Why aren't more data-capable Auto-CPAP machines prescribed?

[SuperSleeper]

Admin Note: Apnea Board is on Linkedin.com and we have a small discussion group over there. There tends to be a lot more health care professionals on that small group than on the Main Forum here, and there is a discussion on Auto-CPAPs that I thought the group here would be interested in reading. So, I'm copying & pasting the conversation over to here, for our members to read here on the Main Forum.

From the Linkedin discussion:

Why aren't more data-capable Auto-CPAP machines prescribed?

I'd your thoughts on why data-capable Auto-CPAP machines aren't prescribed more often? It would seem to me that an RT or doctor would like to see patient data as an aide to determining the effectiveness of CPAP treatment and have the option to use it in auto mode if necessary.

Also, most every Auto-CPAP on the market has the capability of operating in straight CPAP mode in addition to auto mode. This gives both the patient and doctor more options when adjustments are needed, at very little extra cost (most autos cost only about $50 - $100 more than straight CPAPs)

it is my understanding that the medical coding is the same for either straight CPAP or Auto-CPAP, so Medicare and/or the insurance company pays the same amount for both.

If a patient's physical condition changes, necessitating a pressure change, a costly second titration could be avoided by switching to auto mode, letting the machine deliver proper pressures on an ongoing basis and recording the results onto a memory card for analysis.

I oftentimes see patients being given the lowest-end, non-data capable CPAP machine in the DME's inventory. Why is this?

Your thoughts?

[SuperSleeper]

The company I work for dispenses Auto for all orders. We set the units as per the doctors order. It gives the patient and the doctor the flexibility to adjust or change the patients pressures as needed. This works well especially with patients post bariatric surgery. Most auto units can obtain more information than a standard CPAP, AHI, and large mask leaks, which in the end will help assist a patient in achieving compliance and increasing comfort.

I have had some complaints from doctors where if they order a CPAP they want a straight CPAP, not an Auto. Then you have the issue where a patients needs have changed and the equipment is purchased by the patients insurance, and now they are ineligible for new equipment.

[SuperSleeper]

I believe the answer is fairly straight forward. It boils down to how much profit will the company make on that device. Depending on the size of your HME and the volume of PAP devices you issue determines the organizations power to negotiate pricing when purching the device from the manufacture e.g. the more volume the cheaper the cost of purchasing from the manufacturer. The HME provider then has to look at their insurance payor mix. What is the percentage of different insurance companies do they provide for and what is the allowable amount on the device. Remember allowable differs from retail pricing. Take an Aetna patient in my region. The retail price on a CPAP device is $1,300.00 not including supplies. Aetna only allows around $500.00 for the device. That means that if the HME is an in-network provider they are agreeing to accept this pricing and must write off the difference. If a CPAP from the manufacture cost $350.00 and an auto CPAP cost $450.00 then the HME only makes $50.00 off that machine.

The HME then must fact overhead cost such as personnel cost, rent, utilities, etc. Keep in mind that if the patient is set up by an RT, RPSGT or Nurse these employees are paid a higher hourly wage over a non clinician performing the set up. (Now I must state and this may not go well with non-credentialed individual..A clinican has far greater knowledge and generally can identifiy other non-sleep issue that play a role in compliance). It would be great if all CPAP's issued could be Auto's, but the reality is the insurance company reimbursement for the device will define what type of machine that patient is offered. If the patient wants an auto with all the bells and whistles they can have it if they are willing to sign an agreement that they will pay the additional cost of the Auto device. Many patient when faced with this choice decline the auto device. In a nut shell insurance companies and reimbursement are part of the decision process. Hope this help shed some light on why auto's are not issued to everyone.

[SuperSleeper]

Auto-titrators have their role, but are not best for all patients from clinical perspective, patients are unique, and all autos use different algorhythms, some algorhythms do well with a individual patient and some not, most seem to work better with full face masks but not so well with nasal interfaces with the occurance of major mouth leaks, some have difficulty differentiating resp events from artifact or mask/mouth leak, some raise pressure unneccesarily even while the patient is awake, and some underreact to suble obstruction with arousals, i.e UARS. I do not see any benefit for a patient with a relatively low pressure effective pressure in REM/supine to have an auto, there would be no reason for the device to increase pressure. And we find that any PAP device can produce erroneous data with the exception of compliance, due to the fact that the PAP device cannot detect CNS arousals, an important criteria of detecting significant respiratory events.

[SuperSleeper]

First of all, the word is "algorithm", and I say that not just to correct spelling, but to dispel any association anyone might have with "rhythm". An algorithm is a sequential series of steps to achieve a goal. Such steps might include a LACK of rhythm.

