How to Increase Access to Insomnia Therapies with the AASM’s Jennifer L. Martin

Sree Roy:
Hello and welcome. I’m Sree Roy with Sleep Review and I’m thrilled to be here with Jennifer L. Martin, PhD, who became the president of the American Academy of Sleep Medicine Board of Directors on June 6th, 2022. During her one year term, Martin will lead an organization that has a joint membership of 11,000 accredited sleep centers and individuals. She will help AASM achieve strategic goals related to public awareness, technology innovation, workforce development, and advocacy to improve patient care. Can you please describe your involvement with the American Academy of Sleep Medicine over the years?

Jennifer L. Martin:
Well, I’m happy to be here and I’m excited about my year as AASM president. I’ve been active with the AASM now for quite some time. Been a member for about 15 years and even before that, as a student and a trainee, benefited from some of the educational opportunities that the AASM offered so I feel like it’s my home. I’m a clinical psychologist by training. I love integrated care and I feel like the AASM really embodies a lot of the things that are important to me professionally.

Sree Roy:
Excellent. You just touched on this, that you’re a licensed clinical psychologist. Can you explain a psychologist’s role in sleep medicine?

Jennifer L. Martin:
So when I was training, which was now a few decades ago, there was a pretty seamless integration across disciplines in sleep medicine. Before sleep medicine was a subspecialty of medicine, it was a very interdisciplinary field. So I was part of a group of clinicians and researchers back in the nineties where psychologists and physicians had very similar roles in sleep medicine. Over time that’s changed and now a lot of the diagnostic testing and more medical aspect of sleep medicine is handled by physicians and the psychologist role has turned into one of enhancing more behavioral and mental health issues related to sleep medicine.

Jennifer L. Martin:
I’ve been lucky enough to be integrated into sleep medicine in terms of my own clinical practice. I work very closely with sleep medicine physicians, respiratory therapists, our sleep techs. So I feel very fortunate that I’ve been able to carve out a niche in sleep medicine that’s focused on the behavioral aspects of sleep disorders. A lot of what psychologists do in sleep medicine is treating insomnia disorder. A fair number of psychologists in sleep medicine work with pediatric patients so thinking about things like school attainment. And a lot of us also work on helping patients adhere to treatments that they have to use daily, like CPAP for sleep apnea. And like I said, in an ideal world, we all work really closely together and actually co-manage patients.

Sree Roy:
Press release about your leadership mentioned that one of your priorities will be for the AASM to collaborate with other stakeholders to identify and prioritize strategies to increase access to high quality care for insomnia disorder. Can you elaborate on this?

Jennifer L. Martin:
Over the past few years, the AASM has published two clinical practice guideline documents. One on pharmacologic interventions for chronic insomnia and one on behavioral and psychological treatments for insomnia, both focused on adults. And we know, not just from our own guidelines but from other organizations’ guidelines and the available evidence, that there are really good treatments for insomnia disorder. The most commonly recommended first line treatment and the one with the most evidence behind it is cognitive behavioral therapy for insomnia. Now it’s a treatment that benefits a majority of patients. It’s kind of the bread and butter and the core of my own clinical practice, but it’s really difficult for patients to get connected with this treatment. CBTI is a relatively brief intervention, usually requiring between four and eight sessions with a psychologist or sometimes it’s provided by advanced practice providers or master’s level mental health professionals.

Jennifer L. Martin:
But one of the challenges is that there are a lot of patients with insomnia and a few specialized providers. The other challenge that comes up, and I think we’ll probably talk more about this, is that even when a patient can find a skilled provider, getting that treatment covered by insurance is really difficult. And so one of the goals of my custody guidelines is to really focus on how we can get not only CBTI, but some of the other interventions that are based on research and clinical practice guidelines to patients. A lot of the challenges around not having enough skilled providers I think has to be solved by training more providers. That’s not a problem that patients can solve.

Jennifer L. Martin:
The other issue that comes up is that some of the pharmacologic agents that are recommended as options when CBTI isn’t sufficiently effective or isn’t appropriate are also not covered by payers. So sometimes patients have only a limited choice of medications and if they’re experiencing side effects or it’s not working for them, they don’t always have all of the medication options available to them when they’re needed as well. So because of the fact that we have evidence based interventions that work for most people, but a lot of patients with insomnia can’t get them, that’s why I decided to make this a priority for this year.

Jennifer L. Martin:
We also have had some success at the AASM in communicating directly with payers about the evidence based guidelines and getting them to align their policies with what’s best for patients. So we’re trying to see if maybe we can copy some of our success in the area of ​​sleep disorder breathing and use some of those same strategies to improve coverage as one of the things that’s a challenge for accessing evidence based high quality care for insomnia .

Sree Roy:
That’s great that you’re going directly to the payers because that seems like a really efficient way to accomplish this. Are you bringing them evidence of how treating insomnia might actually save them money?

