Respironics rep at ASAA

[-SWS]

...this is what I learned last night directly from the Respironics Rep.

CPAP is the "gold standard" and to be prescribed in ALL cases except where the patient has a medical condition requiring other treatment or the patient cannot tolerate the cpap.

BIPAP is the next machine to be prescribed (yes that's right, BIPAP) I questioned why if a patient can't tolerate the pressure of a cpap why would a BIPAP be any better?

APAP is to be used under two conditions. One, if the patient could not tolerate CPAP or BIPAP. Two, on a temporary basis to confirm pressure requirements.

Very interesting, indeed, Wader! That Respironics rep seems to be in direct contradiction with..... ......Respironics of all companies!!! Take a look at this portion of the Respironics web site justifying AutoPAP as suitable long-term treatment:

http://www.respironicsremstar.com/auto_articles.htm

Does anybody here have a clue why that Respironics rep would have literally defied the official Respironics "walk and talk" regarding AutoPAP? Are we to assume that Respironics as a company is now backing down from their past contentions that AutoPAP is, indeed, viable long-term treatment?

Something really does not add up, here. Maybe Dave has a clue why that Respironics rep seems to be at odds with the rest of Respironics? Anybody?

[-SWS]

I guess nobody here would really have a clue as to exactly what was in that Respironics sales rep's mind. My best guess is that whatever the sleep docs, insurance carriers, and local DME's push constitute the realities or perhaps "politics" of business. I'm sure any xPAP manufacturer's sales rep has to live with those business-place realities if they expect to place sales through that channel.

If the established medical community happens to default CPAP, then BiLevel, then AutoPAP (for either valid or invalid reasons) then those are still the established policies the Respironics rep must heed if he expects to earn revenue.

I really can't blame the Respironics rep simply because he is stuck with the realities of a business world that favors retaining sleep study revenue versus relinquishing it to AutoPAP...

[Mikesus]

I have a feeling it was due to audience influance (who was there exactly?). If he said Autopap first, wouldn't a large part of his audience lose revenue? By using the order stated, there were a lot of chances for a provider to make some serious cash.

1 Rent a CPAP, find out that it doesn't work, refer to sleep clinic to retitrate for BIPAP.

2. Find out that Bipap doesn't work, refer to clinic to retitrate for auto settings.

3. Get auto...


Counting the initial first (if split study) or 2 studies, that is a total of 3 or 4 $2500 sleep studies.

Mess with their money and they are gonna be mad...

[wading thru the muck!]

Just so that the record is straight, Brad, the Respironics Rep, is a very nice guy and was very candid with me off the record. He made is presentation (as I've described) and then after was very responsive regarding any and all questions I asked. Ultimately it's a "look what we do and not what we say" situation. They would not have added C-flex to the Auto if they didn't see it as having an important place in the future of treatment. Keep in mind the earlier threads regarding insurance reimbursement and the auto. To use the car analogy if you could go to the car dealer and get any car for the same price the dealer is not going to want to give everybody a Cadillac. The problem with that analogy as it relates to CPAP is that the DME (car dealers) are charging Cadillac prices for everthing. In my book if you pay Cadillac prices you should be getting the Cadillac!

[chrisp]

Follow the money. It never lies. Just think of all the sleep industry losses if we all just got an auto. Sales would drop cause no one woould need a study every year.

[JR]

My wife works at a hospital and she talked to the RT in the sleep clinic. She said that I wanted to go directly to an auto/pap. The RTs response was that CPAP was prescribed first. If the patient couldn't tolorate it, then and only then, would they prescribe "something different".
I go in for my titration test mid-March. I know that I want an APAP w/C-flex and I don't think they can change my mind! Can I ask for a written prescription and just buy it myself?

[wading thru the muck!]

JR,

As long as you get a prescription for a cpap you can buy the one you want, even if you choose an apap. The reason many Docs resist writting a prescription for an auto is because they know that insurance companies pay the same for a cpap or an auto. If you buy it yourself it doesn't matter.

[Dave Hargett]

Follow the money. It never lies. Just think of all the sleep industry losses if we all just got an auto. Sales would drop cause no one woould need a study every year.

Hardly anyone needs a sleep study every year! Unless you have major weight gain or loss or experience symptoms again, there is no need for another study. All the sleep doctors I know work on that principle - and that is a large number of board certified sleep specialists!

I, myself, went 7 years from my first titration study to my next one. We only did that one because an overnight oximetry study at home found my oxygen levels in the upper 80's for a 20 minute period. We ultimately decided that I perhaps had a mask leak for that period, as my set pressure was fine in the study.

If everyone WAS using APAP, I don't think it would change the pattern of sleep studies very much (for return studies). My opinion, no way to prove it yet.

Dave

[Dave Hargett]

I have a feeling it was due to audience influance (who was there exactly?). If he said Autopap first, wouldn't a large part of his audience lose revenue? By using the order stated, there were a lot of chances for a provider to make some serious cash.

I coordinate that A.W.A.K.E. group. The audience included one manager of a local DME company (who is our regular sponsor and very patient-oriented), and everyone else was a patient or the spouse of a patient.

There were about 25 people there in total. G00fy217 and one other cpaptalk user were also there, in addition to wader.

Having heard Brad speak before, I don't think he said anything different to us. He knew we were all patients. From a pure revenue standpoint, it would be to his advantage to try to talk us all into APAP so that he could sell the higher cost items to the DMEs. and let them sort things out with us patients.

