Dr. Barry Krakow’s Review of Totally CPAP – Part 2

Read what Dr. Barry Krakow, author of Sound Sleep, Sound Mind: 7 Keys to Sleeping through the Night, has to say about my new book, Totally CPAP. This is Part 2 of a multi-part in-depth, critical review. This is taken from his blog. Read Part 1.

Dr. Park continues with a discussion on many of the complexities in dealing with the insurance carriers who usually cover costs associated with PAP therapy, including devices, masks, headgear, tubing and humidifiers as well as for resupply of this equipment. The book does a good job of laying out the various steps and encounters in the process of working with an insurer, and he notes these relationships are often an awkward tetrad involving “convoluted” interactions between patients, sleep centers, insurance carriers and durable medical equipment companies (DMEs). Any person familiar with efforts to acquire a wheelchair, a pair of crutches, or supplemental oxygen will immediately recognize how this relationship works…up to a point. The doctor sees the patient and writes a script for the equipment, let’s say a pair of crutches for someone with a badly sprained ankle. The prescription goes to the DME, who also receives the doctor’s notes detailing the ankle injury and the need for crutches. The DME submits the script and medical records to an insurance carrier who then approves coverage for the crutches, after which the DME contacts the patient to complete the delivery. 

Unfortunately, obtaining a PAP device is a much more convoluted process, involving not only more steps, but also a lot more elements in the whole equation. In fact, in all of sleep medicine, the most frequent complaints are about dealings with the DME company, which explains in part the success of Classic SleepCare, because not only are they exclusively dedicated to sleep apnea devices and supplies, but also, they have created a large infrastructure of operational components to tackle all of the likely snafus that may arise in dealing with dissatisfied patients, disorganized sleep centers and their staff, and vexing bureaucracies within some insurance companies.

As Dr. Park begins his discussion, he focuses on the concept of PAP compliance, because it often proves the pivotal aspect when attempting to balance out the competing interests in this unwieldy process. For example, take the so-called typical sleep apnea patient who takes to PAP therapy like ducks to water. The first night of PAP is a fantastic and uplifting experience. Once this individual receives his or her PAP device, it is worn every night, all night long, and the patient in short order becomes a happy sleeper. Because the device is used every night and most likely for a range of 6 to 8 hours per night, this patient has already achieved compliance. Thus, it’s a win-win-win-win situation. The patient is satisfied with the improved sleep; the doctor is pleased the patient is adapting quickly to PAP and gaining health benefits; the insurance carrier feels good about providing coverage for a patient who is using the PAP device, and the DME not only feels good about helping the patient but also recognizes this patient has the potential to provide additional long-term revenue as equipment is regularly re-supplied per insurance standards.

If every single patient progressed in this manner, many of the problematic interactions among the tetrad of participants would disappear for the most part. As you might imagine, only 10 to 30% of patients fall into this category of the “perfect patient” or in the words of insurance companies, “ the perfectly compliant patient.”

As Dr. Park describes concisely and accurately compliance data comes directly from the device, and he points out the other clinically relevant data also extracted like residual breathing events such as snoring or flow limitations and air leaks. All this information is highly relevant to clinical care, because when you continue to suffer objectively from persistent breathing disruption or mask leaks, you clearly need more attention to set things right. Dr. Park addresses these issues later in the book, but in this chapter he wants you to realize the hours of use per night, per week and eventually in one month will determine your compliance numbers and therefore how much ease or difficulty you will experience with your DME and your insurer.

Dr. Park also brings up an often neglected point on the inaccuracy of the data extracted from these devices in which measurements might rise or fall respectively over or under by as much as 20%. Complicating matters, each manufacturer defines their breathing events with different algorithms. In other words, a lot of what you get from a PAP device looks like it is quantitative but in actuality functions more like qualitative information, such as: do you have residual breathing events or not; and, do you have mask leak or not? Even the calculated hours of use are qualitative because devices don’t record whether or not you are asleep. You could have the mask on for 6 hours and yet feel like you only slept 4 hours, and you might be more accurate than the device regarding the actual sleep hours.

It is at this point Dr. Park makes one of the most pragmatic and essential statements in the book: “Ultimately, what’s more important is how you feel.” Later on, he delves deeply into this area, because he knows and declares that compliance with PAP does not equate to success with PAP. If the device is not providing benefits to you whether in the form of improvements in sleepiness during the day or consolidated sleep at night or both, then something in your system is not even close to an optimal configuration of the device, the pressures, or the mask fit.

