‍Shruti: Welcome to the podcast, Abhinav. Tell us a little bit about yourself and your path to sleep medicine. What sparked your passion in this field?‍

Dr. Abhinav: Sleep Medicine was an accidental discovery. The field accidentally found me about 22 years ago. So, in summary, I didn't choose Sleep Medicine, sleep medicine chose me. I came to the States about 22 years ago as a research assistant in the School of Public Health. I was studying for a master's in public health and needed some funding support for my tuition, so I applied for a bunch of research assistantships to support that and also work on a project for the graduate degree. The first people who called were from the Center for Narcolepsy and Sleep Research at the University of Illinois, and the rest is really history.

From there, I had no information or knowledge whatsoever about sleep. Medical school has a scarcity-of-sleep lecture, and here I was, studying sleep research, helping patients run their research protocols. And in exchange, I was getting funding for my public health master's with the eventual goal of landing up in the World Health Headquarters in Switzerland. That was the goal, and of course, it didn't work out that way. But maybe something better happened. I loved the field, loved how the science worked, recognized the power of this field, which is really going unrecognized. I completed four years there, finished my medical residency, did a fellowship in Sleep Medicine, and for the last 14 years, I've been with the same practice since training in Indiana. So, that's my path. I love the impact it has, and my eventual goal was to do something in medicine that has wide-ranging impact. That's why public health, right? So, public health, you can make policies and interventions and vaccines and improve the health of society. And guess what? That goal is still intact because I'm just delivering it through the power of sleep. And sleep will do that. Nobody has come back in the last 20 years, Shruti, and come back and said, "Oh, I'm sleeping better and I'm so upset because of this. I want my old sleep back." No one, right? So, you can improve almost everything and every aspect of their health with sleep, and that's why I still do it.‍

Shruti: That's lovely. You talked about your sleep center and you've been with them for the last 14 years. Can you tell me a little bit about your practice? How is it set up and what has made you stay there for 14 years?‍

Dr. Abhinav: The Indiana Sleep Center was established in 2007, a few years before I got there. It's part of a multi-specialty practice. It's a partnership with the local large hospital, and the goal was really to provide academic-level care outside an academic environment, and to educate the community. This is on the southern edge of Indianapolis, and this became sort of the mission, to make it sort of the flagship Sleep Center of that area, serving that geography, and I still believe we are working towards that.

My sleep practice is a sub-specialty practice in a larger practice, so we have about seven sleep physicians board-certified, myself included, kind of the anchor of the practice. I call myself the, you know, trying and the others do other things as well. They have other responsibilities such as hospital, ICU, pulmonary. We used to have a psychiatrist as well, and we are training a couple of nurse practitioners very carefully to support us and patients. So, that's how the practice is set up.

And we enjoy the confidence of a lot of our referring primary care physicians, sub-specialty physicians, cardiologists, and take care of these patients. My goal was—it was a sleep center where I joined, but I really wanted to make it a sleep clinic. I wanted to diminish the presence of the sleep center and I wanted to expand the presence of a sleep clinic. So, in the eyes of the people, I wanted them to look at us and say, "Not the sleep center, but oh yeah, let's send them to the sleep clinic so they'll meet a human, a human physician. Clinician will decide what's next. Testing, not testing. Take care of it from start to finish." And you talk about operations, right? So, I wanted to be a one-click, forget-sort of a referral. "Oh, sleep apneas, insomnia. Any sleep disorder you pick, refer to the sleep clinic. They'll get seen, evaluated, tested, treated, followed up, and then they are back to the referring doc all taken care of and doing better. That's what was my mission and passion and I'm still trying and edging towards that.‍

Shruti: You guys also offer HSTs at your practice and how has that impacted your business?‍

Dr. Abhinav: Yeah. So. The whole sleep apnea testing was, you know, around 2010 was becoming it was being validated as a tool for patients who we suspect sleep apnea in and moderate to severe sleep apnea. And we are very strongly suspected. So in that group, it was validated and it was a great advance I feel. To the field. And in 2012 was widely adopted nationwide. And then, yes, the first step. Was that reimbursements are going to shrink because of course it is reimbursed reimbursed lesser than you know a center based sleep study. But I think it was an essential tool for the field to move forward because for a couple of reasons. One, it brought a lot of people patients out of the woodwork because many wouldn't even bring this. Up with their doctors because they would fear the sleep lab and the environment and the expense and the. And they would just be very apprehensive, so wouldn't bring it up, right? The physician community would also fear saying, Oh my God, who wants to do this cumbersome sleep study? It's expensive. They're not gonna be able to use the machine, the CPAP. So forget it. There was a lot of barriers that were preventing people from getting treated. But the home sleep apnea test actually made sleep apnea diagnosis accessible to even non sleep clinicians because they could understand this. It was a simple enough test validated and they could order it conveniently with less expense and get some sort of a starting point diagnostic number right. So that way at least it improves the diagnostic access. I feel, however it did not. Not, and I may be saying this a little bit tongue in cheek here. I don't think it improved the adherence or the success of outcomes or treatment that was I think it was, yeah.‍