I thought that his point was that CPAP with C-flex does handle almost all the patients with relative comfort for the patient and that APAP is not needed for every patient.

One recent research study (196 responses) indicated that 30% of physicians never prescribed APAP and that only 4% of all devices prescribed were APAP.
That goes along with what Brad said and also with the comments on the board here about the reluctance of sleep physicians to prescribe APAP devices.

Dave


Dave

[Guest]

From a purely business standpoint I can see doctors and clinics prefering to retain PSG revenue for retitrations. DME's, of course, prefering to sell CPAP versus AutoPAP to maximize profit---assuming that either sells at the same pre-agreed price and receives the same medicare billing code. I agree that Respironics would have incentive to sell more of their "premium" machines at a higher profit----which corroborates what their web page seems to suggest: AutoPAP as a better-than or equal-to alternative to CPAP.

If everyone WAS using APAP, I don't think it would change the pattern of sleep studies very much (for return studies). My opinion, no way to prove it yet.

I can't follow this logic since many/most follow-up studies are with retitration in mind. If concomitant sleep disorders are suspected, then a follow up PSG would serve dual or multiple objectives. Yet, I don't perceive that many doctors presently feel compelled to "fish" for non-apnea sleep disorders in the apneic patient population at any greater rate than they "fish" for unsuspected sleep disorders in the general population via PSG. Many PSG studies are ordered purely for follow-up retitrations. And a home-based machine that constantly titrates throughout the night sure sounds like a machine that obviates many PSG retitrations to me.

[-SWS]

From a purely business standpoint I can see doctors and clinics prefering to retain PSG revenue for retitrations. DME's, of course, prefering to sell CPAP versus AutoPAP to maximize profit---assuming that either sells at the same pre-agreed price and receives the same medicare billing code. I agree that Respironics would have incentive to sell more of their "premium" machines at a higher profit----which corroborates what their web page seems to suggest: AutoPAP as a better-than or equal-to alternative to CPAP.

If everyone WAS using APAP, I don't think it would change the pattern of sleep studies very much (for return studies). My opinion, no way to prove it yet.

I can't follow this logic since many/most follow-up studies are with retitration in mind. If concomitant sleep disorders are suspected, then a follow up PSG would serve dual or multiple objectives. Yet, I don't perceive that many doctors presently feel compelled to "fish" for non-apnea sleep disorders in the apneic patient population at any greater rate than they "fish" for unsuspected sleep disorders in the general population via PSG. Many PSG studies are ordered purely for follow-up retitrations. And a home-based machine that constantly titrates throughout the night sure sounds like a machine that obviates many PSG retitrations to me.

Got "guested".

[wading thru the muck!]

Dave,

I agree, I think Brad gave us the straight story. As I pointed out at the meeting, for the additional $250-$350 (as quoted by the experts) it costs to buy the auto, it seems a waste of money not to set everyone up with one. As has been pointed out before, if a patient can not tolerate APAP the machines can be switched to CPAP mode. I recently watched a segment with Dr Rosenfeld regarding medicares approval to pay for implanted defibrillators for an additional 500,000 to 1 million patients at $30,000 a piece. Seems to me the old saying "Penny wise, Pound foolish" is applicable here.

-SWS,

I agree about Docs not doing much "fishing" (for sleep disorders that is)

[MelMel]

Just a reminder... Respironics is who created the word Bipap. (bipap is actually trademarked by them because a "bipap" by any other company is called a bi-level) Respironics being the Godfathers of bipap are going to push bipap as a secondary to standard cpap. DME's get higher reimbursement and the manufacturer makes more money since the bipaps are considerably more expensive then a cpap or auto cpap.

Money makes the world go round...

MelMel

[-SWS]

MelMel, you're right! BiPAPs are even more expensive and profitable than AutoPAPs. Also, another factor that might contribute to the CPAP, BiPAP, AutoPAP sequence that is preferred in the medical community: xPAP chronology or history. To my knowlege CPAP came out first---and it initially suceeded at it's simple technical task of delivering fixed pressure. Then BiLevel came out---and was soon operating quite well according to its comparatively basic technical objectives. Then came AutoPAP----which at first was snore based and did not perform particularly well for so many patients. Can't blame the medical establisment for being leary of a technical "Johnny-come-lately" that didn't work all that well at first.

I think AutoPAP is still living it's own tarnished reputation down---despite plenty of medical studies proving the efficacy of modern AutoPAP.

Also, just to clarify, I wasn't taking issue with Chrisp's humorous-but-true "follow the money" advice. I generally think Chris is right on the money when he says: "Follow the money". I do think that home-based titration machines (AutoPAPs) stand to change the rate at which patients go back to the sleep lab for retitrations. With absolutely no disrespect to Dave (whom I respect and admire immensely), to argue that AutoPAPs don't stand to impact retitrations in the sleep lab is similar to arguing that automatic dishwashing machines don't stand to impact the rate at which people will wash their dishes manually.

[wading thru the muck!]

-SWS,

Do you mean it's too late to sell my stock in the Acme Buggy Whip Company. I thought the invention of the Auto would not affect the popularity of the horse and buggy, am I wrong?

We should all remember that Dave's comments are tempered by his position as chairman of the ASAA (and rightly so). He is a hard working evangelist for the diagnosis and treatment of OSA. The midical community moves slowly. If we keep at him and our Docs about how well our APAPs work for us, they will all come around.