In Part I, we ran through a few examples comparing something as obvious as heart disease and the full insurance coverage often provided for related cardiac care to the problem of sleep disorders, in particular sleep apnea, and the general lack of interest and specific lack of coverage in promoting greater use of CPAP. In the zero sum game of healthcare, sleep medicine is increasingly looking like an imminent loser in so far as services are continuously downgraded to a point where patients either adapt to the PAP machine rapidly or the device is withdrawn. The epitome of such a model of care would be undergoing HST, then receiving an APAP device, and then when some proportion of patients struggle after say one month, insurance coverage ceases. The patient can always try again, but in this model, the general belief would be the patient just is not sufficiently motivated to regularly use PAP and therefore any additional insurance coverage is not a worthy expenditure of time, money and resources.
While this approach looks irrational if you know a lot about sleep apnea and the benefits of its treatment, an insurance company’s perspective revolves around the “use it or lose it” paradigm. Currently this view is entrenched among most carriers, because it appears to make a great deal of economic or financial sense. And, it could be reasonably argued that this big picture approach is actually based on a very practical tunnel vision in light of the vast numbers of CPAP users who give up.
In fact, from the above description of the problem of maintenance of use among CPAP patients, it is much more understandable that these businesses would have developed policies to utilize prior authorizations for testing in the sleep lab.
Let’s begin at the beginning of the HST/APAP model and see how it suits the insurance companies’ rationales and policies. Then, I will attempt to show why this model actually hurts the insurers more than they realize.
The basic premise about CPAP use, widely held by many in the field including sleep doctors and techs, sleep center staff, and many other indirect providers of care who engage with OSA/UARS patients, can be succinctly defined as simply as “most people do not want to use CPAP or most people cannot use it.” In other words, across virtually all spectrums of patients, patient care resources, physicians, DME companies, government regulators and health insurers, the belief is that the average patient just will not or cannot use PAP therapy. This belief does not propose it is impossible to use PAP or that there are not lots of people benefiting from PAP. Rather, this belief is the conventional wisdom that subscribes to the facts on the ground where so many more people appear to struggle with PAP compared to those who take to PAP likes ducks to water.
Somewhere between the serious strugglers and the avid users lies a middle ground comprising a vast number of individuals with variable degrees of use and variable degrees of benefit. Obviously, this middle ground does not include OSA/UARS superstars who can implement PAP all night every night within the first week or two of use and easily achieve hours ranging from 6 to 9 per night. These superstars are perceived by the medical and health industry as accounting for only one-third, at best, of PAP attempters and ultimately users. So, while there are many who flatout quit within a few days, the middle grounders look much closer to quitters than superstar users.
With this thumbnail sketch of general PAP use, you can see that the people who pay for the coverage of PAP equipment must be feeling like they are losing a lot of time and money when so much effort is invested in as many as two-thirds of patients who might never become truly regular and diligent users.
What would you do in their circumstances? Would you keep pouring more coverage money into the pot in the belief user rates will eventually rise to a level of cost-effectiveness, or at some point, wouldn’t you become suspicious about the whole PAP line of treatment? Wouldn’t you in fact want to find a way to rather quickly weed out the winners (users) and losers (quitters) so that you could invest your coverage money towards those inclined to stick with the program?
If you think about how an insurance company survives in the real world of healthcare, then prior authorizations would at first glance make a great deal of sense. Below is a brief list of some of the obvious reasons an authorization system would cut losses.
First and foremost, if the insurance company uses strict criteria, it can reject almost anyone from ever returning to the sleep lab. What in fact are the most common reasons someone needs to return to the lab? The answers fall into only a few categories: persistent mask fit difficulties, intractable mask leak issues, unresolved leg jerk issues, and a poor response to PAP therapy due to either the wrong type of device or the wrong pressure settings. There are variations on all these aspects of PAP therapy, such as chronic mouthing breathing and dry mouth, but both these problems are usually related to mask issues or the use of a chinstrap or mouth taping.
