FAQ

With a Direct Pay practice model, we limit the number of patients we see so we can spend the time needed with each patient. That allows us to be easily accessible for appointments and follow ups. We are scheduling out 2 weeks for in-person appointments and one week for telemedicine appointments. This is especially important for children given that wait times to see a pediatric pulmonolgist can be 6 months or more.

Once you are seen in clinic, if a sleep study is indicated, the order will be placed either that day or the following day. The wait time for the sleep study once the order is sent will vary based on the hospital, we send the order to but in general the wait time is not more than three weeks.

The treatment for obstructive sleep apnea (OSA) in children will vary depending on the severity. If the OSA is mild without associated low oxygen levels you could elect “watchful waiting” as tonsil and adenoidal size shrink over time. Another option is a short course of an anti-inflammatory medication. If the child is overweight, then weight lose would be highly recommended regardless of the degree of the severity of the OSA. If the OSA is moderate or severe then referral to an Ear Nose and Throat doctor for assessment of the anatomy of their airway would be recommended. If adenoids and tonsils are large and obstructing then removal could be curative if the child is not overweight. Being overweight could result in residual OSA in some patients after surgery. A follow up sleep study is always recommended in children with moderate or severe OSA after surgery. CPAP is another treatment option for moderate to severe OSA in children. Other options include the use of palatal expansion by a dentist or more extensive surgery when indicated. Myofascial therapies are being studied for treatment as well.

Restless sleep is not normal and causes for restless sleep would be explored by an extensive history in clinic. If there is an underlying medical disorder such as asthma or eczema this could explain your restlessness. Two sleep disorders that quite commonly lead to restless sleep include restless leg syndrome (RLS) and Restless Sleep Disorder. RLS is a clinical diagnosis determined by your history alone but is associated with periodic limb movements of sleep. Restless Sleep Syndrome is associated with multiple large body movements. Both are associated with low ferritin levels. Obstructive sleep apnea and patients with Narcolepsy both can have restless sleep as well. Ultimately, finding out why a patient has restless sleep or poor-quality sleep requires an extensive investigation which we have time in clinic to explore as we take 60 minutes with all of our new patients.

This is a very complex question and takes a full assessment with review of an extensive history but one must keep in mind that the most common sleep disorder is Insufficient Sleep. Numerous patients come to my clinic and after spending 60 minutes with them I finally conclude they are skimping on the amount of sleep they are getting per night resulting in “catch up” sleep on the weekends. This can be described as Social Jet Lag. This is extremely common and easily remedied. We take an Epworth Sleepiness Scale which helps us determine the true degree of impairment a person is experiencing. Patient with insufficient sleep or obstructive sleep apnea may have a mildly abnormal Epworth Sleepiness Scale Score where someone with Narcolepsy the score is quite high. We then spend 60 minutes exploring the likelihood of the presence of a sleep disorder.

No. Most sleep problems can be addressed but spending time with a professional trained in Sleep Medicine. Sleep studies are reserved for diagnosing Obstructive Sleep Apnea, REM Behavior Disorder, and differentiating seizures from parasomnias. Unexplained non-restorative sleep may often benefit from a sleep study. A sleep study is also required prior to performing a Mean Sleep Latency Test used to diagnose Narcolepsy.

Yes and no! Insurance can be used for support services associated with your care such as labs and other tests. (However, we offer some of those items at a very reduced price--often for less than the copay required if insurance is used.) Insurance cannot be used for our professional fee (office visits) as we operate on a fee-for-service basis. A "super-bill" is provided those submitting an insurance claim seeking reimbusement for our professional fee. HSA and FSA cards can be used for our professional services. Working with insurance companies drives the cost of health care up with high administrative costs. Insurance companies dictate how physicians must chart to meet billing requirements hence taking time from patients. Insurance companies reimburse very poorly forcing physicians to see more and more patients to make ends meet. Insurance companies dictate what care I can provide to my patients so we gladly do not work with insurance companies in our practice. By not taking insurance, we can provide affordable care since we require much less overhead. The physician can spend time with the patient rather than time charting to meet billing requirements and can schedule longer time to spend with each patient.

Please see our short video below for the answer to this question.

