OT - Is this Compliance Future? edited

[JDS74]

In looking for original research related to the development of so-call industry standard of 4 hours of use being part of the standard of compliance, I found this interesting article about Anthem Blue Cross on their proposed? change in their compliance standard. It was published in HME News in 2012.

Has anyone heard that this is continuing for them or that other insurers are adopting similar plans?

Private pay CPAP requirements go step further

In any event, it is an interesting approach to continued compliance measurement.
Apparently these folks are the monitoring group in support of Anthem.

Aim Specialty Health

Scroll down to the DME information to see what is required of the DME and how flexible the compliance requirements are:

If a provider is unable to obtain timely compliance information will there be a grace period for the authorizations?

There are no grace periods. Authorizations are valid for the period indicated. If compliance data is not available before the authorization period expires, then the provider should initiate a new request when the data becomes available.

Edit: Here's another out west in Colorado.

Sleep Center of the Rockies Compliance
And it looks as if DOT is / has adopted the 90 compliance rule for issuing a certification that is good for only 90 days.
http://www.sleepresourcefoundation.org/ ... StLuke.pdf

[The Latinist]

Hmm. That may explain why my DME supplier told me that I had to keep the modem on my machine "forever." I'd assumed they would want it back once the 10-month rental period was up. That said, unless there is a significant change in the DME coverage on my Anthem plan, I intend to purchase my future machines out-of-pocket even if it costs me more. I'm done with the DME racket.

[Pugsy]

That explains the rather long worded memo posted for patients to see at the pickup window at my DME..."Attention BCBS patients........" that I have seen there the last couple of years.

[JDS74]

Medicare currently doesn't follow these new "rules" but when/if it does, all private insurance will fall into line.
Modems attached for everyone if you want reimbursement for your supplies.

This may remove the purchase option from insurance reimbursement. That could reduce the monthly payment substantially since CPAP might then be considered ongoing treatment.
Imagine being attached to Apria or Lincare for the rest of your life

Just a thought.

[SmoothieMom]

I have to keep my modem attached for 3 months, then I turn it in. After that, I have to manually upload my data every 30 days or they won't pay for anything.

[The Latinist]

Modems attached for everyone if you want reimbursement for your supplies.

My supposedly-"Cadillac" insurance plan doesn't pay for any of my supplies anyway. And they pay only 50% of my machine and humidifier. Once the rent-to-own period on this machine is up, they've got nothing over me and I don't intend that they ever should have again.

[palerider]

Modems attached for everyone if you want reimbursement for your supplies.

My supposedly-"Cadillac" insurance plan doesn't pay for any of my supplies anyway. And they pay only 50% of my machine and humidifier.

well, that's what you get for going cadillac! prolly has a faulty ignition switch on your unit, if you bump it in your sleep, it might shut off and deactivate the airbags.

[70sSanO]

Unfortunately this results in a Catch-22.

I have to believe that there are a lot of people who will give xPAP it a try, but if it is too much of a hassle they will give up on the treatment. The problem is that there are those who give it a try and continue and are persistent with their treatment and are successful and their lives are so much better for it. Those are the people this hurts.

If someone has sleep apnea and knows they he/she will be have to face the prospect of a DME electronically monitoring their sleep progress... when a person goes to sleep, how long, when that person gets up during the night, how many times, how long, etc... it may be something a person is not willing to do and will never get the study done. Think about having a stranger know your sleep habits for the rest of your life, and storing that data on some server somewhere out there.

I have been on CPAP for 13 years and even though my compliance numbers are probably 99%, I would never let a DME monitor my sleep, my settings, etc.

Can you imagine changing a 4-20 setting and then becoming non-compliant even though you are getting better therapy?

Policing anything never brings about change; it just brings about ways to circumvent it.

John

[Todzo]

There are many things we could change to improve the situation but what is communicated here is indeed the reality that we face even today:

From: http://www.hmenews.com/article/private- ... ep-further

"People start to fall off the curve, and at three, six, nine and 12 months, more and more people have fallen off the curve," said Dr. Tom Power, medical director for AIM Specialty Health. "When you look at it at two years it can be as high as 70% (who aren't compliant). We need to know why they are not compliant. Maybe they are just not a candidate for PAP therapy."


