Let's clear up some misinformation

[Elle]

LTTS, What do you hope will be the outcome of your visit to cpaptalk?

[robysue]

Robysue, two very, very, good posts.

Only if you think taking a Rube Goldberg system and patching it in every corner with duct tape and bandaids will make things better.

That seems to be what RobySue and many others in this thread think needs to be done.

In my posts I am merely describing the way the system appears to work RIGHT NOW to me. And right now, "duct tape and band-aids" pretty much sums up the way the American system seems to work for most folks once they develop a chronic condition, particularly a serious chronic condition such as OSA.

Should it work that way? No. Both sides in the larger health care debate agree that the current system is a mess of duct tape and band-aids that do nothing but make the price of health care skyrocket and the quality of health care decrease.

Where the two sides disagree is how to fix the mess. And both sides are convinced that the fixes proposed by the other side will only make a bad situation worse.

Sorry guys, duct tape and bandaids will only make it worse.

The system needs to be blown up not taped up.

It's true that our current system is a hideously complex system that relies on both private insurance provided to us by our employers as a fringe benefit and multilevel government regulations on both what that private insurance must cover at a minimum and what kind of tax benefits and subsidies our employer receives in exchange for providing us with our health care insurance.

But much as I want the system to change, I'm not willing to buy a pig in a poke. And "blowing it up" by eliminating all government involvement in health care in the hope that the "free market" will fix the system is indeed a pig in a poke.

It's worth noting that this country has been struggling with the the issue of who should pay for health care insurance, and hence health itself since at least the 1920's. And notably the current battle concerning whether to provide universal health coverage has been fought and re-fought numerous times. A somewhat scholarly discussion of the involved history of how our current employer-provided health care evolved can be found at http://eh.net/encyclopedia/article/thom ... .health.us. A second somewhat scholarly article discussing the the history of our current employer-provided health insurance system, why it has persisted for so long, and comparing it to employer-provided health insurance systems in other countries can be found at url=http://www.investigatorawards.org/publi ... er%203.pdf.

Here's a synopsis of some of the more important and relevant parts of our American health insurance history taken from the above articles.

Prior to the 1920's, with the science of medicine still rather primitive, folks who had the money would buy "sickness insurance" that didn't pay for health care, but rather payed for income lost due to an on-going, lingering illness. And in fact, commercial insurance companies by and large did not even sell health insurance: "Commercial insurance companies did not believe that health was an insurable commodity because of the high potential for adverse selection and moral hazard."

During the 1910's and 1920's, however, the quality and effectiveness of medical treatment began to improve quite rapidly. And along with the rising standards for medical care came rising costs of medical care. Hospital insurance (and hospital pre-payment) plans, such as the original Blue Cross plans became important in the 1930s; they were perceived as "win-wins": Paying small amounts on a regular basis in order for a potential future hospitalization to be deeply discounted was advantageous to the subscribers and the hospitals benefited from the income stream from the payment plans as occupancy rates decreased due to the Great Depression. The Blue Cross plans were designed and pushed by the American Hospital Association, a private association of hospitals; but the government was involved right from the start---although in grand American tradition, it was state governments passing the needed legislation to make Blue Cross plans feasible for the hospitals to actually develop as non-profit corporations:

The AHA designed the Blue Cross guidelines so as to reduce price competition among hospitals. Prepayment plans seeking the Blue Cross designation had to provide subscribers with free choice of physician and hospital, a requirement that eliminated single-hospital plans from consideration. Blue Cross plans also benefited from special state-level enabling legislation allowing them to act as non-profit corporations, to enjoy tax-exempt status, and to be free from the usual insurance regulations. Originally, the reason for this exemption was that Blue Cross plans were considered to be in society's best interest since they often provided benefits to low-income individuals (Eilers 1963, p. 82). Without the enabling legislation, Blue Cross plans would have had to organize under the laws for insurance companies. If they organized as stock companies, the plans would have had to meet reserve requirements to ensure their solvency. Organizing as mutual companies meant that they would either have to meet reserve requirements or be subject to assessment liability.3 Given that most plans had little financial resources available to them, they would not have been able to meet the requirements.

The enabling legislation freed the plans from the traditional insurance reserve requirements because the Blue Cross plans were underwritten by hospitals. Hospitals contracted with the plans to provide subscriber services, and agreed to provide service benefits even during periods when the plans lacked funds to provide reimbursement. Under the enabling legislation, the plans "enjoy the advantages of exemption from the regular insurance laws of the state, are freed from the obligation of maintaining the high reserves required of commercial insurance companies and are relieved of paying taxes" (Anderson 1944, p. 11).4 Enabling laws served to increase the amount of health insurance sold in states in which they were implemented, causing growth in the market (Thomasson 2002).