And, here’s where things get horribly frustrating for the DME companies, because they are working the trenches and know whether or not someone is gaining benefit from the device. So, they observe all types of scenarios including the extremes of someone using the device for only a couple hours per night yet reporting clear-cut benefits in their sleep symptoms versus the individual who uses the device consistently night after night for more than 6 or 7 hours per night and still declares a veritable absence of benefit. You can see how problematic these circumstances would be for the DMEs. In the first extreme, they are delighted to be helping someone who is gaining benefits from enhanced sleep, yet they simultaneously need to deliver the bad news that the machine must be returned if the patient does not use it for more hours. Stop and think about the idiocy of this scenario and compare it to a diabetic. The diabetic informs his doctor he’s only using his insulin injections a few times per week instead of every day. The doctor checks his bloodwork and notices even with this inconsistent use the diabetes is somewhat improved. Okay, now in the analogous world of sleep apnea DME rules, the physician informs that patient he’ll need to be returning his medication and insulin syringes because he’s not using it enough. In a word, this is crazy! And, it’s exactly what we are forced to discuss among the tetrad of participants trying to treat a sleep apnea patient. The insurance carrier can literally demand the return of the machine or simply drop insurance coverage until the individual increases hours, even though the patient is already sleeping better, experiencing less sleepiness, and thus technically has achieved the status of a safer driver compared to his pre-treatment condition.

The scenario of lots of use hours with no improvement creates a different set of barriers, because some insurance carriers do not focus on outcomes, but only hours. So they look at the person using 6 hours per night and declare success. Yet, the DME is fully aware the patient is dissatisfied and frustrated with the lack of benefit. The ball is then bounced back into the sleep center’s court, where it is absolutely the duty and obligation for the sleep medicine physician and staff to figure out the problems. Yet, even in this scenario, the insurance carriers may throw up new obstacles and declare the patient cannot be evaluated in the sleep lab, because…you guessed it, the patient is compliant with hours of use and doesn’t need any more treatment. Yes, this exact scenario can and does happen among insurers who are so wrapped up in the world of compliance they forget about the patient’s quality of sleep or lack thereof.

Which returns us to Dr. Park’s essential points…if it all depends on how you feel, then you must be the squeaky wheel if you want to get the right kind of attention. As you can imagine with so many patients not achieving optimal results with PAP or requiring several months or longer to achieve good to excellent results, the convoluted relationships between the tetrad of participants frequently results in delays in care; and, if you know anything about healthcare in general and medical delivery systems specifically, then you know delayed care almost invariably leads to patients receiving worse care or eventually no care as they drop out of the system from frustration and aggravation.

For these reasons, Dr. Park astutely closes out the chapter on the growing trend among people who either do not possess insurance coverage or who incur such high deductibles they need to use a cash-only system to gain equipment and supplies. I was very pleased to see aspects of cash-based medicine discussed in Totally CPAP, because there is no question in my mind at least about this wave of the future in the field of sleep medicine. As the field continues to show signs of shrinkage with fewer sleep centers and fewer sleep specialists, it is clear that “economic disrupters” like home sleep testing are primed to make substantial inroads in the delivery of PAP equipment into the hands of many OSA/UARS patients who otherwise simply cannot or will not work with insurance.

Without insurance coverage factors that frequently lead to artificially elevated pricing, the great news is that costs to patients will eventually start dropping through cash-based competition. Even in the current marketplace, including efforts by Classic SleepCare as well as several online DME companies, there is already a trend on delivering cheaper prices for PAP devices and re-supply. Plus, there is a huge supply of used devices, because so many patients fail CPAP, and having paid for the device one way or another, they either donate their equipment or sell it to online vendors. No one really knows the extent of how this cash-based market will play out, but my prediction is that it will be huge, because so many people have negative attitudes regarding the workings of sleep centers. As such, when individuals hear about the easy option of HST and then buy a device, irrespective of any quality of care issues, the majority of individuals will simply make the assumption that all CPAPs must be the same and most sleep medicine care must be the same. In other words people will “vote with their feet” by choosing to work increasingly with DME companies who will give them the best deals.

If you’re wondering just how fast cash-based medicine is going to disrupt medical care, consider this story on the use of a smartphone add-on, the size of a stick of gum, that actually detected more instances of the cardiac arrhythmia, atrial fibrillation, in one large group of patients compared to a similarly large group who were making visits to their regular doctor over the course of one year. In the study, two groups were assigned to either the Kardia Mobile device or to visits to their general practitioner. Among 500 patients in each group, the smartphone add-on diagnosed atrial fibrillation in 19 patients whereas only 5 cases were detected by physicians.

While several caveats influence this study and are discussed in the link above, the bottom line is users of the phone were able to self-check their heart status at home to send the info to a heart monitoring center to evaluate the results. Nearly half of the patients with atrial fibrillation were asymptomatic at the time, which means had they visited a physician, the doctor would not have had any reason to evaluate them for a cardiac rhythm disorder. In addition, the link describes how even more advanced gadgetry will supplant the device described in the article. Going forward, patients will gain access to technology to diagnose their health problems without having to go through a lengthier cardiac evaluation at a heart center. Do you think these advances in technology are going to change the practice and costs of medical care? You betcha!

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One thought on “Dr. Barry Krakow’s Review of Totally CPAP – Part 2

  1. I purchased this book as soon as I read this review and looking forward to it arriving in a couple of things. This book is as good as it sounds, I probably get a ton of copies to give to all the patients we work with that are struggling with CPAP. And probably a few DMEs.