Shruti: That was my next question, I was wondering like have HSTs improved the patient to difference to treatment plans or do you think it has become more complicated to deal with?‍

Dr. Abhinav: Yeah, it has not. Yeah, in my humble opinion, it hasn't because they still need that educational piece which is missing. You know, it's like you order something off of wherever and you do something on like a DIY kind of thing. I do it yourself thing. There are few professionals involved and if you just do the testing piece alone, you. I think the success in adherence and outcome and compliance is still not. Test field rates are high. Many times you know patient awareness of why they are doing this. What does the result mean? There are lot of nuances in that interpretation because that number that spits out of the home test has to be interpreted with lots of caution. The first biggest problem is did they sleep? Did they not sleep that night? How is the signal? Quality, who is reviewing the data? Is it all machine score tech evaluated, physician seen all of that, right. So there's a lot of nuance there, I feel and too many patients get prescribed the home. Yes, and they are not good candidates for the same. So that's the other problem, right. So heart patients, lung patients, oxygen dependence, strokes, so many other things, other sleep disorders may be overlapping and then they get pushed to a home test because of pair mandates or patient preference or referring doc, you know choice and it doesn't end well so. It's a great tool, but it's being overused. I feel in the short term it's being overused and we're not getting good results in the long term for these patients. That's my point on that. And yes, I see. The business impact of that for sure, of course. I mean we every sleep center if you just look at it as a diagnostic operation, of course, suddenly you had this other alternative that you had to furnish and we offer that full service. But what it did was this is what I tell people that the folks who were sort of in it to win it, those labs they close. The labs that were not labs, what were parts of sleep clinics where they were physicians and you know, taking care of patients, those have still been doing well surviving because what it does is it brings people out. So you have more to test now you've you've widened your funnel of referrals, OK. And then the home test is not a golden shot in the arm that solves all the problems, does it? It doesn't, and it's only meant for severe sleep apnea. Moderate sleep apnea?

So tests will fail. Guess what you do after that. If your home test apnea says no sleep apnea, are you going to stop there? No. Then you will persuade the patient to then do the proper gold standard test. But still, HSTs are helpful for the field.

Shruti: Right. Right, and at your sleep center, your goal is to take care of your patients from A to Z, right? You want them to get better and then stop seeing you.

Dr. Abhinav: Right, exactly. Especially the insomniacs. And then we see them. You know, once a year, if they're stable, sleep apnea, we've held them through the journey of diagnosis and recovery. And once a year, once every other year, we see the patients really for fine tuning their treatment, if that.

Shruti: Shifting the gears to more operations-based queries that I have, what do you think about patient price transparency? How do you deal with that at your clinic and how do you think that has impacted your revenue operations because a couple of years ago the No Surprises Act kicked in. You are obliged to be transparent about the pricing that the patient is going to be facing at the end of the treatment. How do you deal with it? You said something about how you encourage your patients to clear up their dues upfront, right? Tell me a little bit more about that. How you deal with it at your practice?‍

Dr. Abhinav: So as we have partnered with the large hospital system, they help us a little bit with this aspect and for us to stay in 100% compliance with the act and patients have access to their pricing on their plans and many patients, you know Shruti will access their pricing on their particular insurance portal. So they will also get an estimate of different facilities of what charges they are bound to experience and see if they go to different facilities. So yes, we have done our part and I think so have the other hospitals around here in Indiana. So it's like you pick a procedure and it'll tell you, OK, if you have insurance, Product X, you need a  sleep study at this hospital hospital ABCDEF or lab XYZ. These are the estimated charges. So. It's helped us and I don't think we've encountered a patient who says Oh I love the physician here, Doctor Singh, but I can't do my study here because you guys are charging too much more. So I think there has been some equilibration in the markets and I don't know exactly what but it's not that somebody is charging 5X and somebody else is charging less money, you know? So it's not that stark. I feel 5 years ago we would have a few calls to the lab saying I can't come here because you guys are charging and you know, we don't decide these prices because the way our structure is that our partners help us with some of these negotiations and I don't. We don't have too much say in fixing a price as a as a clinician, but it's helped. It's that I haven't had any problems or loss of volume because of this act. So that's my answer.

