Replies to This Discussion

Permalink Reply by Mike on March 23, 2009 at 2:34pm

Rock, I can tell you what happens from a patient's perspective, but it's not pretty:

in my case, the doctor made the diagnosis, and prescribed a CPAP pressure and a type of mask (nasal), he also specified heated humidification. then he handed me a list of dozens of DME suppliers in the area, and I chose one at random. It was up to me to fax the full sleep study and RX to this DME, who then drop shipped the cheapest machine possible while still fulfilling the order. The machine and mask came with the manufacturers' DVD tutorials, and I watched those and tried my best to make sense of it all. No education. No choice. No value-add.

I don't think there are any formal certifications required of DMEs. But yes, it's possible, but not very common, for DMEs to strike up exclusivity agreements with certain manufacturers to get preferred pricing from that manufacturer.

The thing to remember is that the DME is a business. They are trying to buy the machine/mask low (from the manufacturer), and sell (get reimbursed by the patient's insurer) high. So they have every incentive to provide the lowest quality machine that fulfills the MD's script.

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Permalink Reply by Judy on March 23, 2009 at 4:43pm

I could cite the "pipedream" the manufacturers rely on the medical profession to provide. I could cite you stories of lousy DME suppliers - or I can offer a suggestion based on my own experience and that of others I've read about in the various apnea support forums. (Mind you, the few of us who lucked into a GOOD local DME supplier from the get-go are less likely to search for and find these apnea support forums).

First off, the patient should NOT just rely on the sleep lab or sleep doctor or prescribing doctor (not always the sleep doctor, often the referring physician) for the choice of local DME suppliers. They should call their insurance company and ask what local DME CPAP suppliers they are contracted with. HOPEFULLY, they will have the option of more than one! And they should shop their options before committing to any equipment offered.

Second, the patient should be provided w/a copy of the doctor's dictated results AS WELL AS the full scored data summary report w/condensed graphs AND their equipment order (script) and either asked what local DME supplier they want their equipment ordered from or better yet advised to call their insurance re above and to SHOP each optional DME supplier until they find one 1] that will supply a fully data capable xPAP, 2] that has a LENIENT mask exchange policy, 3] that has a RRT who sets them up w/their equipment and accessories, one they are COMFORTABLE with, one that will willingly answer questions.

SUPPOSEDLY, the local DME supplier provides the education, advice and support new CPAP users need. In reality, DON'T COUNT ON IT. Local DME suppliers DO HAVE to have an RRT on staff - that doesn't mean that the RRT is the one who sets up the equipment OR has contact w/the patient.

If you know of a local apnea support group by all means tell your patients how to contact them. Encourage them to go to at least a couple of the meetings. Encourage your patients to spend some time at the various online apnea support groups if they have and use a computer. This forum, of course, is a good one to recommend, another excellent apnea support forum is cpaptalk.com as is apneasupport.com and talkaboutsleep.com. cpaptalk.com is probably the busiest of the forums.

If your patient did well w/the mask they used during their titration write down the name and size and give it to them. That might not necessarily be the one they will end up w/but at least they will have SOME idea of a mask to try if they get confused w/the masks the DME offers. On the other hand, including the titration mask on the script isn't a good idea either. That just encourages the DME supplier to not bother showing or trying any others w/the patient.

AND a HEARTFELT thank you for caring enough about your patients to find an apnea support forum and ask these questions!!!!! GOOD ON YOU for doing so!!

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Permalink Reply by RockRpsgt on March 23, 2009 at 8:20pm

Judy said:

I could cite the "pipedream" the manufacturers rely on the medical profession to provide. I could cite you stories of lousy DME suppliers - or I can offer a suggestion based on my own experience and that of others I've read about in the various apnea support forums. (Mind you, the few of us who lucked into a GOOD local DME supplier from the get-go are less likely to search for and find these apnea support forums).

First off, the patient should NOT just rely on the sleep lab or sleep doctor or prescribing doctor (not always the sleep doctor, often the referring physician) for the choice of local DME suppliers. They should call their insurance company and ask what local DME CPAP suppliers they are contracted with. HOPEFULLY, they will have the option of more than one! And they should shop their options before committing to any equipment offered.