Yes! Despite paying premiums to your insurance company, you still have a large deductible. Your personal out of pocket cost for labs or x-rays with direct pay care will be substantially less than what you will be charged by your insurance company to meet your deductible for the same labs and x-rays. For example, with direct pay through my practice a CT scan of the head will cost you $130.00 versus $785 charged to you using your insurance if you have not met your deductible. A chest X-ray would cost you $32 if you ordered through my practice versus $108 charged to you by your insurance company. Iron labs would cost you $26 versus $79 and so on. So, you save a substantial amount using a direct pay practice with your high deductible insurance plan. In addition, you can submit our superbill to your insurance company for those labs and x-rays if you have an out of network deductible amount. The consultation fee can also be submitted in the same way. Unfortunately, we have no control over the possible reimbursement amount as that will depend on different insurance companies and your personal plan. You can also use your HSA/FSA card to pay for all services including the consultation fee, labs and x-rays. However, you can always use your insurance plan if that works better for you for the labs and x-rays but not for the direct pay consultation fee as we do not bill insurance for our physician services.

Currently we are unable to care for any Medicare or Medicaid patients. Our hope is to add Medicare patients to the list of patients that we can see in the near future. Please check back in the few months for an update.

Our goal is to provide affordable healthcare with reasonable and transparent pricing. At this time, we do not offer payment plans and all fees will need to be paid at the time of service.

Yes and no! Insurance can be used for support services associated with your care such as labs and other tests. (However, we offer some of those items at a very reduced price--often for less than the copay required if insurance is used.) Insurance cannot be used for our professional fee (office visits) as we operate on a fee-for-service basis. A "super-bill" is provided those submitting an insurance claim seeking reimbusement for our professional fee. HSA and FSA cards can be used for our professional services. Working with insurance companies drives the cost of health care up with high administrative costs. Insurance companies dictate how physicians must chart to meet billing requirements hence taking time from patients. Insurance companies reimburse very poorly forcing physicians to see more and more patients to make ends meet. Insurance companies dictate what care I can provide to my patients so we gladly do not work with insurance companies in our practice. By not taking insurance, we can provide affordable care since we require much less overhead. The physician can spend time with the patient rather than time charting to meet billing requirements and can schedule longer time to spend with each patient.

No, most patient can be cared for with an initial 60-minute consultation which allows for a thorough assessment of your problem. This consultation is made available in writing for you and your primary care provider with extensive recommendations. If testing is necessary, those orders will be part of this initial consultation fee. Review of the results of the tests ordered during the consultation including a sleep study if indicated is included in the initial consultation fee as well. If a more extensive follow up is needed to discuss further detailed recommendations, then a follow up appointment will be recommended. Some patients based on the complexity of their presentation or diagnosis are better served after the initial consultation with an “active membership” to provided time for diagnostic testing, and stabilization of the treatment plan. This will require a 4-month commitment. Examples of patients that fit into this category might include a patient with 1.) Uncontrolled asthma, 2.) A new CPAP machine, 3) Newly diagnosed Narcolepsy, 4.) Chronic Insomnia or 5.) Long Covid. Please note with a monthly membership we will communicate with you through text, email, frequent phone calls and telemedicine visits where you will end up saving on the cost of multiple follow up visits requiring co-pays that you would now not have to pay. Also, since we care for a limited number of patients you do not have to wait long periods for follow up. Lastly, to put things in perspective, if you do require a membership for short term or long term it is equivalent to cup of coffee per day.

We prefer to see all of our new patients in person for the first visit if possible. This allows for a full physical exam and a firm foundation to develop our relationship together. If you live a far distance from the practice location in Olathe, Kansas, depending on your clinical problem, a telemedicine initial visit may be provided if we feel it will not compromise your care. For example, if you have recently seen an Ear Nose and Throat doctor and we have the oral exam documented with outside medical records then a telemedicine visit would work fine. If we feel that a physical exam is essential say for pulmonary lung complaints then we would recommend an in person visit. Many follow up appointments work well via telemedicine thereafter. Phone follow up visits are offered only for those patients with memberships and who are known to the practice.

No, though they both charge a periodic fee, in the concierge model, you are paying a premium price to simply have access to a doctor where the fee doesn’t cover any of the cost of your actual care. With concierge medicine, they still bill your insurance company. In the direct pay model of Direct Specialty Care, your visits are covered by an affordable fee and you get access to significant discounts on labs and x-rays (cost plus 40% for non- members and cost plus 20% for members). The direct pay model of Direct Specialty Care is an affordable health care modal for the average individual and NOT concierge medicine.

Please see the details on the website as to which membership would work best for you. We have “Active memberships” where you are actively being managed which requires a work up with labs, x-rays and changes to your medications with frequent follow ups. We also have “Stable memberships” where you are stable and simply need to be seen twice a year and have your medications refilled.