Jennifer L. Martin:
We haven’t gotten that far yet. So one of the issues that comes up is that payers don’t usually think about patient care over the long run. So most people have insurance for a number of years and then they change jobs or they change insurance. So it’s not clear that the cost savings are realized in a short period of time. The cost savings are usually realized over a person’s life, maybe not their entire lifetime, but over a longer period of time. So I think what the more compelling argument is when we treat sleep disorders in general, people have fewer accidents, injuries, they’re less likely to develop mental health symptoms in the future. So untreated sleep disorders can lead to problems that are expensive for payers, but in terms of cost savings, that’s a little more difficult to show in the short term.

Sree Roy:
Okay, that makes a lot of sense. Yeah. I’ve been reporting on sleep disorders for almost a decade now and I’ve definitely found that reimbursement or lack thereof is a big challenge when it comes to treating insomnia disorder. Do you have any other comments on how sleep medicine can help overcome these reimbursement challenges when it comes to insomnia?

Jennifer L. Martin:
Well, I think that one of the challenges is that CBTI in particular is a psychotherapy and reimbursement for psychotherapy hasn’t gone up in more than a decade. When we look at Medicare, for example, which is the largest payer and their fee schedules are often copied by private payers. So in fact, reimbursement for mental health services in general haven’t kept pace with inflation. So what’s happened as a result is that a lot of the providers, really good providers out there, can’t afford to take insurance and operate their practice, even if they could do that 10 or 20 years ago. Again, because the cost of doing business are accelerating at a faster rate than the reimbursement. Most psychotherapy sessions are 45 to 60 minutes so you can’t also just increase your volume in the same way that you can with things that are more procedure based.

Jennifer L. Martin:
And so I think that what sleep medicine can do as a field is be a part of the chorus that’s advocating for increasing the value that we put on mental health treatments in general. I know there are a lot of other organizations who also see this as a priority, that treating mental health conditions in general should be covered at a reasonable rate for providers. Because what has happened over time is that a lot of the really good CBTI therapists don’t accept insurance. They only take private pay clients and that creates a disparity in access to care. But I think none of us feel good about, although we do want our colleagues of course to have thriving and successful practices.

Jennifer L. Martin:
I think there could be some models for integrating some of these treatments within sleep medicine centers that could perhaps defray some of the overhead costs. So in fact, just last week we had a collaborative summit around insomnia and we were hearing about some practice models that are successful in the current landscape, including having a behavioral sleep medicine psychologist within a sleep center. That way they don’t have to advertise their practice, they don’t have to cover all the overhead for scheduling, and things like that. And that seems to be a model that some people are leaning into now.

Sree Roy:
That does sound like an innovative model that could make a difference because that’s really… It is sad that it’s not accessible to a lot of people. Beyond insomnia, are there any other goals for your one year term that you’d like to share?

Jennifer L. Martin:
One of the goals that I have as a AASM is to create an organization where all members of the sleep team president feel equally valued. Sleep is not a condition that exists in one part of the brain or body. It’s everywhere. And as I mentioned, I’ve had the good fortune to work really closely with a range of providers who are as passionate about taking care of sleep disorders as I am. And one of my goals is to make the AASM welcome to everyone on our team. So we’re really trying to understand the needs of people who practice in dentistry and nursing, obviously psychology and medicine so that we can make sure that we’re all working together and providing a really high standard of care for all of our patients.

Sree Roy:
That’s definitely an important goal. Are there any social media handles you’d like to share for audience members who want more information or maybe other folks who are listing who might be interested in joining the AASM?

Jennifer L. Martin:
Yeah, so our Instagram and Twitter accounts are just AASM ORG. AASM Org. One of my favorite websites to tell people about is sleepeducation.org. There’s a wealth of resources there about a range of sleep disorders, and my favorite feature is that you can enter your zip code and find an AASM accredited sleep center near you. And for anyone who has sleep disorders, that’s always a great place to start. If the center doesn’t have the services that you need, for example, they may not have a psychologist on staff, a lot of times they can get you connected with providers in your area. Or can tell you about some self-guided online programs that might just involve you seeing a sleep medicine physician and then following up after you do an online treatment yourself.

Sree Roy:
I send people to that website all the time for the sleep center finder actually.

Jennifer L. Martin:
Yeah, me too. Me too. Another organization that I want to mention is the Society for Behavioral Sleep Medicine. They have an index of providers who do CBT for insomnia, so that’s another resource if people are looking specifically for CBTI where they can find someone. I think they have them listed by state so not quite the search by zip code function, but still a good place to start if you’re looking for help.

Sree Roy:
Fantastic. Well, thank you so much for chatting with us about the American Academy of Sleep Medicine today. And if you want more from Sleep Review, please visit us at www.sleepreviewmag.com. Thanks so much for tuning in today.

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