CPAPtalk.com

harry33 wrote:Ive long thought that this sort of CPAP would come and put all the sleep lab staff out of a job
several tests have shown that apnea sufferers, given a simple CPAP that they can adjust, usually get near enough to their required pressure

I agree. I think that if your therapy makes you "feel good" it is working. But, I think it is helpful to verify your "feel good" by looking at some results that you can obtain with the software for your machine. And, I think you ought to try changing the pressure parameters of your machine to optimize your treatment. I did: viewtopic/t46080/viewtopic.php?t=6234. But, if you don't feel capable of doing this, then you've got to rely on your sleep doctor. Mine have not impressed me as being on top of things.

My sleep doctor is planning to re-titrate me next spring. That is nonsense! My AHI is less than 0.5, so I'm not going along with it. I figure she needs to earn some money with her sleep lab. At that time my initial two-night sleep study will be 4-1/2 years old (by a different doctor), so I suppose there is some guideline that says Medicare will pay for another one: one of the reasons Medicare is bankrupting the nation. [Sorry]

I've often wondered why a prospective CPAP patient wouldn't be given an APAP and the results read after a week and the determination made as to the need for CPAP and the pressure that ought to be used for treatment. My daughter was evaluated in this manner—never had a sleep study (Tallahassee, FL). She was determined to need CPAP, but she didn't get an APAP. (How often is that the case.)

Jerry

old64mb wrote:...which ultimately is going to be more expensive to the insurer than simply dispensing an APAP.

Me thinks this is not possible with ONE Billing code. Just not possible.

old64mb wrote:About the only way this would work is if there are two different reimbursement rates for CPAP versus APAP, and I don't see that happening any time soon. More that this particular insurance company doesn't understand sleep medicine economics, me thinks.

I will go one better--there isn't any reason to distribute or make "Cpap only" machines anymore. Since every single Autopap can be used as a fixed pressure Cpap, there should be only two categories of machine made--the Autopap/Cpap combination, and the Bilevel type--Bipaps, and Bilevel machines. So, there would be only two types of machine. Second, EVERY SINGLE machine made should be user full data capable. Every OSA patient should have the OPTION of monitoring their own therapy if they wish. Those who don't wish to do so can use a RT/DME, with sleep doctor monitoring. Those who do should not have to worry about separate software--it should be integral with all machines, and USB capable for every operating system available---Windows (whatever version), Linux, and OSX for Mac. All you'd need to do is plug your cpap into a USB port with no additional interfaces, and install the appropriate version of the software on your 'puter. This is simple enough to do.

I have CIGNA Insurance who uses the dreaded APRIA.

After reading this post, I thought I'd give them a call and ask if they supplied AutoPaps.

They said that Cigna does not allow them to supply AutoPaps.... of course Cigna claims that Apria decides what to send the patient.

NEITHER ONE OF THEM gave a hoot about what the DOCTOR decided the patient needed.

So it's still the same old crappy Apria... nothing has changed.

Bottom line is that it is cheaper for the DME AND insurance company to send you a straight CPAP.

Profit is still the driving force behind the Insurance companies and DME's.

pratzert wrote:...

Bottom line is that it is cheaper for the DME AND insurance company to send you a straight CPAP.

Profit is still the driving force behind the Insurance companies and DME's.

How is it cheaper for the insurance company if, for example, six months or a year later, the patient is still doing poorly, after many more trips to his/her sleep doctor ($$$), and said sleep doctor ends up prescribing a different (or different type of) machine ($$$), and/or decides that the patient needs another full night titration study ($$$)? Given that cost between an Escape and an AutoSet II can't be more than $100 to a medium to large DME.

brain_cloud wrote:

pratzert wrote:...

Bottom line is that it is cheaper for the DME AND insurance company to send you a straight CPAP.

Profit is still the driving force behind the Insurance companies and DME's.

How is it cheaper for the insurance company if, for example, six months or a year later, the patient is still doing poorly, after many more trips to his/her sleep doctor ($$$), and said sleep doctor ends up prescribing a different (or different type of) machine ($$$), and/or decides that the patient needs another full night titration study ($$$)? Given that cost between an Escape and an AutoSet II can't be more than $100 to a medium to large DME.

I don't know about your insurer, but mine will only provide a machine once every 5 years.

As far as another titration study, the Dr. would have to do some real fancy dancing to explain why his recent $2000 study was incorrect.

They protect themselves..... it ain't right... but that's how it works.

