NPR article on apnea and insurance

[wolewyck]

http://www.npr.org/blogs/health/2012/01 ... t=1&f=1007

[chunkyfrog]

I see too much emphasis on the bottom line.
It makes sense for initial diagnostic psg to be in a lab; just to rule out or diagnose other problems.
Titration could be done at home in most cases, especially when a split study is not done.
It is nonsense to require a separate lab titration unless the patient has significant additional health problems.
Once diagnosis is done; patient education should be addressed--including access to data and other sources for equipment.
Keeping apnea patients in the dark is wasteful, and medieval.

[Lizistired]

In other cases, Holt says, the labs prescribe CPAP machines right away without first suggesting other strategies that could reduce apnea, such as losing weight or sleeping on your side.

That's it, You stopped breathing xxx times last night and your O2 dropped to 78%. Just lose some weight and you might be able to breathe again...
Duh

[Lizistired]

I thought this was interesting. It was one of the comments on that article relating to COPD. If I put it here I will be able to find it again... and it might be of interest to others.

It has been shown people with sleep apnea also have erythrocytosis / polycythemia / increased red blood cell production. Doctors believe the increased red blood cells FOLLOW the COPD , caused BY the COPD. The problem with that line of thought is that lowering of red blood cells is the ONLY treatment which has shown a positive effect in COPD.
"Phlebotomy decreases blood volume and viscosity, increases cardiac
output and improves exercise tolerance in patients"
"Improvement was dramatic"
Evidence for increased red blood cell production CAUSING the COPD comes from studies which show people who take erythropoietin to raise red blood cells commonly begin to manifest respiratory problems which coincidentally resembles COPD.
"serious side effects that may be caused by erythropoietin alpha may include problems breathing"

and then found this...

Absolute polycythemia:
The overproduction of red blood cells may be due to a primary process in the bone marrow (a so-called myeloproliferative syndrome), or it may be a reaction to chronically low oxygen levels or, rarely, a malignancy. Alternatively additional red blood cells may have been received through another process. For example being over transfused or being the recipient Twin in a pregnancy undergoing Twin to Twin Transfusion Syndrome.
http://en.wikipedia.org/wiki/Polycythemia

Might do a double red cell donation and see if it affects my O2.....

[archangle]

That's it, You stopped breathing xxx times last night and your O2 dropped to 78%. Just lose some weight and you might be able to breathe again...
Duh

Yeah sure. The patient has probably already been told many times that he's going to die if you don't lose weight. Let's withhold potentially life saving therapy and pretend that will make the patient lose weight. What percent of people who decide to lose weight succeed?

[BlackSpinner]

The usual short sightedness of insurance companies - the cost of testing and cpap machines instead of paying for heart attacks and strokes. The article focuses mostly on the annoyance of the spouse to snoring and yeah right, as if people will work at losing weight when they are tired and nibbling to stay awake!

[chunkyfrog]

This mess is not going to get any better.
Between insurance companies cutting corners, hoping the next carrier gets stuck with the big claim,
and care givers blatant discrimination against those deemed to be morally inferior (read: fat);
we are obliged to fight tooth and nail to get what we need to survive.

[DougVK]

Wow,

While I agree weight loss can help, I for one could lose around 70 lbs, but in the mean time I shouldn't suffer through the night with an SPO2 of under 80%. It is dangerous to say treatment should be withheld for people with dangerously low O2 levels at night, to encourage them to lose weight.

[robysue]

Getting on my soapbox:

To use an analogy that we often use around here: OSA is like diabetes; it's a rather common, chronic condition that has serious health risks if left undiagnosed and untreated. And it requires a patient who is knowledgeable and willing to be actively involved in the day to day management of the condition.

But during routine physical exams, it's standard practice to send all patients to get tested for diabetes regardless of whether the patient has any symptoms or risk factors for diabetes. And why? Because diabetes testing only requires a simple blood test instead of an elaborate (and expensive) lab test or home test that requires a highly trained tech to come out to the house and set the equipment up and then return to pick the equipment up.

To get a referral for a sleep test, though, you have to have some pretty clear symptoms and you often have to have some pretty clear risk factors. There are plenty of folks here who went for years complaining of daytime fatigue and exhaustion, but were not referred for a sleep test because they were female. Or young. Or normal weight. Or didn't report serious snoring. But when they were finally able to convince the doc to send them for a sleep test, they were relieved (and not surprised) that it came back positive for OSA, and sometimes severe OSA.

And so I guess I just don't get this idea that docs are "over prescribing" sleep tests to diagnose OSA and then over prescribing CPAPs to treat it.

