Come 6 o'clock in the evening, you'll find Steve Yates doing a jig in the corner.
Sometimes that's the only way to satisfy the inexplicable and infuriating urge to move that sets in every night before bed, making sleep impossible.
Yates' restless leg syndrome has gotten worse since he was a teenager. So when his sleep doctor recommended another sleep study — his last was a decade ago — to check for additional causes of his restlessness, he agreed.
Yates, 60, didn't learn anything from his night at the sleep center in February, except to always inquire about cost and alternatives before agreeing to any medical procedure.
He'll be paying off the $3,984 sleep study in monthly installments for the rest of the year.
"I'm kicking myself," said Yates, who lives in Perkasie in northern Bucks County.
A lot of people are spending that much and more in search of the elusive good night's sleep.
More than a third of Americans don't get the recommended seven hours of shut-eye and as many as 70 million people have a chronic sleep disorder, according to the Centers for Disease Control and Prevention and the National Center on Sleep Disorder Research.
Sleep studies, the gold standard for diagnosing sleep disorders, are such big business that the number of accredited sleep centers across the nation has soared from 500 in 2000 to 2,600 today.
Independence Blue Cross, the largest private insurer in the Philadelphia region, has seen a 28 percent increase in the number of sleep studies it has been billed for over the last five years, with about 32,390 studies in 2017 alone.
And that's just to get the diagnosis. Treatment — from breathing machines for sleep apnea to special pillows and mattresses for those without a specific disorder looking for a little more comfort — balloons this most natural human function into a $40 billion-a-year business.
Sleep studies — often the gateway to this big business — vary in cost significantly, from a little more than $100 for an at-home test to the thousands that Yates spent for an overnight lab stay.
Only people with a suspected sleep disorder — such as restless leg, or sleep apnea, in which the airway becomes blocked during sleep — need to be studied. But after decades of ignoring sleep problems and a rise in medical conditions such as obesity associated with sleep disorders, demand is steep.
"This problem or this series of problems are so common and we haven't been paying attention to them for so long," said Karl Doghramji, medical director of the Jefferson Sleep Disorders Center. "The recognition of these disorders and the impact on body function is increasing, and with increasing recognition, doctors are now paying more attention to the possibility of these problems when they interview patients."
‘A badge people wore’
Not so long ago, hard-charging Americans were bragging about how little sleep they needed.
"It was almost a badge people wore — I'm working harder, I'm losing sleep over it," said Ilene Rosen, a professor of clinical medicine at the University of Pennsylvania and immediate past president of the American Academy of Sleep Medicine. "Now people are realizing how sleep is one of the pillars of health."
Insufficient sleep makes people more likely to develop diabetes, cardiovascular disease, chronic obstructive pulmonary disease, and obesity, among other chronic conditions.
Drowsiness causes hundreds of fatal car accidents, according to the National Highway Traffic Safety Administration and costs $411 billion in lost productivity annually, according to a Rand Corp. study.
Chronic sleep deficiency has even been associated with premature death.
In response to these eye-opening statistics, the sleep medicine business has boomed.
Not only are more consumers seeking out sleep specialists, other doctors also are referring their patients to these in-demand practitioners.
Bruce Kramer, of West Chester, was so worried about his memory that he went to a neurologist to find out whether something was wrong with his brain.
The doctor determined Kramer, 56, was fine in that department. But he thought perhaps an undiagnosed sleep disorder was contributing to Kramer's difficulties, and referred him to a sleep specialist.
Kramer hadn't taken his snoring seriously until he was diagnosed with sleep apnea and began sleeping with a continuous positive airway pressure (CPAP) machine. Suddenly, he felt better and his memory improved a little.
"I knew I snored," he said, "I just didn't know how much it impacted me."
Sleep apnea has dangerous implications for heart and lung health, and, aware of these risks, doctors have pushed patients to get tests.
The American Academy of Sleep Medicine now estimates that 12 percent of adults have sleep apnea.
High cost for decent sleep
Mention "sleep study," and most people think of sleeping in a lab, head studded with electrodes.