Second, the patient should be provided w/a copy of the doctor's dictated results AS WELL AS the full scored data summary report w/condensed graphs AND their equipment order (script) and either asked what local DME supplier they want their equipment ordered from or better yet advised to call their insurance re above and to SHOP each optional DME supplier until they find one 1] that will supply a fully data capable xPAP, 2] that has a LENIENT mask exchange policy, 3] that has a RRT who sets them up w/their equipment and accessories, one they are COMFORTABLE with, one that will willingly answer questions.

SUPPOSEDLY, the local DME supplier provides the education, advice and support new CPAP users need. In reality, DON'T COUNT ON IT. Local DME suppliers DO HAVE to have an RRT on staff - that doesn't mean that the RRT is the one who sets up the equipment OR has contact w/the patient.

If you know of a local apnea support group by all means tell your patients how to contact them. Encourage them to go to at least a couple of the meetings. Encourage your patients to spend some time at the various online apnea support groups if they have and use a computer. This forum, of course, is a good one to recommend, another excellent apnea support forum is cpaptalk.com as is apneasupport.com and talkaboutsleep.com. cpaptalk.com is probably the busiest of the forums.

If your patient did well w/the mask they used during their titration write down the name and size and give it to them. That might not necessarily be the one they will end up w/but at least they will have SOME idea of a mask to try if they get confused w/the masks the DME offers. On the other hand, including the titration mask on the script isn't a good idea either. That just encourages the DME supplier to not bother showing or trying any others w/the patient.

AND a HEARTFELT thank you for caring enough about your patients to find an apnea support forum and ask these questions!!!!! GOOD ON YOU for doing so!!

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Permalink Reply by RockRpsgt on March 23, 2009 at 8:28pm

And a big thank you to you too Judy. I know that the DME that our lab uses, or so I have been told, actually makes an appointment with the patient. They then go to the home and do a demonstration on the different mask and an education on the machine. At least this is what I am instructed to tell them. As for CPAPtalk.com. The first time I was on the site there was a blog telling the pts that had problems keeping thier mouth shut with a nasal mask to duct tape it shut.I have not been back or would I recommend this site to any of my pts. All of my potential cpap pts now leave with this site address.

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Permalink Reply by Mike on March 23, 2009 at 8:31pm

That's what we like to see. Here on SleepGuide.com, my view is that it's a respectful place where all sides of a story get heard --- i'd hate for mob mentality to kick in and drown out anyone's voice, unless that voice is being disrespectful/offensive.

Rock Hinkle said:

And a big thank you to you too Judy. I know that the DME that our lab uses, or so I have been told, actually makes an appointment with the patient. They then go to the home and do a demonstration on the different mask and an education on the machine. At least this is what I am instructed to tell them. As for CPAPtalk.com. The first time I was on the site there was a blog telling the pts that had problems keeping thier mouth shut with a nasal mask to duct tape it shut.I have not been back or would I recommend this site to any of my pts. All of my potential cpap pts now leave with this site address.

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Permalink Reply by sleepycarol on March 23, 2009 at 10:08pm

Rock Hinkle

I visit cpaptalk.com often and feel that probably the duct tape trick was made tongue in cheek and not as a remedy. No one as far as I know (have been a member since August of 2007) on that forum advocates that a patient use duct tape as a method of keeping their mouth shut. They DO advocate trying tape (usually the blue 3M easy release tape) if you have mouth leaks and a chin strap does not work. Chin straps are typically not very effective for stopping the lip flutters and air from leaking out a slightly open mouth. I have suggested to forum members that they may want to try taping, using a gentle tape. Denture adhesive strips will also work and some like those better.

As far as the danger of taping that argument doesn't fly -- look at the Oracle mask. It is used by sealing the mouth with device and your nose is plugged. It would be more difficult to remove in case one needed to than a piece of tape (the ends should always be turned back making a tab for easy removal).