Thus, if we look at each of these factors, how essential is the lab environment in resolving them? From a pragmatic point of view, a patient could make repeated trips to the DME provider or to the daytime sleep center staff to be fitted and to receive a new mask to attempt to resolve all mask issues. For the problem of leg jerks, the patient could be tried sequentially on multiple different medications or supplements or both over a period of weeks and months until the patient reports enhanced sleep consolidation and a resultant improved response to PAP. Last, regarding the PAP device itself, the patient could be sequentially switched from CPAP to APAP, and then to BPAP, and then perhaps even ABPAP. After a trial with each new device, the patient would return for a data download and discuss progress, at which point the provider, physician or sleep technologist adjusts the pressure settings based on the information acquired in the data download.
While all the above seems pragmatic, it turns out to be erroneous on several fronts, but we’ll get to these fallacies in the subsequent post. Let’s imagine for the moment there are no other options, as is the case nowadays with many sleep centers restricted by insurance policies prohibiting or severely curbing sleep lab use. From the insurance companies’ viewpoint, these sequential interventions are not that expensive (especially if the DME creates a PAP device loaner system) and could lead to either success or failure. Most of the time, the results are a mixed bag, because these processes take too long for the average patient to maintain interest or motivation to continue. In other words, a huge proportion of patients drop out of care anywhere along this timeline, because what’s usually happening is a worsening of sleep, which in turn kills motivation within a matter of days. Theoretically, acceptance of this fact (of early failure) is more than acceptable to the insurers, because they believe these patients returning to the sleep lab would never have transformed them into satisfied customers who regularly us PAP.
It is important to note the insurance company does not perceive itself as doing anything wrong or evil. It is persuaded that PAP patients are mostly losers (quitters), and they don’t want to foot the bill. If they enact tough authorization systems, it never occurs to them they are harming their patients. What occurs to them is that they are not only saving money for the company, but they may also be helping patients recognize sooner than later that PAP therapy is not a good treatment option for them. Though this logic seems somewhat twisted, the insurers merely need to look at most of the adherence data about PAP in the scientific literature to be persuaded they are on the correct side of the argument. Again, if insurance companies put too much money into a losing proposition, then they go out of business and all their customers lose out not just the sleep apnea patients.
Do you see something clearly wrong or obviously illogical with these lines of thinking? The most rational concern is whether or not the above mentioned problems actually can be fixed sooner or more effectively by returning to the sleep lab, thus cutting down the timespan between first starting with PAP and then appreciating actual treatment gains and benefits. And, even more importantly, is there something about returning to the sleep lab that turns things around such that the patient reports sleeping better?
This concept of “sleeping better” is unbelievably critical to this discussion, so permit me to delve into its meaning and its impact on patient care. To start, consider our previous discussions about the Ceiling Effect, where with every improvement in sleep quality, the individual patient often appreciates things have gotten better, however, a majority of patients do not spend time speculating on whether “more better” is in reach. Instead, they normalize the new better, accept it as the current achievement, and often are content to feel stable with this level of improvement.
So far so good as long as the person discerns the improvement, because as noted above anyone who uses PAP and experiences a decrease in awakenings (insomnia) or in sleepiness (enhanced sleep quality) is highly likely to stay focused and motivated to continue PAP. In other words, these folks have an apparent potential to turn into superstar users and certainly do not resemble the quitter pathway. Some of them may turn into strugglers, the middle ground, but again if the benefits are tangible and consistent, they will continue to seek to reap the gain of PAP.
Now, here’s a crucial question that must be answered to really appreciate how clinical care fails so many patients and at the same time why insurance companies understand better than most the pitfalls of PAP therapy. “When should someone be able to declare they are sleeping better with PAP?” This question is not a hypothetical, because as noted above, a fair proportion of cases are not only not sleeping better with the early use of PAP, they are instead sleeping worse. To reiterate, it is no surprise such an individual would become a quitter in a matter of days. What we have learned at our center is the highest probability for greater use resides among those patients who declare they slept better either the first night of using PAP therapy or the first night of using a different mode of PAP therapy when they were switched from CPAP to BPAP, ABPAP, or ASV as the most common examples.
