Do Sleep Doctors hate APAP machines?

[cbramsey]

I was not aware of APAPs until I saw the sleep doc I use now. He prescribed it. So, I like this doc A LOT for sending me down the path of APAP.

[Dawei]

My experience to date leads me to agree with Scott's view that docs disagree about APAP vs CPAP for medical reasons, not for financial gain.
When discussing this, it seems important to separate the general term 'doc' into those who are certified sleep specialists (American Board of Sleep Specialists in the U.S.) and others who are not, such as those who are Family Practice, Internal Medicine, etc. I have the impression that sleep docs are more informed and more likely to appreciate the technology of today's APAP equipment. Like Paula02, I have also heard from my DME that a number of docs in our area are not enthusiastic about APAP machines, but I heard this with an interesting twist. My DME told me his firm would like to begin stocking all AutoSets instead of a variety of ResMed machines. This RT explained that his firm does a fair amount of business with ResMed, which he described as their primary product line for PAP equipment. He added that his firm is talking with ResMed in an effort to have them make this supply change, but ResMed's reps are hesitant because some docs don't want to write for APAP equipment.
Maxdave, you could make a strong case if you were to present your doc with ResScan printouts of your sleep using the fixed CPAP pressure as well as when you were using your S9 in AutoSet mode. I think it would be hard for him to argue against AutoSet when viewing the comparative AHI results.
That's what I did; went in with a printout of the ResScan detailed graphs when I was using an AutoSet loaner. Earlier, he told me he didn't care who printed out the data, me or my DME, just so he could see it. Using ResScan software, the printout was in a format that he is quite familiar with and made it quite easy to see what the AutoSet was doing for me.

[DCwom]

...begs the two main questions we all have, 1) CPAP vs APAP, and, 2) the medical industry's effort to "keep you on the hook".

My opinion is that doctors disagree on CPAP vs APAP for reasons of health, not financial gain. However....(again my opinion only)...whereas doctors may be altruistic, the medical industry as a whole holds back information to generate income. They disclose information to avoid liability. It's a game and as I see it, that game is most obvious in the sphere of "continuous positive air pressure", a new medical industry created by the medical industry.

Topic #1 - Since I didn't sleep long enough during my sleep study my doc prescribed a APAP rather than doing another sleep study. My doc is also a CPAP user himself so I'm very fortunate to have him as a doc.

Topic #2 - The medical industry is like any other industry, they want to make money, and repeat customers are always good for business. I'm not sure why so many people are shocked by this, take a look at the folks who line up for each new Apple product, most are repeat customers.

I work in the medical device industry and I can say that I've never found the greedy attitude of evil that a lot folks attribute to medical providers. The sales & marketing critters want to make sales and won't turn away someone who wants to buy equipment, but this isn't any different than any other business.

[ScottBerglin]

Apple customers return to buy additional products, not to recalibrate their original equipment for the equivalent cost of new equipment.

The default rule of the computer industry is to charge you for any service you are not willing to do yourself after you've read the manual.

The default rule of the medical PAP industry is to charge you for what you could easily understand and do yourself if you had the manual.

There may not be a greedy attitude of evil, but the results are the same as if there was. (parenthetically...I love what a Presbyterian minister told me long ago, "Nobody sins on purpose...all sin is in the name of some virtue".)

[DCwom]

Apple customers return to buy additional products, not to recalibrate their original equipment for the equivalent cost of new equipment.

The default rule of the computer industry is to charge you for any service you are not willing to do yourself after you've read the manual.

The default rule of the medical PAP industry is to charge you for what you could easily understand and do yourself if you had the manual.

Scott, I think you're lumping DMEs (service providers/dispensers) in with the whole medical PAP industry. It is true that some DMEs are not so desirable, unfortunately they are the face of the industry that most of the public sees. The same is true in the hearing device industry, the dispensers vary greatly in their level of customer service and concern.

[archangle]

While individual doctors may be good, the whole system is corrupt.

The money interests in the medical system always find ways to rationalize actions that maximize the profits for the medical system.

The system works hard to convince the doctor that the newer, more expensive, more profitable medicine, procedures, tests, and equipment are better.