How is it cheaper for the insurance company

Here is my view of the "Insurance Industry allowing and the DME providing a CPAP or the more expensive APAP"

The insurance company is playing the odds and betting that there will be zero or minimal future charges based on their current "let them eat CPAP" business model. The insurance company has all the historical data they need to determine what policies and practices give them the lowest expenditure per insured. We can all propose scenarios that will cost the insurance company more. The insurance company will have run all our scenarios plus all theirs through a risk assessment model and determined which policies and practices provide them with the highest Return-on-Investment (ROI). Currently, the insurance company sees the highest ROI and profits by encouraging (likely through contract wording) their contracted DMEs to provide compliance-only machines, and to only provide APAP machines to newbies when they are "beaten down" by the newbie's arguments and tenacity.

I'd say that Pratzert is spot-on correct......and the answer to the puzzle is simply mathmatical. Of those who are given poor service and issued cheap, crappy machines....at least half.....and probably more than half...simply "give up" and no more money is spent on their care. The more who give up, the lower the costs to the insurance company.

Gerald

cinco777 wrote:

How is it cheaper for the insurance company

Here is my view of the "Insurance Industry allowing and the DME providing a CPAP or the more expensive APAP"

The insurance company is playing the odds and betting that there will be zero or minimal future charges based on their current "let them eat CPAP" business model. The insurance company has all the historical data they need to determine what policies and practices give them the lowest expenditure per insured. We can all propose scenarios that will cost the insurance company more. The insurance company will have run all our scenarios plus all theirs through a risk assessment model and determined which policies and practices provide them with the highest Return-on-Investment (ROI). Currently, the insurance company sees the highest ROI and profits by encouraging (likely through contract wording) their contracted DMEs to provide compliance-only machines, and to only provide APAP machines to newbies when they are "beaten down" by the newbie's arguments and tenacity.

I used to think that decisions at large firms with plenty of resources just had to be data driven and rational, but 15 years at a large semiconductor firm has corrected that assumption. And I certainly am prepared to bow down and prostrate myself before the living word of true and authoritative actuarial guru-dom, but I wouldn't be surprised if the data that you would want to know in order make a serious attempt at that risk assessment model doesn't even exist, since it will be largely driven by the long-term differences in future medical charges between the droppers-out and the stickers-with.

Dollars to Donuts, the current models are made of Balsa wood and rubber band propellers.

Gerald wrote:I'd say that Pratzert is spot-on correct......and the answer to the puzzle is simply mathmatical. Of those who are given poor service and issued cheap, crappy machines....at least half.....and probably more than half...simply "give up" and no more money is spent on their care. The more who give up, the lower the costs to the insurance company.

Gerald

Before I knew the effects of OSA I would have agreed and don't doubt many insurers thought that way. But after learning the health effects of untreated OSA my guess would be in the long run it would be cheaper to treat it than to treat the effects of it.

Brain_Cloud wrote

I used to think that decisions at large firms with plenty of resources just had to be data driven and rational, but 15 years at a large semiconductor firm has corrected that assumption.

An Insurance Company is a specific type of large firm - one that must assess and monitor the risk of something bad (an expenditure by them for an insured's care) happening and then determining what the cost to an insured needs to be to cover the expected charges and what policies and practices they need to put in place to ensure profitability. An insurance company's business plan is based on minimizing payouts - they do this by assessing risk and managing it. Large technology companies have a completely different business model - they produce products, real honest to goodness products that consumers will buy if competitively priced, reliable, innovative, "cool", feature rich, ... Apple has a much different business model than an Insurance Company.

Most all insurance companies pay by HCPCS code, NOT by brand and/or model!!!! They contract w/the local DME providers at a set price per HCPCS code. Thus in almost all cases it is the local DME provider, NOT the insurance company, who decides whether you get a straight CPAP or an APAP.

brain_cloud wrote:charges between the droppers-out and the stickers-with.

Dollars to Donuts, the current models are made of Balsa wood and rubber band propellers.

b_c, I like the way you think....
and for a newbie, you have an uncanny grasp of the prevailing nomenclature.

....not being a betting man myself, I would take that bet in a heart beat.

carbonman wrote:

brain_cloud wrote:charges between the droppers-out and the stickers-with.

Dollars to Donuts, the current models are made of Balsa wood and rubber band propellers.

b_c, I like the way you think....
and for a newbie, you have an uncanny grasp of the prevailing nomenclature.

....not being a betting man myself, I would take that bet in a heart beat.

Thank you, O wizened, cycling, geezer.