As a RRT you can not recommend taping due to liability issues, but forum members can suggest it and if done properly should be a safe alternative to uncomfortable chin straps. I would much rather see one tape, then to give up on cpap due to air leaking from the mouth. I have taped occasionally when I have wanted to check my numbers to make sure my leaks are kept to a minimum. I use a nasal pillow mask (the Headrest) and do not want to go back to using a full face mask all the time. I am fortunate in that I don't need to tape as my leak lines are consistent with or without taping.

For myself, if it wasn't for cpaptalk.com I would have given up on therapy as I was given the wrong machine initially and my experience with the local DME's was far from satisfactory. But I also realize that cpaptalk.com can be overwhelming with all of the knowledge that is posted there. For new members just starting out I feel that sleepguide is a good choice in getting their questions answered in a straightforward manner without over loading them with information that may overwhelm them in the beginning.

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Permalink Reply by Butch Hernandez on March 23, 2009 at 10:47pm

I have been very fortunate to have worked on the DME side as an RPSGT in the past. Let me tell ya, it was an eye opening experience to say the least. Most DME's in my area employ RT's to handle CPAP setups, pt education and follow up. RT's are more plentiful and their respiratory background helps DME's advertise their "expertise". It became obvious very early on that pts were not getting the proper equipment OR education. I agree with Mike that they indeed buy as low as they can in an effort to be reimbursed as much as possible! So the DME gets to keep up their numbers, turn a profit, keep the referrals coming in and the business keeps on rolling...so, how's the full bearded pt doing with his brand new, shiny full face mask? Who knows. I constantly ran across pts using the wrong mask and size all the time. Clogged CPAP filters that the pt never knew had to be changed/cleaned. New cushions and headgears lying around that the pt had no clue how to replace, or when. CPAP compliance downloads with astronomical leaks and sporadic usage. My point is that on the other side of the script, pt care suffers without the proper person to teach them proper usage and maintenance. It is up to us to guide these pts so they can truly benefit from all of the testing and expense that ultimately leads to a better quality of life for them....after all, that is what it's all about!

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Permalink Reply by The SleepGuide Crew on March 23, 2009 at 11:18pm

Amen!

Butch Hernandez said:

I have been very fortunate to have worked on the DME side as an RPSGT in the past. Let me tell ya, it was an eye opening experience to say the least. Most DME's in my area employ RT's to handle CPAP setups, pt education and follow up. RT's are more plentiful and their respiratory background helps DME's advertise their "expertise". It became obvious very early on that pts were not getting the proper equipment OR education. I agree with Mike that they indeed buy as low as they can in an effort to be reimbursed as much as possible! So the DME gets to keep up their numbers, turn a profit, keep the referrals coming in and the business keeps on rolling...so, how's the full bearded pt doing with his brand new, shiny full face mask? Who knows. I constantly ran across pts using the wrong mask and size all the time. Clogged CPAP filters that the pt never knew had to be changed/cleaned. New cushions and headgears lying around that the pt had no clue how to replace, or when. CPAP compliance downloads with astronomical leaks and sporadic usage. My point is that on the other side of the script, pt care suffers without the proper person to teach them proper usage and maintenance. It is up to us to guide these pts so they can truly benefit from all of the testing and expense that ultimately leads to a better quality of life for them....after all, that is what it's all about!

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Permalink Reply by RockRpsgt on March 24, 2009 at 10:55am

Thanks everyone for the insight! SleepyCarol I will give CPAPtalk.com another shot. Actually the only real chance I gave them was when I was still stalking the pt and tech forums. It is probably unfair of me to judge without getting a better opinion from the various members on the site, also allowing them to see mine. I will tell you that it was duct tape that made me leave. I will look into the oracle mask. It is not one that we carry at my lab. We cater to Resmed, Respironics, and Fischer Pykel. I personally believe that as a tech, Comfort and tolerance issues begin with me. I feel that it is very important to get a pt into, or as close to the best, most comfortable mask for them. Communication is key during the studies, and I believe can set the tone for the pt and the machine. I educate to the best of my knowledge. I also stress the importance of pt honesty. "speak up" I tell them if it is uncomfortable. " We have 50 different masks in this office. Surely 1 will be right for you" I make sure that my pts understand the importance of the studies, and the cpap procedures, and explain my part, as a tech in great detail. after all this I cross my fingers and hope that the DMEs continue my effort, else it is all for naught. I can only hope that as this industry grows, the pt, tech,sleep dr, and dme bond grows with it. It truley takes a positive role of all four to cure a restless night's sleep. If anyone has any ideas to help me do a better job please, please let me know. Thanks again sleep guide! this is a good thing you have done.