Notably, these early Blue Cross plans were sold ONLY to "employee groups" so that there would be a large number of young and healthy individuals in the group who would presumably not actually use any coverage in a typical year. (Indeed, in the earliest plans, only the worker was covered---not his dependents).

By the end of the 1930's, after defeating federal legislation for universal healthcare earlier in the decade, the doctors decide to get into the act with pre-cursors to the Blue Shield programs, again with the help of state legislation and again focusing on selling the plans to "employee groups rather than individuals:

Thus, to protect themselves from competition with Blue Cross, as well as to provide an alternative to compulsory insurance, physicians began to organize a framework for pre-paid plans that covered physician services. In this regard, the American Medical Association (AMA) adopted a set of ten principles in 1934 "... which were apparently promulgated for the primary purposes of preventing hospital service plans from underwriting physician services and providing an answer to the proponents of compulsory medical insurance" (Hedinger 1966, p. 82). Within these rules were provisions that ensured that voluntary health insurance would remain under physician supervision and not be subject to the control of non-physicians. In addition, physicians wanted to retain their ability to price discriminate (to charge different rates to different customers, based on their ability to pay).

These principles were reflected in the actions of physicians as they established enabling legislation similar to that which allowed Blue Cross plans to operate as non-profits. Like the Blue Cross enabling legislation, these laws allowed Blue Shield plans to be tax-exempt and free from the provisions of insurance statutes. Physicians lobbied to ensure that they would be represented on the boards of all such plans, and acted to ensure that all plans required free choice of physician. In 1939, the California Physicians' Service (CPS) began to operate as the first prepayment plan designed to cover physicians' services. Open to employees earning less than $3,000 annually, the CPS provided physicians' services to employee groups for the fee of $1.70 per month for employees (Scofea, p. 5). To further these efforts, the AMA encouraged state and local medical societies to form their own prepayment plans. These physician-sponsored plans ultimately affiliated and became known as Blue Shield in 1946.

With the aid of several important pieces of legislation and Supreme Court rulings in the 40's, employer-provided health care plans started to become common place AND the conventional insurance companies started to take notice that Blue Cross and Blue Shield had effectively solved the problems of "adverse selection and moral hazard": By selling their plans only to employee groups, both the Blue Cross and Blue Shield plans insured their own bottom line by making sure the pool of the insured contained plenty of young, healthy people who would be spending little or nothing on reimbursable medical care for years and years to come.

And the fact that employer-payed health insurance premiums were not taxable as income tax to the employee AND provided the employer with some significant tax benefits as well provided incentives for unions to fight for health care benefits and for employers to provide those benefits.

And then add in the tremendous growth in the both the effectiveness of medical treatment AND the cost of that treatment in the 1940s and 1950s: The older system from the 1920s where friendly Doc Smith would make house calls and take into account how much you might actually be able to pay for his advice disappeared for good: Employer provided health insurance became the way that middle class Americans paid for their health care.

The net result was an explosion in the number of Americans covered by employer-provided health care plans that were no longer limited to just the older Blue Cross/Blue Shield plans.

Of course, the two big direct federal health care programs---Medicare and Medicaid---were passed in the 60s. Notably these two acts provided insurance to two groups that were (and still are) largely excluded from being able to buy private health insurance aimed at "employee groups". And because they could not buy into those "employee group" plans, the only private insurance available to them were the prohibitively expensive individual health insurance plans---if they even managed to qualify for such a plan.

And the sad fact is: Doing away with Medicare and Medicaid completely will not solve the health care crisis in the US. The elderly and the poor are among the sickest groups in our population. And hence they properly consume a lot of health care. And neither the "free market" nor private insurance is going to step forward and provide them with health insurance at a cost they can afford. But we're not likely to "not treat" these uninsurable folks when one of their conditions goes critical and they show up in the ER. And of course, by that point, it's a whole lot more expensive to provide the care than it would have been to treat their chronic medical problems all along.

[ltts]

No DME is under any obligation to carry any make and model of supply you want. None. Your insurance company has made you captive to a limited number of DMEs by not allowing others to be in network with them and send a claim. In exchange for that exclusive contract they have demanded / set rock bottom prices for DME reimbursement. And with rock bottom prices come rock bottom service and product selection. it's economics 101, and you have your insurance company to thank for it.