They dismiss the data modern CPAP machines collect because an in-lab sleep test is more "accurate." They claim that CPAP data is unreliable, and so they ignore it. Yes, an in lab PSG sleep test is "better" in some sense, but that doesn't mean you should ignore CPAP data. CPAP data is every night, the PSG is one time in an unfamiliar environment, often in a poorly run lab that's noisy, not at the patient's normal sleep time, not with the patient's normal equipment, etc. You probably can't get insurance approval for a test more than every two years or so.

Good data on one lousy night's sleep can't compare with decent but less detailed or accurate data taken every night under real world conditions. It can help to tweak the machine settings. Even if it's not definitive, it can be a useful warning and clue to the actual problems. It is measurement of the treatment in action. If the patient has a particularly bad night, you can look at the data and you may see that he really did have a lot of apneas that particular night.

A PSG is more profitable, so the system finds reasons to ignore CPAP data.

It's like ignoring a patient's home blood pressure and pulse readings and insisting on only looking at an EKG every few years. A data capable CPAP/APAP is like a mini-EKG all night every night. The bias against APAP is so high that many doctors just throw away this valuable diagnostic information despite it being readily available.

The "I am God" medical crowd thinks they can find "THE" correct CPAP pressure from a PSG. Pressure needs vary from night to night, with sleep position, patient stress, other medical conditions, quality of sleep, etc. Anyone who thinks he can find the correct pressure within a few pressure points is a fool, a liar, or a megalomaniac. (Possibly all three.)

They will say that an APAP will run away and go to too high a pressure. APAPs can be set to a narrow pressure range. If you think 10 is the correct pressure, you're a fool if you think the real pressure might not be a point or two higher or lower. Set the APAP to a narrow range of around 10. Then look at the results and see what seems to be working.

Most doctors will bump the pressure up a couple of points if the patient reports he's still having apnea. Why are they so afraid to let the machine do it automatically based on actual data, when they'll do it based on patient complaints?

If the APAP does "run away," you can look at the data and fix it. You can even set the APAP to manual CPAP.

The APAP is less profitable to sell, and generates fewer office visits, so the medical mafia finds reasons to not do it.

The biggest problem they ignore is that patients giving up on CPAP kills 10 times more patients than poorly adjusted CPAP. If APAP and in-home data analysis improves patient comfort and compliance, it will save many, many more lives than not doing it.

Unfortunately, taking the time to do CPAP/APAP right doesn't show up on the bottom line, so the medical mafia has a strong bias to just dispense a dumb manual CPAP and then smugly blame the patient if it doesn't work.

[DCwom]

While individual doctors may be good, the whole system is corrupt.

The money interests in the medical system always find ways to rationalize actions that maximize the profits for the medical system.

The system works hard to convince the doctor that the newer, more expensive, more profitable medicine, procedures, tests, and equipment are better.

This is capitalism and a driving force behind continued innovation in the medical field. When something becomes a commodity profits drop, innovation wanes, and investment drys up. What if no company ever pitched an APAP to a doctor? This whole thread wouldn't exist.

As for sleep study verses CPAP I agree that the daily CPAP data is very valuable and should be part of a patients total treatment plan.

[ScottBerglin]

Regarding Capitalism:
--------------------
The doctor wants to maximize office visits.
The clinic wants to maximize sleep studies.
The manufacture wants to maximize CPAP machine sales.
The DME wants your repeat parts and service business.
None of them want to disclose your prescription to you, or give you the clinician's manual to your machine.
What they are trying to protect is their "monopoly" on your health decisions.
The concept of monopoly is anathema to capitalism.
Innovation thwarts monopolies, causing leading-edge technologies to become average commodities, replaced by new leading-edge technologies. ApneaBoard strikes me as part of that innovative process.

[DCwom]

Regarding Capitalism:
--------------------
...
None of them want to disclose your prescription to you, or give you the clinician's manual to your machine.
What they are trying to protect is their "monopoly" on your health decisions.