Shruti: What do you think about patient financial clearance? What have you identified as the biggest bottleneck in patient scheduling, particularly in your practice?

Dr. Abhinav: Yes. So once the patient has had a sleep consult and we believe in sleep consult before test order so you know 10 years back everybody would order a sleep study, right. And then that becomes into variation in notes and clinical history. And incompleteness leading to device coverage issues and so it was just becoming very. And then at some point I was very firm in my belief that you know every patient needs a consultation. OK, so like, I'm not going to send a patient directly to a cardiac Cath lab, am I? No, I would want them to see the cardiologist first. So why would I do that to something as important as sleep and sleep apnea, which can have wide ranging or just as much impact. Over time, so I said, consult first. Everybody got mad like, no. How can you see all these people? They have the same story. All of them. I said it doesn't matter. It's the same story for the doctor. It's not the same story for the patient because they are experiencing sleep apnea at different ways. Right. So they need to hear how the sleep apnea impact is. Hurting their life and health. Some are very sleepy, some have heart issues, some have diabetes control issues, some have driving and focus and mood dysfunction. Not everybody has everything right. Do you see all the colors of the rainbow every time in full throttle? No, you know, so you've got to so that I felt consult first, helped us a lot. So once they heard the story. Oh my God, all this is because of my snoring and sleep apnea, or my insomnia or me not sleeping well. Oh, yeah. That was the first piece that led to improvement in shore rates. And we've seen this in our own operations when they see different clinicians and styles of, you know, in different practices around the city. They'll say, oh, nobody ever told me this. Oh. I never, I just. I just went straight to the sleep lab. I didn't even know I was going to see the doctor after the sleep test. You know, all these little variations of how people get the sleep test. And I said no, no, no, no, no, no, no, no, stop. So consult first helps the patient understand and puts gets more investment from them to follow through second. When they know they have a face they've connected with and I said, look, you don't have to worry about these results. We'll meet after the results and I will break out your PSG on the screen and share it with you. What these numbers actually mean? There are tons of numbers on a report. How are they going to know? And then those seeds, which are painful, actually operationally to keep doing for every patient then need and put a foundation of good adherence down the road.

So that's how I feel. We have separated ourselves from the surrounding areas. We invest a lot. It sounds like repetitive stuff as a clinician, but for the patient, they're hearing it for the first time. Every patient is going to hear their story for the first time, right? How this is connecting. So that's. That's helped us. I feel in these. So those were the bottlenecks. The big bottlenecks are no shows, not scheduling, cancelling patients says Oh yeah, I'm not going to do this now. I don't have the time. All of this. Oh, my knee surgery is coming up. My other things take precedence. But if they had heard from the doc, then they would push it. Up the priority list. So that's one big bottleneck that we've I feel improved their scheduling show rate.‍

Shruti: Here at Aarogram we care about Patient adherence a lot and it always gives me a lot of joy when I hear that there are practices out there that are doing it comprehensively. They're taking care of the patients and it's very hard to do this and follow through on what you described without good staff, which leads me on to my next question. Which is that the U.S. healthcare is facing a staffing crisis. How are you navigating this issue at your practice and what are the biggest challenges you face whilst training new staff or whilst hiring them and what are you doing about it.‍

Dr. Abhinav: Yeah, you nailed it, right. You just hit it right on the head. Yes, very hard. So we had, first of all, the pandemic led to volume issues, right, because Labs had to close and recover from that acute attack of let's say throughput pressure because we couldn't, patients couldn't come, everything was on pause. Then when we got back, we didn't have staff, staff were either tired or moved on, so we were doing everything like you said. You were thinking that we were so staffing agencies, ads, word of mouth, and there was a shortage. Like every sleep center had 4 openings. So bonuses, incentives, quality of life, trying to be competitive with pay scale revisions, all of that we went through and fairly to keep ourselves competitive. And what we were offering, you know, staff, whether it's your front desk, whether it's your authorization person, whether it's your hsat daytime tech, whether it's your night. In tech, you know, a good working environment place and the knowledge that you have 78 clinicians in a large practice who will always. Help with volumes, right. So in terms of volume, all kinds of volumes, so if they are dedicated to helping the patient, the byproduct of that dedication is that the sleep lab gets a steady flow of referrals in. So that's what I think the the staff who's going to sign on sees that like, OK, this is the guy. This is the team. This is the practice, OK? They've been around since 2007, there's that and they care about the patient and this is an important aspect. So they don't feel that. Oh. We're going to lose our jobs. The home test is going to take over. We won't be needed. You know those sort of things. And the second thing is cross training. So every tech, you know, cross training into the home sleep apnea test world. Then we had some research that we got involved in to invent us, not invent ourselves. It walked in and. And we that also protected some volumes, right? So then staffing was we could offer that to the staff, we were testing some devices and other things, some new pharmacological molecules were requiring some sleep testing. So it was interesting. So you have to invent yourself and diversify and not just rely on one stream of revenue.‍