Ah. I see.

The DME signed a contract with my insurance that they would provide me two masks per year. One mask in January and one mask in July.

The DME signed a contract that they would provide me a set of nasal pillows every month for the two masks.

The DME signed a contract to provide up to four replacement straps per year for the two masks.

The DME sold me a mask in January, but per your statement, they are not required to provide nasal pillows in February, March, April, May and June for the mask they sold me in January. Nor are they required to provide me with a new strap in April for the mask they sold me in January.

They signed a contract, saying that they would do this... but they are not obligated to honor that contract, unless they happen to feel like it.

Very interesting.

The contracts don't require them to service any patient. They have no obligation to accept the referral. Now I am not saying there is no insurance company on the face of the universe that doesn't require this, but I can't think of a single one off the top of my head. And they definitely don't specify which make and model the DME has to provide. I am never seen an insurance contract like that in 27 years of working in DME (and believe me, I review a LOT of contracts).

In fact the contracts are completely stilted in the insurance payers favor. They are allowed to change the utilization limits, for instance, tomorrow, without any penalty, regardless of the contract that is place. For instance, your insurance company could decide, tomorrow, that they will only pay for one mask a year, and there is nothing the DME can do about it, except tell you what the rule change was, and require you to pay out of pocket for any additional masks you want beyond that one year. So as long as the payer can change things like utilization limits in mid contract they can hardly require the DME to service any of its patients.

Now let me give you an example of how fee schedules impact the makes and models that a DME will provide. Medicare competitive bidding was instituted in 10 metropolitan areas last year. Prior to that they paid between $30 and $35 dollars a box for diabetic supplies. The cost of product to the supplier was about $19-21 per box, but bennies could get name brands like acu-check, one touch, etc. After the bidding was done there were 70% less DMEs in those areas that were allowed to service Medicare patients that needed diabetic supplies. And the reimbursement dropped to $14 dollars a box. The result was that DME providers that "won" the bid were only offering cheap chinese knock off strips that cost them $9 a box. No way is a Medicare beneficiary in those 10 areas going to get a name brand product. It's just impossible economically for them to buy a name brand product for Medicare patients let alone ship it, bill it, be accredited, have the correct liability insurance, be bonded, etc., etc.

You think Medicare cares that the patient isn't getting the name brand product they want? Do you think the bid required them to provide a name brand product. No way, Jose.

So again, it all goes back to the insurance payer. That's the world we live it, like it or not. And as long as you are focused on the DMEs you are not focused on the real source of the issue.

[rocklin]

LTTS, What do you hope will be the outcome of your visit to cpaptalk?

Yes, please cut to the chase.

What email or snail-mail message do you wish us to convey to our local reps concerning H.R.1041, aka FIMBA?

And why is it in our interest to do it?

[ltts]

LTTS, What do you hope will be the outcome of your visit to cpaptalk?

I hope you will all realize who is actually making a killing here, and it's your insurance companies. You should be pitching a fit to them and demanding that they cover these features that you consider so necessary, instead of making the inaccurate assumption that DMEs are ripping you off. It's a shame none of you were there to stand up for these issues when manufacturer's and DMEs were busy advocating on your behalf. And believe me, they did, for a long time. To no avail.

Instead you appear to be making incorrect assumptions on who the profit monsters are in health care. It's the insurance payers. In fact go to google right now and put this in the search box "health insurance ceo pay" -- then tell me who, exactly, is making a killing. As I have said at least a half dozen times, your collective ire is pointed in exactly the wrong direction if change is what you hope to effect.

[Elle]

You can't accomplish much when you won't engage. You simply transmit your agenda and then ignore everything everyone here has told you. Most of the members here have recognized this and have decided to ignore you. Why can't you get that message? It is a curiosity to me.

[Guest]

LTTS, What do you hope will be the outcome of your visit to cpaptalk?

Yes, please cut to the chase.

What email or snail-mail message do you wish us to convey to our local reps concerning HR1041, aka FIMBA?

And why is it in our interest to do it?

Tell the first round of bidding has shown that the competitive bidding programs reduces patient access to care in an unacceptable way, and let them know that you don't want the inevitable cheap chinese knock off brands of equipment and supplies that will inevitably result from the drastic cuts in reimbursement that we have seen in the first 10 MSA (metropolitan statistical areas).