That is not the case with CPAPs/BiPAPs/AutoPAPs, tho - they all recognize the rhythm of human breathing. And we should never stray far from the reality and purpose of PAP machines - to keep our breathing rhythmic, even if the rhythm changes from time to time.

My own personal experience is thus, and it of course colors my comments, but I am sure I am hardly unique in this. I was diagnosed with apnea in July 2006. Thru a long series of medical ball-dropping, I received my first BiPAP in May 2007. Fine. My pulmonologist at the time did NOT offer me a variety of equipment, nor a variety of suppliers or support firms. I was lucky to have gotten the information that I could use a BiPAP (which I greatly preferred to the CPAP instrumentation used in the sleep study), much less an AutoBiPAP!

And the company I was shunted to did not inform me that there was a wide variety of equipment out there. It was one model - which turned out to be way behind the technology curve, ie, no chip for recording data, and "hidden" buttons for adjustment. And did I mention that I paid top dollar for the equipment? (I was told it was for the "human support" and "supplies", but honestly - how often do you need to change the hose? And "human support" was nothing more than a guy coming over to show me how to plug it in and show me a limited selection of nose/mouth coverings.

After 2 years, I had the strong feeling that the adjustments of my device needed to be changed. I asked the support company how to do that. They demurred, saying they would not divulge such information to me (on my own equipment!), and for them to adjust it I would need a Rx. So, silly me, I asked my MD for a Rx that would allow us to experiment with the settings. Oh no, you can't have that! You have to GO BACK INTO THE HOSPITAL for another sleep study! Oh, I see... And what if, after 6 months, I wanted to know if I needed another adjustment? You guessed it - back into the old hospital!

I changed pulmonologists. My new one, a very simpatico man, suspected that an AutoBiPAP might work better for me, but he'd like to see the data from my chip. I sat in amazement at learning that there was far better technology that I could have used (and that existed in 2006/7, when I was dispensed my clunker), but also in chagrin - my dumb unit had no chip!

He, like me, thought it stupid to have me go back into the hospital for another (costly, if only for the insurance company; but still - aren't we as a society trying to keep unnecessary medical costs down?) sleep study. He attempted to arrange for me a loaner BiPAP with a chip from another hospital, which was administratively doable, but took a very long time.

Ultimately, I took matters into my own hands. I went online and bought an AutoBiPAP with a chip. Insurance wouldn't cover the cost - my old piece of garbage (which cost 2x what the newer, more capable model did) was only 2 years old, and they would not pay for a new machine for 5 years, so I would have to wait 3 more years. I paid for it out of pocket (I was desperate and by this time, quite angry), and yet it cost less than what I still owed on my old machine after insurance, after 2 years!

Getting an Auto changed the conversation with my new pulmonologist - adjustments should not be needed, since the whole idea of an Auto is that it ADJUSTS AUTOMATICALLY DURING THE NIGHT, applying greater pressure when needed and less when not. Instead, he could look at the data on the chip and assess my condition, not the settings of the unit.

I will continue this saga in another comment.

[SuperSleeper]

(continued, sorry - but I think many people would like to know this)

But wait, there's more! I didn't need to use any ramp up button, because an Auto does the ramp up. It was quieter, being newer. It was SMALLER, being newer. I MYSELF could look at the data if I so chose. (Ok, I'm a techie, but still...)

I was also in weight loss mode, and as I lost weight, my apnea patterns changed - but the efficacy results did not, because the AutoBiPAP changed automatically with my needs. And we had easy access to the data to monitor that!

No trips to the hospital, no calling the "support" company, but a lot of control of my condition under the supervision and encouragement of my doctor!

EPILOGUE: So, after all that, as blood returned to my brain, as it were, I got to thinking... How would the support company make the adjustments on my old clunker unit? They said I'd have to "send it in" for the adjustment (but oh, not to worry, they'd supply a loaner in the interim, helpful were they!), and that suggested some magical instrumentation. But I thought, geez, that's a lot to go thru for a rather simple piece of equipment...

I decided to go online. I found the Apnea Board and, to my surprise, the technician's manual for the old clunker unit, which I did not own. Turns out it was easy to adjust - there was a HIDDEN BUTTON that, when pressed, enabled adjustment of everything! Yes, it was that simple! Had we had that manual, my MD could have worked with me to experiment with various levels of pressure, etc, without a sleep study. But, lacking that little, iddybiddy piece of information about the secret switch, we were dead in the water!