Shruti: Is Gen Z starting to trickle into the workforce at your workplace?‍

Dr. Abhinav: Ohh you said it. Yes I want to say very begrudgingly. I say yes and. By and large, we've been OK because we probably live in a little bit of a country, part of the US, but boy, they have been and and we treat our staff as as we treat our closest friends and family. We try to make them feel invited and they feel that. We try to keep them connected. I think the biggest problem is isolation. With this Gen Z. They are on their own and they're scrolling through their screens and you know, it's so fragmented they don't have a meaningful relationship of 5 that they can list for you. They don't outside of their family, outside of the immediate parents. I don't think they can pick 5 names.‍

Shruti: But but the they're also very passionate about their work and with the right mentorship, I think I've seen at many workplaces myself that you can really, if you want to find someone who's really excited about the work and it's got to be Gen Z. If they are motivated enough. So that job falls on us. I think that that is our job. Make sure that we retain the new new wave of younger folks who are joining the community and and I feel like the Sleep Medicine community is very small. So retaining this generation is very important.

What are your thoughts on Revenue leakage at your sleep center. Revenue Leakages are when you miss out on catering to the right volume of patients or when you miss out on reimbursements, when you're so caught up in the in the paperwork that you're unable to schedule patients at the right time. Or maybe you have some space in your clinic that is used at night, or let's say some nights there's no patient coming in. There certain labs that are only working at night and not operational in the morning. What are your thoughts on that?‍

Dr. Abhinav: I see, correct, as much as I can share. We always look at this, we try to repurpose how we can make that a 24 hour operation. And the way because we were structured remember from 2007, so there are. These are legacy and we are in the process of seeing how we can increase our utility of that space and overhead first of all. And second, as far as losing patience and not being able to schedule them, that rarely happens. So we still take pride in trying to expedite our insurance. Approval first from the point of receiving the referral. We check with the patient like, hey, we got a referral from Doctor Singh office. Are you ready to go for this? They'll say yes. And then we put a timeline in front of them, like, OK, this may take about 10 business days for insurance authorizations. And we'll be in touch again and then we'll find a good suitable date for you and a match you with a tech availability slot and. Off we go. And then we keep in touch. I think the first thing is communicating with the patient in in a, in a personal way that helps reduce leakage so that they won't cancel, they'll. And final hardest.‍

Shruti: What channels do you use to do this? What channels do you use to keep in touch?‍

Dr. Abhinav: We are still a little old school, so it's mostly phone calls with emails, phone calls and emails. Some texts, not much, and we have a portal that's functional. And so they can also see some updates there. But mostly it's one person calling them and hearing the same voice through and through. And that I feel helps and we've had lucky to have you know our front desk staff who's really been the backbone of this. She really takes care of the patient as if they're the only one she's talking to all day, and she makes them feel like that. And then they also appreciate that.‍

Shruti: I've heard this theme before from other sleep center managers as well. The more pleasant the lab is, the more personable the staff is, the more likely it is for the patients to adhere to the treatment that you want to offer them. Which is something that checks out. I love that you are so passionate about sleep. Tell me a little bit about your book, please. You told me something about 360 degrees of sleep awareness. Tell me more about that?‍