When someone wakes up in the morning from these experiences and actually notices sleep was more refreshing, quality was better, sleep was deeper and there is a sense of feeling rested, this individual has tasted and thus lived through the experience of objectively better sleep that has translated into subjectively better sleep. In a nutshell, the patient’s consciousness has been transformed overnight, because there is no way they could foresee or imagine the feelings of this changed experience.
Such individuals can always presume intellectually they expected to sleep better with PAP because it’s what they’ve heard from family, friends and providers beforehand. But to test drive PAP and to experience this change in one single night has a dramatic impact on the patient’s experiential knowledge, which will drive the person to maintain the involvement night after night, that is, start using and maintaining regular use of PAP. For this reason alone, we have long pointed out the serious problem of making patients wait 2 to 4 weeks after a titration to get their PAP devices. PAP devices should be waiting for them in the morning after the titration as they walk out the door in a model of care resembling something akin to a Bed and Breakfast, where breakfast is a new PAP setup.
We’ve already published papers describing the use of this single parameter “sleeping better” to predict who will and who won’t end up as a PAP user. And, we believe there is so much common sense to this approach, we remain continuously puzzled by the lack of attention this paradigm receives in most circles of clinical sleep medicine care, particularly among sleep medicine specialists. Most likely, far fewer sleep technologists are constrained in this way because they observe first-hand their patients’ high degree of satisfaction upon awakening from better sleep.
Tacitly, the insurance companies understand this point even though they do not put much effort into its realization. They know that if the patient isn’t doing well early on, they won’t become a regular user. We are in effect saying the same thing, but the difference is huge when considering how we attack the problem before the first titration, during the first titration and soon after the first titration. This after-care issue is crucial among those who don’t report sleeping better.
When someone says they slept worst or there was no change in sleep, we then explore the degree of motivation they are expressing. Surprisingly or not, there are a number of types of patients who write off the first bad night as a forgettable and a non-decisive factor. They want PAP, and they want it now, because they figured out beforehand it’s going to be well worth the discomfort, pain, or suffering to make it all work. These patients might suffer from serious cardiac conditions or uncontrollable blood pressure or misdiagnosed depression and so on. They are sick and tired of being sick and tired and possess enough knowledge to embrace PAP as the answer to which there is no further questions.
But, a sizeable group of non-responders (worse sleep or no change) need rapid and aggressive intervention. Some of these patients must return for a PAP-NAP. Others need retitrations within days or weeks after the first one. Some patients need a clinic appointment to ask about other options for which most soon realize PAP is the better option if there was some way to get used to it. We have worked with all these types, and we have pushed as hard as we possibly can in the most gentle and diplomatic ways among these cohorts of soon to be quitters or early strugglers.
The secret to success is the same as it is for the superstars. They have to gain an experience in which the sleeping better phenomenon hits them square between the eyes. On the most mundane level, one of the more simplistic ways to achieve this process would be to switch the patient immediately to nasal strips. Instead of haranguing them about PAP therapy, which appears impossible at the moment, conduct a rearguard action and agree with them that PAP is off the table. Then, delve into the simplicity of nasal dilator strips and inquire whether they would be willing to attempt an experiment with this intervention for a few weeks or months, after which a follow-up clinic appointment can occur.
This option is ideal because it removes all the pressure (pun intended) from using PAP. You can also start treatment with medications for leg jerks in some of these cases. In both instances, it is very common for the patient to return to clinic in a few weeks or months with a brand new perspective. They have now tasted better sleep, because of the nasal strips or the leg jerk medication. Now that they understand something physical was really mucking up their sleep and have experienced the transformation in their sleep with an easy to use therapy, all options are back on the table. Many such patients are ready to move forward with PAP as they now expect “more better” sleep to ensue.
What must we do to educate the insurance companies on the various steps in this model of care?