I used to think that a tracheostomy was indeed “the ultimate cure” for sleep apnea. But as they related in a recent commentary[1] that is not the case:

“...central apnea following tracheostomy is well described in severe OSA patients, perhaps suggesting that the mechanism underlying baseline OSA may be a critical variable.[10,11]”


At it's base what is happening here is that sleep apnea is more complex than it first appears. No, removing the obstruction (which might well be there for a reason) is not a cure nor necessarily even a good band aid.

Any treatment which will be effective long term will need to take into account the nonanatomic[2,3] features of sleep apnea and what causes each one. It also will need to take into account that as the body heals changes will occure. Before you can solve a problem you need to understand what causes it. We are not there yet.



[1] Orr J, Javaheri S, Malhotra A. Comparative effectiveness research in complex sleep apnea. SLEEP 2014;37(5):833-834

[2] Danny J. Eckert, David P. White, Amy S. Jordan, Atul Malhotra, and Andrew Wellman "Defining Phenotypic Causes of Obstructive Sleep Apnea. Identification of Novel Therapeutic Targets", American Journal of Respiratory and Critical Care Medicine, Vol. 188, No. 8 (2013), pp. 996-1004. doi: 10.1164/rccm.201303-0448OC

[3] Sairam Parthasarathy M.D., Emergence of Obstructive Sleep Apnea Phenotyping. From Weak to Strong! American Journal of Respitory and Critical Care Medicine VOL 188 2013
-- critical closing pressure [Pcrit] - Arousal Threshold - ventilatory control Loop gain - and genioglossal Muscle responsiveness. Pcrit, Loop, Arousal, Muscle (PALM)--

[10] Fletcher EC, author. Recurrence of sleep apnea syndrome following tracheostomy. A shift from obstructive to central apnea. Chest. 1989;96:206-9

[11] Guilleminault C, Simmons FB, Motta J, et al., authors. Obstructive sleep apnea syndrome and tracheostomy. Long term follow-up experience. Arch Intern Med. 1981;141:985-8

[robysue]

If someone has sleep apnea and knows they he/she will be have to face the prospect of a DME electronically monitoring their sleep progress... when a person goes to sleep, how long, when that person gets up during the night, how many times, how long, etc... it may be something a person is not willing to do and will never get the study done. Think about having a stranger know your sleep habits for the rest of your life, and storing that data on some server somewhere out there.

Given the very negative stereotypes about CPAP therapy that people already have, I too think that this kind of monitoring---particularly if it becomes permanent monitoring will indeed make many people even more reluctant to be diagnosed with OSA.

And it's not just the creepy idea that the stranger's are allowed to essentially spy on you as a condition to receive needed medical treatment ....

There are some potentially really nasty legal thickets entwined in here: Will it become routinely acceptable to examine a PAPer's CPAP data (particularly compliance data) anytime the CPAPer is involved in a crash? What if the other driver may be partially at fault, but claims the PAPer could have/should have reacted faster or better and didn't because the CPAP data indicates that person only used their machine for 5.5 hours the night before?

What if life insurance companies decide that any PAPer must grant them full access to the CPAP data before the life insurance company will write a quote for a policy? What if PAPers start to be routinely denied life insurance if some bean counter somewhere out there in the web is not happy with the pattern of usage?


Smart pills, the first of which was approved by the FDA back in 2012, also give me a bad case of the heebie-jeebies. The Washington Post recently had an article on them (http://www.washingtonpost.com/national/ ... story.html). The article creeped me out for the same reasons and it did mention a number of legal and ethical issues raised by smart pill monitoring ...

Maybe it's just me, but I think if you have to resort to spying on people to get them to take their meds or do their PAP, then you're doing something wrong in terms of communicating with your patients.

[robysue]

There are many things we could change to improve the situation but what is communicated here is indeed the reality that we face even today:

From: http://www.hmenews.com/article/private- ... ep-further

"People start to fall off the curve, and at three, six, nine and 12 months, more and more people have fallen off the curve," said Dr. Tom Power, medical director for AIM Specialty Health. "When you look at it at two years it can be as high as 70% (who aren't compliant). We need to know why they are not compliant. Maybe they are just not a candidate for PAP therapy."

