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Insurer Reimbursement: Could Less be More?
If you haven't heard, Medicare and private insurers are putting the screws to the DMEs that provide our Sleep Apnea equipment in an effort to cut costs, much to the chagrin of DME providers. One aspect of the cost-cutting is to deny reimbursement to DMEs and other providers that cannot show that their patients are complying with CPAP treatment. While at first blush, this might seem like an adverse development for us patients, the problem for us might be that the insurers didn't do this sooner, and that they haven't yet gone far enough.
My thinking is this: for too long, DMEs could get away with giving out to patients the most basic, least effective and "dumbest" machines out there. These are the machines that cost the DMEs the least (and thus result in the greatest margins), but which also reduce the likelihood of us getting well with Sleep Apnea. With no feedback given to the patient on how the patient is doing, the patient quickly kicks aside the treatment altogether when something goes wrong, because there is no obvious path to fix the problem. As we know, data-capable machines provide this feedback so that we are not "flying blind," but rather can tweak our therapy if something is not working, and quantify the results of the tweak.
Now the reason the dumb machines were put out there in the first place was because the DMEs could get away with it. Not any longer. Insurers are saying you have to give out data capable machines, because there is no other way you can prove to us that the machines are being used and unless we have that proof, we're not going to reimburse you for it. And look what the result is: chances are slim that any newbie to this forum is being prescribed a machine that doesn't at least have some basic data capability.
But let's not rest on our laurels. That's a step in the right direction, but just a baby step. What we are really after with data monitoring isn't just knowing that the machine is on, but knowing that it is being effective. So I would advocate that the insurers make the DMEs reimbursement conditioned on efficacy data, and not just compliance data. My guess is after a little while with this regime in place, we'll see a big move forward in patient compliance rates, and in innovative technology designed to improve compliance.
My thinking is this: for too long, DMEs could get away with giving out to patients the most basic, least effective and "dumbest" machines out there. These are the machines that cost the DMEs the least (and thus result in the greatest margins), but which also reduce the likelihood of us getting well with Sleep Apnea. With no feedback given to the patient on how the patient is doing, the patient quickly kicks aside the treatment altogether when something goes wrong, because there is no obvious path to fix the problem. As we know, data-capable machines provide this feedback so that we are not "flying blind," but rather can tweak our therapy if something is not working, and quantify the results of the tweak.
Now the reason the dumb machines were put out there in the first place was because the DMEs could get away with it. Not any longer. Insurers are saying you have to give out data capable machines, because there is no other way you can prove to us that the machines are being used and unless we have that proof, we're not going to reimburse you for it. And look what the result is: chances are slim that any newbie to this forum is being prescribed a machine that doesn't at least have some basic data capability.
But let's not rest on our laurels. That's a step in the right direction, but just a baby step. What we are really after with data monitoring isn't just knowing that the machine is on, but knowing that it is being effective. So I would advocate that the insurers make the DMEs reimbursement conditioned on efficacy data, and not just compliance data. My guess is after a little while with this regime in place, we'll see a big move forward in patient compliance rates, and in innovative technology designed to improve compliance.
Views: 56
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Comment by Judy on February 7, 2009 at 4:47pm
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I can see how difficult the shoddy local DME suppliers make it for the reputable local DME suppliers who try so hard to provide good products and service to their clients. Thanks for being one of the latter, Daniel!!!
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Comment by Daniel on February 7, 2009 at 2:53pm
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It burns me up to hear horror stories like yours. That's one of the reasons I decided to start my own business. Your story isn't quite as bad as a patient I know of who originally received a BiPAP Plus, a basic BiPAP with no data recording ability at all. I explained to her what data recording can offer to a patient, so she went to her doctor and got a prescription for a BiPAP with Smart Card capabilities. She took the Rx to the provider, and believe it or not, they snapped a smart card module to the back of her BiPAP Plus and gave it back to her. A month later, she sent me the smart card to get a download, and the card didn't show any usage. They gave her the module, but the device was too dumb to do anything with it! Even worse, the card was used previously, and had data from 2004 on it, before she was ever diagnosed with sleep apnea! She is now in the process of threatening the company and having the sleep lab remove their name from the lab's list of trusted providers.
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Comment by sleepycarol on February 6, 2009 at 10:50pm
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Daniel,
Good for your company in providing data capable machines!!!
When I received my script it was for a "smart cpap with a pressure range of 8 - 12, heated humidifier, and a Fisher and Paykel full face HC431 mask." Unfortunately, I was completely clueless and as a result ended up with an M series Plus machine. I was told by the DME that because it was the "Plus" machine it was a great machine and could record data for me. This machine was set to a pressure of 10. I was told this was common practice at all DME's -- they pick the middle number to set the machine to.
Boy, was I ever dumb. Finding informative forums on the net the same night led me to the realization that I had been duped. I took the Plus machine back and set it on the counter and went to a different DME (with my doctor's and insurance company's blessing) and received the correct machine.
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Comment by Mike on February 6, 2009 at 10:30pm
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Judy, understood that Medicare is just requiring compliance data now. But what I'm suggesting is that they should require efficacy data of the DMEs too. With respect to Daniel's concern, I think things don't have to be so black and white --- it's not the case that a patient would need to be cut off if the patient wer getting some therapeutic benefit, even if not the full therapeutic benefit. The criteria for reimbursement could be set so that patients making a "go of it," and the DMEs supporting them, would still qualify. There's room for shades of gray, no?
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And Mike, to clarify, all Medicare is requiring that the xPAPs be COMPLIANCE DATA capable, they aren't requiring the efficacy data we patients want. I was real excited to read that too - until I re-read it because I felt it was just too good to be true. It remains that the DME suppliers must be able to provide PROOF, not just a statement from the patient, that they are in compliance.
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I meant to say "mask and/or mouth leaks"
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Daniel, those large leaks would appear in the Efficacy data and the patient, DME and/or doctor would know what adjustment to make - more assistance w/proper fit, addition of a chin strap or a different mask. As it is now w/o full data capability no one has any idea of how much of a problem, if any, a mask and/or mask leaks are. How many times is a pressure change ordered "by guess and by guess" when it could well be the leak rate that is the real problem?
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If insurance companies reimburse based on efficacy rather than compliance, then a large portion of OSA patients will be screwed. What if someone uses his/her CPAP every night, but due to mouth-breathing, large leaks interfere with the efficacy data? What about someone whose AHI was 140 events per hour, and by using CPAP, AHI was reduced to 32 events per hour, and he reports feeling four times better than he used to?
On the poistive side of things, I'm starting to see more and more prescriptions where the physician is specifying that the patient needs a device that records compliance and efficacy data. A DME who tries to go cheap isn't conforming to such a prescription. At SomniHealth, all patients receive devices with these capabilities no matter what. If more doctors were educated about the full capabilities of the devices and wrote more specific prescriptions, then we'd start to see people getting more capable machines on their nightstands.
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