Here’s a few articles that profile the Direct Care approach to medicine: Direct Primary Care: Restoring The Doctor-Patient Relationship (Forbes) Medicine is About to Get Personal (TIME) Physicians Abandon Insurance for Blue Collar Model (US News) The Doctor Will See You But Not Your Insurance (AARP) Direct Primary Care (American Academy of Family Physicians) Patients Pay Monthly Fee, Not Insurance Co-Pay to See Raleigh Physician (WRAL)

Chronic cough can be caused by many things but the most common causes include: asthma, post nasal drainage from multiple causes like sinusitis or allergies and acid reflux.

Asthma is often suspected by a history of recurrent wheezing but sometimes can simply present with recurrent coughing called “cough variant asthma”. The definitive way to diagnose asthma is with spirometry. Spirometry measures the obstruction of airflow upon forced expiration. Asthma is a one of the many forms of obstructive lung diseases and symptoms can often occur episodically. Patients with asthma will show improvement in airflow obstruction upon exhaling during spirometry after taking bronchodilator medications. If improvements in airflow meets diagnostic criteria this confirms the diagnosis of asthma. You can have a normal spirometry and still have asthma due to the episodic nature. If asthma is still suspected then ordering a Methacholine Challenge test can confirm the diagnosis as it induces obstruction of the airway if you have asthma. There can be false positive Methacholine Testing in patients with allergies.

It is normal for every person’s oxygen levels to drop at night but not more then 2-3 %. The reason your oxygen level drops at night is because your lung volume drops with sleep. You should not be concerned if your oxygen level drops by only 2-3% but if you consistently see it drop more than that amount or if you see it drop below 90% consistently you should have an evaluation. This can be a presentation of untreated and unknown asthma or due to significant hypoventilation at night. If the oxygen level drops intermittently at night, then you could have obstructive sleep apnea.

Patient that presents with recurrent “bronchitis” every winter or patients that present with persistent chest symptoms such as coughing for weeks after every viral illness very likely have undiagnosed asthma. Asthma is characterized by chronic inflammation at the airway level. If a patient gets sick with a viral illness which most often happens in wintertime, then this stirs up the inflammation already smoldering in the airways leading to persistent chest symptoms that can last for weeks. The solution is to confirm your suspected diagnosis of asthma and start treatment prior to those winter months and your recurrent “bronchitis” will end.

Shortness of breath is one of the main symptoms that a pulmonologist gets consulted about. The work up can be quite complex as it includes determining the health of not only the lungs, but the airways of the lungs, the pulmonary arteries of the lungs, and also how the heart works with the lungs. The actual sensation of being short of breath is less determined by your oxygen level but more so by your carbon dioxide level. It is also tied to how much work it requires for your body to” move” your lungs. It is the “work of breathing” that determines your sensation of being short of breath. If your airways are obstructed like with asthma or COPD and it’s hard to breath out then you are short of breath. If your lungs are stiff either from fibrosis or from fluid or from pneumonia you have a hard time moving them because of their stiffness or weight and then you are short of breath. So we try to differentiate all aspects of the pulmonary and cardiac system that can increase the work of breathing and can cause low oxygen levels to determine why someone is short of breath.

Prevalence varies according to age. Ten percent of 7-year-old children still have incidents of bed-wetting. Two to three percent of 12-year-old children still experience bed-wetting.

Taking iron correctly is extremely important to ensure optimal absorption. Iron should be taken on an empty stomach either withvitamin C or orange juice. All dairy products should be avoided for one hour afterward. Stools may turn black and constipation may be a side effect.

Improvement should be expected if iron is taken daily as directed within 8 weeks. Resolution of symptoms is slow and gradual and may only be recognized in retrospect.

An otolaryngologist or ENT (Ears, Nose and Throat) doctor may be appropriate if /when your child has been diagnosed with Obstructive Sleep Apnea and evaluation for removal of your child’s tonsils and adenoids needs to be considered.

Securing the home, windows and doors, is the most important task parents should do to protect a child that is sleepwalking.

Snoring is an indication of resistance of airflow through the upper airway but may not necessitate a sleep study. Unfortunately, despite a thorough history and physical exam, we are not able to completely predict the degree of Obstructive Sleep Apnea (OSA) a patient may have, therefore sleep study is the most comprehensive way to rule out OSA.

Yes. We often see multiple members of the family that have RLS.

Yes, though obesity a significant contributor to OSA, even patients who are not overweight can have a predisposing boney structure of the face and jaw that can lead to OSA.

Yes, sleep talking can be normal and simply a manifestation of a short arousal out of sleep. If sleep talking is excessive, this can be an indicator that perhaps another underlying sleep disorder is contributing to these arousals.