Google this "peter cramton study access to care" and choose the first link. He is an economist at U of MD, and he just published a study on how this has impacted patients and how it will continue to impact them negatively over the long term. The study is dated Jan 2012. First link on his page.

I will give you a highlight here - there were 67% less claims for PAP products in the first round bid MSAs since the bid program took effect. That means Medicare beneficiaries could not find a provider to supply them in those areas. It does not mean 67% of patients in those areas suddenly did not need PAP supplies any longer.

[ltts]

You can't accomplish much when you won't engage. You simply transmit your agenda and then ignore everything everyone here has told you. Most of the members here have recognized this and have decided to ignore you. Why can't you get that message? It is a curiosity to me.

Won't engage? Pardon me? I have spent upwards of 12 hours engaging in this discussion, often repeating many of the same facts over and over again (that ANY of you can easily verify by calling your insurance payer). In exchange I have been called a liar, a pimp, and every other name in the book. You're actually pretty rude people on the whole.

Do you know that in many other forums professionals volunteer their time to help people understand some of these complex healthcare and health insurance issues, and no one calls them liars, and pimps, etc?

[Elle]

It doesn't feel like a discussion. Why do you suppose so many members are being combative toward you? Something is not right.

Do you not sense the essence of the transaction here?

[ems]

So, Ltts... what you are saying is that not one person who participated in this thread is intelligent enough to understand what you've been saying over, and over, and over? Not one person? Do you really think that? And, if that is the case, why do you keep posting and insisting we don't get it, over, and over, and over? Why is this so important to you? I could care less what your name is or who you work for, but I would really like to know why you are sooooooooooo vested in what you are attempting to say?? It's rather strange. Put another way... what's it to ya?

[Slartybartfast]

. . . because that's what trolls do.

[ltts]

It doesn't feel like a discussion. Why do you suppose so many members are being combative toward you? Something is not right.

Do you not sense the essence of the transaction here?

Enough. As I posted previously I think many members are combative toward me because you've invested your beliefs in a bunch of misinformation you have been fed by people who have no clue whatsoever what they are talking about, yet purporting themselves to be experts on this topic.

You are welcome to believe a patient rather than someone with 27 years experience in the field of DME, most of them spent educating DME providers on these issues and advocating on the patient's behalf. That's your perfect right, although not a very smart way to achieve your objectives, in my humble, but informed opinion.

The fact is I am very well respected in my field, and all you have here in the way of "expertise" is a person that calls themselves "Therapist," which is illegal in about 18 states, since she isn't actually one (and the fact that her friends call her that does not make it legal, by the way).

Needless to say, I can see why this forum does not get experts to hang around and help people understand these issues as do other forums.

[ems]

. . . because that's what trolls do.

Naw... I don't think she is a troll. I do think she likes to stir up trouble and I am wondering why, and what she expects to get out of it.

[Elle]

Ltts, This forum is an established community. It is as if you walked into a cocktail party and said "everyone in this room is an idiot and I will tell you why". You were shunned but continued to tell us why we are turdish.

It is like you have a compulsion to transmit your story and can't help yourself no matter what kind of reaction you are getting. It is interesting to watch.

[robysue]

But you aren't going to get great product selection and service when the insurance contract pays low reimbursement rates. It's like going to MacDonald's and expecting a waiter and a 4 star menu. Not going to happen. And the insurance company does not give a rat's patooty about the service and product selection.

To use your analogy of restaurants: My doctor has prescribed "one restaurant meal" in order to treat my medical condition. My insurance company has contracted to pay the DME-restaurant $12 to provide me with "one restaurant meal". And the same billing code covers both a semi-decent Old Country Buffet Meal and a Big Mac Extra Value Meal. Now, I know enough to know that $12 is enough to pay for the semi-decent Old Country Buffet Meal (about $11 locally here in Buffalo) and that $12 is far more than the standard price of a Big Mac Extra Value Meal (about $7 locally here in Buffalo).