I wouldn't go so far as to call it a monopoly, any CPAP provider has the choice to provide you with manuals and your prescription, they simply chose not to for business reasons. Its about what the market will bear and for the most users (not apnea board readers of course) the end-users aren't asking/demanding so the providers don't need to provide the info. There could be a gray area about FDA regulations and manuals/prescriptions and if they can provide this info, but that's another thread

I agree that forums like Apnea Board are helpful in driving end-user demand for improved service & technology, unfortunately we are a very small percentage of end-users.

[SuperSleeper]

DCwom, I'm not sure what you're saying but you seem to be saying that "capitalism" is to blame for the corruption and twisted priorities of our "medical system"...

If you think we have real "capitalism" in the U.S. medical markets today, I think you need to re-evaluate this position. What we have is a socialistic and heavily regulated and governmentally-controlled medical system. Hardly capitalism at all - and definitely not a "free market". (and next year when Obamacare begins, it will be even more socialized).

Too many people want to "blame capitalism" for all the ills of this medical "system", when that's not at all what we have. You need to blame "socialized medicine" or at least "government-controlled medicine", I think, because that is basically what we currently have in the U.S.

The health care insurance industry is already a mess of hard-to-understand (and sometimes conflicting) rules, regulations, procedures, etc. governed by numerous laws created and enforced by numerous governmental agencies.

The DME industry is also.

The hospitals, labs, sleep centers, doctors, etc. are also.

Government-controlled Medicine? Yep. Capitalism or a free market? Hardly.

When something becomes a commodity profits drop, innovation wanes, and investment drys up

Where did this come from? Everything that is sold and bought is a "good" or a "commodity", including all goods and services offered by the medical companies and service providers. It is the ability for companies to freely market and sell their goods and services which allows for competition in the market, price stability for consumers, etc. The competitive market (if we had a true capitalistic market here) would incentivize companies to innovate and invest in new ways to deliver a better machine or service so that they can gain greater market share.

It is not a free, capitalistic market that is causing DMEs to distribute low-end, non-data capable CPAP machines to patients - it is the socialistic government's reimbursement regulations for Medicare and Medicaid Services (http://www.cms.gov) and the Dept of Health & Human Services and their numerous sub-agencies and divisions that is causing this. DMEs get reimbursed the same amount for CPAP by Medicare, Medicaid and insurance companies (who follow CMS rules & regs). This stupid government-supported reimbursement schedule is what makes it profitable for a DME to give a patient a low-end CPAP rather than an APAP. This is direct governmental interference into the free market pricing structure.

We've talked about this before on Apnea Board. As a general rule, DMEs get reimbursed roughly $1500 for a CPAP, whether or not it's a non-data-capable low-end piece of junk or a nice fully data-capable APAP. So, given this lousy governmentally-ruled "system", the DME would rather give the patient a low-end machine that cost them $500 (they make $1000 profit that way [$1500 - 500 = $1000 profit])... rather than giving them a nice data-capable APAP that cost them $1000 (they only make $500 profit that way [$1500 - $1000 = $500 profit]). Both CPAPs and APAPs have the exact same billing code and reimbursement schedule.

In a true capitalistic system, a supplier would make a mark-up percentage on the item sold. So a DME would make more money by pushing APAPs into the market - because in a true free market, they would make more money as a percentage of the purchase price (generally APAPs cost more than CPAPs). So if the stupid government would get out of the way and let the free market decide the price of CPAP machines - the DMEs would have an incentive to push APAPs, rather than low-cost, non-data-capable CPAPs.

For instance, in a truly free market where a DME would have a price markup of 20% on CPAP and APAP machines, they would rather sell a higher-end APAP, because they'd make more money. (20% of a $1000 APAP is a lot better than 20% of a $500 CPAP)

But no, we can't have that in the U.S. - instead, we have a myriad of confusing laws and regs enforced by numerous agencies, departments and divisions of government to "protect us from ourselves". The disappointing result of this over-regulation is that the patient gets poorly served with machines of lesser quality, all at a higher overall cost.

But, it doesn't matter. The whole stinking world is moving more and more towards socialism and these systems are all going to crash and burn eventually. Soon, countries won't be able to support these programs. Just keep your eye on the wonderful "socialistic utopias" of Europe over the next few months and see how it all turns out when government decides it knows better than the free market.

As Margaret Thatcher said, "The problem with socialism is that eventually you run out of other people's money to spend."