A child’s initial bedtime routine at the start of the night, if it requires parental presence to fall asleep, will determine the child’s need to repeat that same routine in the middle of the night. Addressing this initial bedtime routine is key to stopping children from seeking parents in the middle of the night.

This is one of the most common problems we deal with and simply discussing the sleep schedule is often quite revealing. Parents are often completely unaware of what their adolescents are doing once they go to their rooms for the night.

With early school start times the risk of automobile accidents on the way to school are very real. Adolescents who are not well rested may struggle academically or with emotion management. Ultimately, learning to maintain healthy sleep/wake schedules leads to better quality of life during and after school.

Our biological clocks are very sensitive to light --whether sunlight or from artificial sources. Lights from electronic device screens can shift our biological clocks so that we fall asleep later and conversely bright light in the morning can shift our clocks backwards helping us wake up sooner. One form of treatment includes use of a light-box.

You must have excessive daytime sleepiness as the main presenting symptom to be considered to have Narcolepsy. That presentation could be as subtle as taking a nap when you never needed one before or as severe as falling asleep while eating with friends.

Sleep paralysis is just like it sounds—while asleep or waking up— you are fully conscious but cannot move. This can be extremely frightening. Sleep paralysis is directly related to falling asleep or waking up out of the REM (Rapid Eye Movement) sleep stage. You can experience sleep paralysis by simply not getting enough sleep. Sleep paralysis can also be part of the set of symptoms associated with Narcolepsy.

Cataplexy is most commonly associated with the diagnosis of Narcolepsy. Patients experience cataplexy when they develop muscle weakness such as weak knees, slumping over or simply having an internal feeling of weakness in association most often with laughter or excitement but can occur with other strong emotions.

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OSA is typically thought of as a mechanical blockage in the back of the throat which can be at the level of the soft palate or tongue during sleep. OSA is much more complicated than this and includes the patient’s overall airway muscle tone; the patient’s response to arousals; and the patient’s response to carbon dioxide called “loop gain.”

OSA is just like it sounds—an obstruction in the airway while the patient attempts to continue to breath despite that obstruction. CSA is different in that the patient’s brain does not send a message to breath so there is just a pause in breathing. Common causes of CSA include Congestive Heart Failure, opioid usage, traveling to high altitudes.

This is a syndrome that includes both Chronic Obstructive Pulmonary Disease (COPD) and Obstructive Sleep Apnea (OSA). Management of OSA in the context of COPD is complex and requires the expertise of a pulmonologist who is comfortable managing bi-level ventilation.

Untreated sleep apnea can lead to hypertension, elevated blood sugars, congestive heart failure, pulmonary hypertension, atrial fibrillation, and strokes.

RLS typically presents in the evening/night with an uncomfortable “urge” to move your legs. Movement will bring momentary relief but the symptoms then return leading to an inability to fall asleep or stay asleep. Optimizing ones’ ferritin levels (the body’s form of stored iron) can lead to significant resolution of symptoms.

All good doctors should respect and encourage the pursuit of a second opinion if you have concerns about the recommended course of treatment. If you would like to discuss whether asking for a second opinion is reasonable, we can help.

Your doctor should have a patient portal you can send your questions to. I would send your most important question and not abuse this access.

Most doctors understand that as a spouse, or adult child, that you are the best person to know what your loved one has communicated in regard to their desired care. Most situations don’t require a medical power of attorney but having one is always helpful and would be best have one in anticipation of a possible need.

The limits of that role are totally determined by the friend that asked you to accompany them to the doctor.

Patients have a tendency to not question a doctor’s recommendation or ask for further explanation of terms or plans of action. We always recommend that before proceeding with any plan to get ALL your questions answered.

Doctors should welcome any questions and encourage you to seek a second opinion if you would like to do so.

We recommend talking directly to the doctor. Medicine is complex. Even nurses may not completely understand why certain decisions are made. It’s always best to talk directly to the doctor to get a complete explanation from their perspective to rule out misunderstandings. If you want to make a complaint within the doctor’s organization this is generally done through the patient advocacy office at a hospital. If your concern is more serious and you fear that malpractice has occurred, you will need to seek legal advice or talk to the medical licensing board in your state.

- Someone trying to decide what nursing home is best for an aging parent - Someone who has a critical ill loved-one that would like to discuss the pros and cons of a tracheostomy or feeding tube placement - Someone who has a critical ill loved-one who would like to discuss the complex terminology the doctor uses to describe what is going on with your love one in the ICU or hospital - Someone who would like advice on how to advocate for accommodations for academic testing for college entrance.