So I walk into the DME-restaurant and politely ask if I can please get the Old Country Buffet meal since I've effectively got $12 to pay for the meal and this meal is covered by my insurance company's billing code for the meal my doctor prescribed for me. But the DME-restaurant insists that all my $12 will pay for is an overpriced Big Mac Extra Value Meal. And they insist that there's no real difference between that $11 Buffet and the $7 Big Mac meal anyway---that I won't be able to tell any difference between the two meals. And then they tell me my insurance company simply won't pay for the Buffet meal---that I have no choice but to accept the overpriced Big Mac Meal instead of insisting on getting the Old Country Buffet Meal that my $12 will actually pay for and that will be better for my health in the long run. Or perhaps they tell me that the $11 Old Country Buffet meal is a deluxe item (because it contains some real veggies) and that unless my doctor specifically prescribes it, I'm not even allowed to request it, let alone eat it. (Gotta watch those real veggies---they really drive up the price of the meal!) Or perhaps they tell me that they can "upgrade" me to the Old Country Buffet meal by charging me (but not my insurance company) a $4 dollar "upcharge fee"---so that the DME-restaurant collects $12 + $4 = $16 dollars for a meal that should only cost me $11.

Now please explain to me just why I should be so stupid as to pay $12 for a Big Mac Extra Value Meal that I can readily get elsewhere for $7? Particularly when I can call around and find another DME-restaurant that will let me buy the Old Country Buffet meal for the $12 price my insurance company has contracted for?

Getting back to CPAPs: Between the patient's copay and the insurance company's share of the bill, my insurance company reimburses an in-network DME $900 for any E0601 cpap machine. And $900 is enough to buy a brand new Resmed S9 AutoSet RETAIL from on-line shops AND from honest DMEs selling to folks buying CPAPs totally out-of-pocket. And yet you keep claiming that I have no right to insist that I get my full $900 worth of CPAP equipment---that I should understand that legally the DME is only obligated to provide me with a machine that has a RETAIL price of $550-$600 even though they will charge me and my insurance company the full $900 my insurance company has agreed to pay. And that I should NOT feel "ripped off" by the DME when this happens.

No, not quite. In fact you analogy is 180 degress wrong. Reality is your insurance company is paying for the old country buffet, but you want to use the voucher for a filet minion with a baked potato on the side, a nice glass or red wine and creme brulee for dessert. And don't laugh -- I travel on business all the time, so your analogy hits home with me. When the plane has a mechanical failure overnight I get a 6 dollar meal voucher. I don't get to go to a four star restuarant and order whatever I'd like on the airline. That's reality. And that's the real analogy that fits here.

No, that's not at all the case: My insurance pays for Old Country Buffet and I wanted Old Country Buffet. You keep telling me I needed to settle for the Big Mac.

My insurance company allows $900 for the total cost of the blower. And $900 will easily buy me an S9 Elite or a PR System One Pro (the Old Country Buffet) because, in fact, it's enough to buy the more expensive S9 AutoSet (the Old Country Buffet PLUS a Hershey's Chocolate Bar from the 7-11 on the way home) at normal RETAIL prices from a wide variety of less than smarmy DMEs. You want to convince me that the $900 my insurance company authorizes as payment for the blower is only enough to buy an S9 Escape or PR System One Plus (the Big Mac Extra Value Meal) that are sold at a normal RETAIL price of $600-$750 from a wide variety of less than smarmy DMEs.

Please tell me why I should authorize my insurance company to waste a total of $900 (Their $450 along with my $450) to buy a machine that is only worth $600 to $750 at most?

And note this: Every DME that I contacted told me that they would file a $900 claim with my insurance company for the CPAP they planned on providing me and that as per my 50% copays, I would pay $450 and the insurance company would pay $450. And that these payments would be made as 10 monthly rental payments---$45 for me to pay each month and $45 for the insurance company to pay each month. And every DME except the one I went with insisted that the only machine that $900 would pay for was an S9 Escape or a PR System One Plus, both of which retail for substantially less than $900. Now, it's true that legally they are under no obligation to sell me the Old Country Buffet if they can snooker me into buying their overpriced Big Mac Extra Value Meal. But I'm still entitled to point out that my insurance company has in fact authorized a payment that is sufficient to pay for the Old Country Buffet and that I am unwilling to settle for the Big Mac.

And of course, if the DME chooses to toe the line and insist that all I can get is the Big Mac because of my insurance company's $900 allowance, then I'm entitled to walk out the door and take my business and my insurance dollars elsewhere.

And that's precisely what I did: When I first interviewed the DME I chose to work with they told me up front that they set all their new patients up with the patient's choice of a Resmed S9 AutoSet or a PR System One Auto. They don't even stock the S9 Escape or the System One Plus because they believe all their patient-customers should have access to full efficacy data AND they've found that the big local insurance providers pay them enough to provide these machines and still make a profit on the machine. Their business model is to make sure that all their customers succeed at becoming happy, long-term compliant CPAPers who continue to buy supplies from them for years and years to come. And when this DME filed a $900 claim my insurance company for the blower unit on the S9 AutoSet, the insurance company authorized the full amount (no questions asked) and started paying their $45 monthly rental payments and I started paying my $45 monthly rental payments.