Spying on your patients does NOT seem a good way to increase positive communication between the patient and the DME or sleep doc. And that is what wireless monitoring of CPAP usage is in my humble opinion: It's spying plain and simple.

I understand that long term full time compliance with PAP therapy is not good. So is long term compliance with prescribed therapies for many other chronic medical conditions. Is the answer really spying on your patients?

Understand: I'm not actually opposed per se to the fact that BCBS is thinking of requiring regular follow-up with CPAPers as a basic requirement for BCBS to continue paying for the equipment. But that follow-up should be done by a medical practitioner instead of a DME bean counter. But unfortunately that's where I see this going: The DMEs (and not the docs) will be the ones who become responsible for monitoring compliance. And the DMEs will buy into the manufacturers' schemes of wireless monitoring (for life???) rather than actually improving real communication with the patients.

And with increased pressure from the insurance companies and the federal government on decreasing costs, the DMEs will have even more incentive to set newbies up with bricks with modems to insure that they get paid for the equipment.

The real loser in the long run is the patient: Right now they're treated like they are idiots who can't possibly be trusted with their own data. In the future, they'll be spied on as well as treated like idiots.

[Kiralynx]

Imagine being attached to Apria or Lincare for the rest of your life

Just a thought.

THAT is beyond terrifying!

Interestingly, I have BCBS, and they did an outright purchase. I asked the RT when they needed to read my card, and they said they didn't! (Maybe that's because it is my second machine.)

[Todzo]

...There are some potentially really nasty legal thickets entwined in here: Will it become routinely acceptable to examine a PAPer's CPAP data (particularly compliance data) anytime the CPAPer is involved in a crash? What if the other driver may be partially at fault, but claims the PAPer could have/should have reacted faster or better and didn't because the CPAP data indicates that person only used their machine for 5.5 hours the night before?...

... What if PAPers start to be routinely denied life insurance if some bean counter somewhere out there in the web is not happy with the pattern of usage?...

...Maybe it's just me, but I think if you have to resort to spying on people to get them to take their meds or do their PAP, then you're doing something wrong in terms of communicating with your patients.

[/quote]

The person who produces the data should control the data.

It is our data and we need it now!!

I believe that everyone on xPAP needs the feedback from the data to make informed decisions such as “should I drive today”. The software download should be automatic and enough preliminary analysis should be done sufficient to generate an alarm (perhaps audible or a flashing red light) if the data indicates a bad night.

And always available to the person who produced it on demand every day.

On another track I think that anonymous data going to a central place would be a boon to medical research. Then we really could find how how usable xPAP is or is not and have some clues as to why.

[tortoisegirl]

Agreed this is a scary thought, especially when it goes beyond just the patient/insurance/doctor/DME. I was surprised that my insurance allowed my machine to be run as an outright purchase. In fact, my DME did not let me rent it since the insurance would allow immediate purchase (although they said within 2 months they could still change it back to rental and I could return it). I didn't have an issue with it once I did the math on the difference between two months of rental and purchase.

Yet the DME asked to swap my data card when my doctor sent a pressure change to them. Not sure if it was only to get a data card back since they sent me one, or they actually downloaded compliance data. My insurance said they wouldn't need compliance data. The DME had me sign a standard form though when I got my setup that said insurance may still require compliance data even after purchase. These policies vary so much that the DME couldn't tell me what I would be subject to.

At least I finally was able to get a consistent answer between my insurance & DME on supplies...insurance will pay as medically necessary, which the DME says is anything that isn't excessive. Not sure what that is lol, but I assume the standard schedule would be fine (which is what the DME person recommended for cushions). I was shocked my insurance paid for a replacement mask immediately after I got my first one. And annoyed the DME billed it just because they could, instead of swapping it out for free, so now I owe my copay on a mask I wore only 1 night. Good thing I'm not one of those folks going through 5 masks in the first month or whatever. Best wishes.

[OhHelpMe]

Hmm. That may explain why my DME supplier told me that I had to keep the modem on my machine "forever." I'd assumed they would want it back once the 10-month rental period was up. That said, unless there is a significant change in the DME coverage on my Anthem plan, I intend to purchase my future machines out-of-pocket even if it costs me more. I'm done with the DME racket.

More reasons that CPAP stuff should be OTC. Prices will go down and many more outlets will sell machines and stuff.