I understand that the home tests are substantially cheaper than in-lab PSGs. And that home tests have come a long way and may be appropriate for many people. But until it becomes mandatory that the home sleep tests include EEG leads, the home sleep tests will only provide definitive positive results for the folks with the most clear cut cases of OSA involving real O2 desaturations. And that means that for folks like me----who don't desat but who still have tons of arousals caused by sleep disordered breathing---will either face a longer struggle to get an appropriate diagnosis (because of a false negative on the home test) or will undergo even more rounds of testing than we do now (because of ambiguous results on a home test). And do keep in mind that the arousals and the associated cortisol surges can be just as damaging in the long run as the O2 desats that others experience with OSA.

But what really bugs me about this article are two things.

First, there's only a passing acknowledgement of the serious health risks of having untreated OSA and the cutsy remark about snoring being a "simple annoyance" for the bed partner. But there's no acknowledgement at all of the very negative impact that untreated OSA has on the daily life of many of its undiagnosed victims. No mention of the crushing daily fatigue and sleepiness. No mention of the fear of falling asleep while driving. No mention of the constant brain fog that interferes with daytime functioning on the job and at home.

And then there are the statements from the industry reps themselves. First there's this quote:

Dr. Fred Holt, an expert on fraud and abuse and a medical director of Blue Cross Blue Shield in North Carolina, says some patients aren't having basic exams done first and are therefore being prescribed expensive tests they don't need. Not everyone who snores has a chronic disorder, he says.

What "basic exams" for OSA is he talking about? Just what does he think a doc should do with a person who reports serious chronic snoring? Keep in mind that even a home sleep test is not a basic test. So just what screening tests is he talking about? And also keep in mind that the screening that PCPs do before sending folks for a sleep test or ordering a home test seems to do a pretty good job: Most of the folks referred for sleep tests do test positive after all.

And then there are these two quotes:

In other cases, Holt says, the labs prescribe CPAP machines right away without first suggesting other strategies that could reduce apnea, such as losing weight or sleeping on your side.

and

Doctors should focus instead on common-sense approaches to sleep apnea, she (Helen Darling, the president of the National Business Group on Health) says, like losing weight, before turning to expensive testing and medical devices.

Like much of the rest of this article, these quotes continue the stereotype that apnea is largely (if not exclusively) a lifestyle disease of the fat (and lazy) who happen to snore loud enough to wake the dead.

Lose weight as the first line of treatment for OSA? As others have pointed out, the overweight folks who get diagnosed with OSA will have been told by their docs numerous times to lose weight. And more the most part it just ain't going to happen. How long do you wait for the patient to lose weight before telling them they need to treat the apnea with a CPAP or oral device?

Side sleeping as the first line of treatment for OSA? It's true that for many of us, our OSA is worse on our backs. But for most of us, the difference between sleeping on our backs and sleeping on our sides is not enough to be considered effective treatment in the sense of getting the AHI down to less than 5. And then the old "sew a tennis ball in the back of your night shirt" also just doesn't address the fact that a truly dedicated back sleeper will find a way of moving around to get the comfortable on the back in spite of the tennis ball.

And what other "cheap" and "common-sense" treatments are there for OSA?

Snore strips? They don't prevent the upper airway from collapsing in someone who has OSA.

Oral appliances? They can be just about as expensive (or more expensive) than a CPAP machine AND they're typically less effective to boot.

Like pugsy said much earlier: This article is way too focused on the insurance companies' bottom line. It's not focused at all on the real issues that need to be dealt with concerning the diagnosis and treatment of OSA:

• How do deal with the fact that OSA is still vastly under diagnosed? In other words, how do you get folks with obvious symptoms to get tested for OSA in the first place?
• What categories of patients might benefit from routinely being sent for testing regardless of whether they have symptoms? For example, it's become routine to screen people who want bariatric surgery for weight loss for OSA before authorizing the surgery because untreated OSA in this population is both widespread AND because untreated OSA has serious implications for how well the patient will tolerate the surgery. It seems likely that other very high risk groups---such as folks diagnosed with congestive heart failure---might benefit from routine screening for OSA since treating the OSA may make their other conditions easier to treat more effectively.
• How can the industry make the home tests sufficiently accurate for a wide range of OSA sufferers?
• What's the best way to get folks properly titrated at pressures that are effective and that they can tolerate?
• How to get folks to become (and remain) compliant with CPAP therapy in the face of difficulties adjusting to therapy?

And note that providing all diagnosed patients with auto titrating machines that record full efficacy data might just be a critical first step in solving those last two issues. And in solving them in a way that is friendly to both the patients affected by this disease AND the health insurance companies' bottom lines.