Now note, I never wanted the BiPAP that I'm now using. I wound up with the more expensive BiPAP (The T-Bone special at Ponderosa WITH the all you can eat buffet bar!) because the E0601 machine I started out with did NOT resolve my symptoms even though I was sleeping with the mask every night, all night long AND at least two mask styles had been tried AND I was comfortably using the mask that I still use with no serious leaks. My sleep doc had to fill out paperwork justifying the BiPAP as medically necessary because the E0601 was not effectively treating my condition. The BiPAP is NOT an E0601 machine---it is billed under a different code; my insurance company authorized a total payment of about $1800 for the BiPAP, of which I was responsible for $900---i.e. my standard 50% copay. So the BiPAP is not some kind of "deluxe" upgrade. I will say that my DME was gracious enough to NOT charge me and my insurance company for the second humidifier unit--at the time I was switched to BiPAP, the Resmed S9 VPAP did not yet exist. Hence I had to switch brands and thus humidifiers. I will openly state that I was grateful the DME didn't charge me for the second humidifier and I do regard that as a free gift---going above and beyond what they are obligated to do morally as well as legally.

Now to address your issue about what your insurance payer pays the DME and how much you can get for the same money online, you might want to go back a few pages where I list about 25 items that represent real overhead for a regulated DME (and mention that the list I provide isn't even one third of the actual increase in overhead).

Obviously my DME manages to control all those 25 items you claim are the difference since they have chosen to sell ONLY the Resmed S9 AutoSet and PR System One Auto as their standard E0601 machines. And they are not losing money doing this.

There is a REASON your insurance company will not pay an online retailer -- they don't have the credentials and don't follow the regulations the insurance company requires. If you will read that post of mine you will have to agree that those burdens cost REAL money. Truth be told the online retailers margin is much higher than the DME. But unless you're paying out of pocket its of no benefit to you to go online.

I don't care whether my insurance company will or will not pay an on-line DME. The fact remains, however, that there are GOOD, HIGH QUALITY brick and mortar DMEs that sell their machines at the same prices as the on-line places do. My brick and mortar DME is one of them. The price they charged my insurance company for the S9 AutoSet was quite comparable to on-line prices. The price they charged my insurance company for the PR System One BiPAP Auto was quite comparable to on-line prices. The prices they charge for masks, pillows, hoses, humidifier tanks, and filters are all roughly comparable to the prices at cpap.com.

And this brick and mortar DME does make money.

They make money because most of their customers become happy, long term CPAPers who continue to buy supplies from them---even when insurance is NOT involved.

And the long-term profit they make by NOT losing 50% of their customers during the first difficult year more than makes up for the reduced profit margin on each machine they ship out the door. In other words, one of the ways they've cut down on some of the overhead is by getting most folks to actually use the machines for the full compliance period AND beyond so they get paid for the machine and they get paid for years and years of supplies. With successful patients, they don't have the problem of dealing with gobs of "slightly used" CPAPs that are returned because of non-compliance. Because every customer walks out the door with an APAP, they have no need to keep on hand a supply of "loaner APAPs" to deal with when a customer comes in with a doctor's orders for a two or three week switch to APAP for an autotitration to investigate whether the person's pressure needs to be adjusted. And because their customers become CPAPers for life, they have a built-in solid return business: We return over and over again through the years to replace our masks, our nasal pillows or cushions, our hoses, our filters, our humidifier tanks, and so forth. And sometimes when we're there, we'll splurge and buy something spur of the moment that insurance doesn't have its greedy hands in at all---like mask pads, hose cozies, hose hangers, and bed pillows. All of which has to be very good for the DME's bottom line.

And because most of their new CPAPers become happy, long-term customers, their customers refer others to them. And we all wind up finding out about friends and family with new OSA diagnoses. And we let them know just what we think of our DMEs and our docs since those are the things we do get to choose in this crazy situation. Crappy insurance we can't do anything about since it's tied to our job. But it's possible for many of us to avoid a crappy DME or a crappy doctor. And if we know a great DME or a great doc, we're sure to spread the word every time we hear of someone being diagnosed.

(and many of the online retailers are operating illegally as well).

Reputable on-line CPAP suppliers are most certainly NOT operating illegally. This is an insult to our host.