But at-home sleep studies are fueling much of the testing increase. Primarily used to diagnose sleep apnea, home tests cost $150 to $500.
At-home tests explain why there was a 9 percent increase in sleep studies among Medicare beneficiaries between 2010 and 2014, yet a decrease in spending, to $189 million in 2014. At-home tests accounted for 12 percent of all sleep studies in these patients in 2014, compared with less than 1 percent in 2010.
Sleep tests performed in a lab use advanced electrodes and sensors to measure more than a dozen different metrics in addition to breathing, such as brain waves, leg and eye movement, and oxygen levels.
At-home tests focus on breathing and chest movements, using bands across the patient's chest and abdomen, and an air tube under the nose. They're adequate for diagnosing sleep apnea. But more complex problems such as narcolepsy or seizures during sleep require lab testing, said Doghramji, the Jefferson sleep doctor.
Suspected sleep apnea sufferers with heart failure, lung disease, brain abnormalities, or other medical conditions also aren't good candidates for an at-home test.
The cash price for a lab test, not including a doctor's fee, ranges from $577 to just under $4,200 in the Philadelphia area, according to Philly Price Check, the Inquirer's searchable database. (Please help us improve the database by going to philly.com/healthcosts to contribute your own billing information, or email it to us at email@example.com.)
Medicare pays $702 for an in-lab study.
Sleep studies are often covered, at least in part, by insurance plans, but that coverage varies significantly.
Yates, for example, has a health plan with a $7,500 deductible that he hadn't yet met when he had his sleep study, which is how he wound up with the entire $3,984 bill.
Prices also differ depending on how many variables are being tracked.
So why not avoid a potentially big bill and just use a FitBit or similar device to track your sleep?
Doctors and the American Academy of Sleep Medicine say they like that activity trackers – which can monitor not only exercise but how much of your time in bed is spent slumbering — have gotten people more interested in their sleeping habits. But the data they produce are not standard across devices and have not been validated in medical settings.
"The issue is they have not yet crossed the barrier from consumer products to medical products," Doghramji said. "They're not ready for primetime from a medical standpoint."
Gadgets to help you sleep
For people seeking an answer to such a frustrating problem as sleeplessness, a sleep study may be an enticing option.
But many other issues, such as depression, anxiety, or simply less-than-ideal sleeping conditions could be at the root of your problem. If that's the case, a sleep study likely won't produce a diagnosis.
But that doesn't mean you can't participate in the booming business of sleep.
Activity trackers — which claim to tell users how many hours they slept, how often they awoke, and how long they were in deep sleep — are getting popular among fitness fanatics who know sleep is important to their health, as well as among people who have no intention of being active.
"We can expect a lot more innovation and competition in this space because not everyone goes to the gym, but everyone needs to sleep," said Steve Koenig, vice president of research for the Consumer Technology Association.
There are sensors that fit under mattresses and alarm clocks that wake you at the optimal point in your sleep cycle – on the theory that lying in bed awake is counterproductive to good sleep and that waking from deep sleep can leave you feeling especially groggy. The Sleep Number 360 smart bed adjusts its firmness in response to body movement at night. Prices for a queen size mattress start at $1,700.
At the Brookstone store in the King of Prussia Mall, a $70 pillow that stays cool all night and a $99 programmable sound machine are top sellers among customers seeking sleep help.
"It can be a woman whose husband snores and wants to drown him out, or a man who gets warm at night and wants a solution," said Ginni Fay, the store's manager.
The American Academy of Sleep Medicine cautions that such direct-to-consumer technology can't claim to diagnose and treat sleep disorders.
The Consumer Technology Association is drafting standards for how activity trackers measure sleep, which would help validate the technology and accelerate new development, perhaps some day giving tracking devices a place in medicine.
Rosen, the professor of clinical medicine, said it's clear that in sleep, as in the rest of medicine, the role of technology will continue to grow.
"Our field is still a nascent field," she said. "There's a lot of science yet in sleep we don't know."
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