Dr. Abhinav: So let me go with the second question first. So the 360 degrees of sleep awareness was born out of. This hunger. Seeing so much of clinical time is spent by so many doctors in so many specialties, and sleep is rarely brought up and very well knowing that it really impacts almost every pathology you can think of. And we can find a paper that says, yeah, good sleep helps, that poor sleep hurts that. And you name it and I'll dig one up for you. That wasn't happening enough and. Being in a in a community setting, they ask myself how can we add to this and it is also a mission of our sleep center. So we went about by saying, OK, good, this is going to be on all of us. So wherever we meet whoever you meet, patient family friend. Grocery store clerk, you name it. You know your drive through checkout person, handing you your meal. I mean, this is a bit extreme, but literally has happened that you will talk about their sleep. Hey, how do you sleep? You know, you'll bring up what you do, and immediately you see the eyes light up and there's a quest. Ohh, So what do you do? Oh, I'm asleep, dog. Oh, really? Hey, you know, I have my mother, my aunt, and they go on. Oh, they have a machine or they have not. They don't sleep well. They. And that's how it began. So I started doing a little bit of teaching at a local university. They offered a position. I took it. So now I'm teaching Sleep Medicine to 4th year Med students as an elective rotation. Teaching at the local residency program and that you have to do. I feel once you teach these young minds and you talked about Gens, put these young seeds of this and they see it live in your clinic because it's a unique rotation. They don't get offered this commonly across the country. They take that with them like, wow, this thing touches everything and and that seed. Now you plant what I call in my 360 degrees is this you plant a sleep eye on the back on the front on the sides of your forehead. It's like a cave lamp and it lights up, you know, so they're always looking for sleep and it becomes habit. And the Academy took notice and they've. Featured this concept in their montage like everybody should be doing this, so you talked about passionate text, passionate front office, right. So all of them know the basics of sleep science and they will tell the patient like, Oh yeah, you're doing this because this will help your blood pressure. This will help your mortality, your mood. You'll feel better. And it starts there. Every touch point will explain this. And so now my wife just almost walks away as soon as somebody says, hey, So what do you do? She looks at me and says I'll be in the car. You know, I'll be home. I'll see you because she knows it's an hour gone from there. So. So that's the 360 degrees of sleep awareness. And I couldn't be happier. And that led to so many examples that I was giving patients. About how sleep is affecting them in their language, meaning if they are a plumber, a painter, a pilot, a driver, an engineer, a physician, and I was telling them like this is how low sleep is hurting you and all of this finally found place into conversation, which patients kept asking. So. So where's your book? So where's your book? And I kept telling them. Read this book, read that book, read that book. Where's your books? I said every time I say, wait, where is my book? Yeah, where is my book? And so 2 years ago, a good friend of mine, Charlotte Jensen and I got together. And she said Yep. Let's do it and we put a book together. It's called sleep to. Deal. It's on Amazon, and it really puts together a general starting primer about how sleep affects health and it's based. World patients that I've looked after and how their lives changed and everybody can identify with someone. In the book.‍

‍Shruti: At Aarogram, we believe that being efficient in our business is a healthcare as a healthcare provider also means providing more patient centric care. Therefore we ask this question to every guest on our podcast and this is a fun one. What's the most ridiculous? Ingenious or witty way in which you have solved? The workflow problem in your healthcare setting.

Dr. Abhinav: It may not sound very witty, but. What I've firmly believed in is, you know, patient education. I just love that. I want to see the twinkle in their eye, OK. And I'll tell you another. Thing the patient has to laugh. I know. Call it corny. Call it whatever you want. The patient needs to laugh before they leave the room. OK, simple. It's very simple somehow and if you make it a contextual joke, meaning and I always tie it in, I almost should write a stand up routine for this. Right, so a they're tense in your room. They've come to this somewhat, begrudgingly, somewhat pushed by someone their their spouse, their wife. They're getting elbowed to the couch because of the snoring or they're having a heart issue. They're sort of tense and unhappy. They've heard about people with machines, for example, sleep apnea, not using like, oh, my God, I'm going to get. This is bad sleep. Study this. So they're already that stressed, right? So and they're seeing a Doctor Who, like, who enjoys going to a clinic, getting vital checked and getting height, weight and sitting and like, oh, God, what new thing are they going to tell me, you know, so that I think once you make them laugh and they understand the problem and they have a laugh piece in there. There's a twinkle in the eye and they walk out saying like that clinic. I'm gonna do what they say because these guys care about me and patients don't care about how much you know. But they know how much you care, and that is, I feel, the backbone. Yes, it doesn't translate into measurable revenue. You cannot put an ROI on this. It's hard. But I think it's the essence of what we do in healthcare. Remember healthcare, the last part is care, right? So if there is no care, there is no health.

Shruti: That's lovely. That was a beautiful hack. I'm so glad that you shared your time with with me today. And I hope our listeners pick up your book. I'll share a link of the book in the description of the episode as well. Thank you so much, Abhinav, for being with us today.

Dr. Abhinav: Thank you shruti. This was a pleasure.