But as if that was not bad enough - turns out that same technicians manual explained that THE DATA WAS BEING RETAINED IN THE UNIT, AND THAT IT COULD BE DOWNLOADED INTO A COMPUTER!! That is, all the same data - and some softward, btw, that you could buy - could be put into a conventional PC and analyzed six ways from Sunday!

Did the "support company" tell me that? Did they inform me that a second (or third, or fourth, or...) sleep study was entirely unnecessary?

No, but they dutifully sent me hoses, straps and nose pillows (what I use, to great effect and comfort) every three months! And, of course, charged me a yearly fee for them...

I dumped that company. I've been using my AutoBiPAP with pleasure, actually looking forward to using it each night. I bring my little chip with me to the MD every six months (and things are going so well, it's now just yearly), and the results are great. I feel great! And I have a huge supply of hoses, straps, nose pillows - which I don't anticipate needing for decades. (Oh, and I could buy them online as well, for a fraction of what the "support" company was selling them to me for.)

Knowledge is power, as they say. I wish I had known, 5 years ago, that there were such things as AutoBiPAPs, that there was such a thing as Apnea Board, that there were units with chips for easy access to data, that AutoBiPAPs adjust automatically, obviating the need, in most cases, for further sleep studies, and that all the accessories I'd ever need were easily available on-line.

Shoot - I wish I had know just that my stupid old unit - for which I paid top dollar - was collecting data all the time and that could download that data to a computer and that there was software that would present the data in a useful was to my doctor.

No, instead I was shunted to a company whose interest was only gaming the insurance system and sucking me financially dry. With a complicit pulmonologist.

ALL PATIENTS SHOULD HAVE AUTO UNITS. ALL UNITS SHOULD HAVE CHIPS. ALL EQUIPMENT OWNERS SHOULD HAVE ALL MANUALS.

There are no medical or health reasons for this not being the case.

[SuperSleeper]

In trucking auto-pap with full compliance and efficacy data capability is the norm.

It's a cost issue.

[SuperSleeper]

The Sleep study doctors are in the same business as the durable medical goods providers. I have read the biggest margins are by selling you the bottom of the barrel machines and charging you 3 times the amount of the machine. The sleep study guys told me themselves if I had a Cpap that had patient data they could have retitrated me right then and there without a study and just "adjusted" the machine.

First they make you rent it, then they make you buy it along with your insurance company. They just made 200 percent on my last machine and I dont care if I have to pay out of pocket for a RESMED s9 Elite with humidifier and Climate Line. And if I cant get prescribed for the unit I am getting new doctors 100 percent. And I want access to the data reguardless of who says I shouldnt have that info. I am done being ripped off. I stopped buying masks from the supply companies. Last time I ordered from Apria, I ordered 2 hoses, 2 filters, 2 fine filters (to try them and I was allergic to them) and 1 mask. They tried to charge my insurance 1000 plus dollars. I dont care if they have a trained monkey to press a button, I am not going back I will set it myself or have my MD do it.

<B>Everytime you take a sleeping pill, you dont take one, you take pain meds, your pain medication changes, your asthma medication changes, you work 12 hours vs 8 hours, your weight changes, your pressure on your cpap should change.</B>

If you have no option of an "autopap" you are cutting yourself short and your doctor and durable medical goods company is taking you for a ride and your wallet, time, and brain is going to suffer. This is my third set of sleep studies coming up and I am NOT doing another. I am buying a machine with Autopap, paitent info and rainout protection. I dont have the money, time, nor patience to keep this up and I need to stay on top of my pressures so I can be the sharpest at work since my job is technical in nature and when my cpap is not at the right pressure I do not feel rested and my JOB suffers and I suffer.

[SuperSleeper]

Right on, Brett! Funny how the entire medical system cost could be drastically lowered by the approach you mention. But then again, the medical community would not get so much...

[SuperSleeper]

We use AutoPAP/CPAP on all of our patients. It does cost the DME more, but we are able to use this data to adjust CPAP pressures and save the patient further titration studies. Plus we have modems to call in to Encore Anywhere until they are compliant so we can look at this anytime to see if we need to call the patient. We also use a lot of AutoPAP to adjust patient pressure that are enrolled in our Bariatric Program.

We can tell a lot from the downloads when we see the patient at their 2 week tech appointment. We obviously watch leaks, but our Physicians have become very good at telling when the apneas on the downloads are centrals and may need to change therapy,

The use of AutoPAP allows us to switch back from CPAP at anytime if the patients starts having difficulties due to issues such as weight loss or weight gain.