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Permalink Reply by Judy on March 24, 2009 at 3:34pm

Rock, I agree w/SleepyCarol that this forum is less overwhelming w/TMI too fast as compared to cpaptalk.com

And I'll also warn you upfront the majority of users on cpaptalk.com are there because of their LOUSY experience w/local DME suppliers AND sleep doctors! They go on the offensive quite easily if you, from your side of the fence, are too strong in your opinion of what they have found thru EXPERIENCE USING their CPAP does work. They recognize the difference between what THEY can do and what you can COMFORTABLY advise, so better to offer alternatives such as for mouth taping than coming out STRONGLY against it. Something as simple as "DUCT TAPE??? Ouch!!" could well have brought a clarification at least on the type of tape. Or even a comment such as "Personally and professionally I could NOT recommend mouth taping". Or even something as simple as saying "That hasn't worked for my patients, just how did you do that so that it worked for you? Maybe you have a special circumstance that made it successful?" Unfortunately, for the professionals to "survive" on cpaptalk they have to be more tactful and diplomatic than the members often aren't.

If you want to understand the patient's side of the story and get a feel for what a good local DME supplier can be and what info patients would have appreciated from the get-go I would suggest to most "professionals" that they just monitor and read as they have time w/o commenting unless it is something positive. It is unfortunate that that is the way it is. But frankly, totally understandable as you read of what most have experienced. Few have any reason to have much respect for the sleep profession as a whole.

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Permalink Reply by RockRpsgt on March 24, 2009 at 4:45pm

Thanks Judy. I am trying to get a feel for the entire process. I want to be able to give my pts as much ammo as possible as they begin this journey. I try and listen to all of the post and put myself in the pts shoes(as much as I can). This is a learning process for me as well.

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Permalink Reply by RockRpsgt on March 24, 2009 at 4:59pm

Judy, I wish that I had a better alternative to mouth taping. I don't. I do understand the need to keep the mouth shut, and the want to use a more comfortable nasal or nasal pillow mask. I hope that everyone at least tried a chin strap or some alternative. As a sleep medicine technologist my 2 goals are tolerance, and compliance which leads to better health for my pts. I understand and am very sorry for everyone's bad cpap journeys. Hopefully through my questions and participation I will be able to strive to make it better..

Judy said:

Rock, I agree w/SleepyCarol that this forum is less overwhelming w/TMI too fast as compared to cpaptalk.com

And I'll also warn you upfront the majority of users on cpaptalk.com are there because of their LOUSY experience w/local DME suppliers AND sleep doctors! They go on the offensive quite easily if you, from your side of the fence, are too strong in your opinion of what they have found thru EXPERIENCE USING their CPAP does work. They recognize the difference between what THEY can do and what you can COMFORTABLY advise, so better to offer alternatives such as for mouth taping than coming out STRONGLY against it. Something as simple as "DUCT TAPE??? Ouch!!" could well have brought a clarification at least on the type of tape. Or even a comment such as "Personally and professionally I could NOT recommend mouth taping". Or even something as simple as saying "That hasn't worked for my patients, just how did you do that so that it worked for you? Maybe you have a special circumstance that made it successful?" Unfortunately, for the professionals to "survive" on cpaptalk they have to be more tactful and diplomatic than the members often aren't.

If you want to understand the patient's side of the story and get a feel for what a good local DME supplier can be and what info patients would have appreciated from the get-go I would suggest to most "professionals" that they just monitor and read as they have time w/o commenting unless it is something positive. It is unfortunate that that is the way it is. But frankly, totally understandable as you read of what most have experienced. Few have any reason to have much respect for the sleep profession as a whole.

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