Tag Archives: DME

Confessions of Sleep Apnea Man

There are elements of medical care in the U.S. that just plumb confound me. One is the requirement of a prescription for the most mundane of items, particularly when you think about where we could be focusing our efforts.

Please indulge me a moment while I ‘splain the background on this.

I went through a sleep study back in 2002, where I was diagnosed with sleep apnea. Apnea is a condition most identified with snoring, although not all snorers are apnea sufferers. After the diagnosis, I was provided with a CPAP machine, the device most commonly used in the treatment of that particular condition.

Sleep apnea is described as a potentially serious sleep disorder in which breathing repeatedly stops and starts. What it really was, however, was a condition that kept my wife awake at night. I don’t know why the doctors didn’t treat her instead. The CPAP (Continuous Positive Airway Pressure) machine is designed to gently pressurize your airway, keeping it open, providing for a more sound sleep.

Mostly for your wife.

You see, the CPAP literature says the machine is designed to alleviate apnea episodes and reduce potentially fatal risks. The fatal risk it is most likely to alleviate is stopping your spouse from shooting you in the face with a bazooka at 3 am.

I have used the same CPAP machine since 2002, and it has performed very well. I do sleep much better using it, as does my wife. I usually take it with me in my travels, and therein lies the conundrum that has produced this missive.

My unit, now about 13 years old, is somewhat clunky for the frequent traveler. This is especially true when one does not generally check luggage. Somewhat bigger than a large box of Kleenex, the device either must be packed within my carry-on or in its own travel bag. As a medical device, it does not count as one of my two carry-on items under FAA rules, but it is nevertheless bothersome to have to tote a fairly significant extra bag around. Prior to the advent of PreCheck, it had to come out of the bag and be run through the X-ray equipment on its own. Until about five years ago, it even had to be pulled aside by TSA for explosives testing. If TSA was efficient, that would occur while I was having my prostate checked by Two Finger Lou. If not, the testing added a few minutes to every pass through security.

Today, as a government-fingerprinted “Known Traveler” with my very own “Trusted Traveler” ID number (don’t get me started on that), I always fly as a PreCheck passenger. The device no longer has to come out of the bag, so for trips of just a few days I pack it inside my carry-on. Of course, as we all really know, size does matter, and this is an issue for trips longer than just a few days. While I have become a very efficient packer and can get four or five days of clothes into a carry-on with the machine, anything longer requires that the unit be carried separately.

With that in mind, I ordered a “travel CPAP”: a machine about a quarter of the size of the one I have been using. After I placed the order with an online company, it notified me that it required a prescription for the machine to be on file before it could fulfill the order. I have a prescription for CPAP supplies on file with the company, but apparently being able to buy the supplies is different than buying the machine that uses them. According to the FDA, CPAP devices are considered Class II medical devices and require prescription by law.

The issue is that my sleep specialist, whom I have not seen in more than 12 years, changed practices a decade ago, and records no longer exist with the practice where I was diagnosed. Without those records, no prescription will be forthcoming. I frankly don’t know what my options are with the practice. I suppose I could set up an appointment, go through another two-night sleep study, spend a couple hundred in co-pays and have my insurance billed God knows what for the effort, all to get a piece of paper confirming something we already know I have.

All for a machine whose basic function is blowing air.

If we applied that logic here, you would need a prescription just to read my blog.

Can someone in the medical community take a moment to explain this to me, an admitted medical ignoramus? Have these machines been abused in some unimaginable way? Were teens buying these machines in droves to huff air? Are they somehow vital in the making of meth? For Christ’s sake, in the hands of evil men, what indeterminate hell could they unleash?

What aren’t you people telling us????

Someone should tell the FDA that CPAPs don’t kill people; drugs kill people. Maybe the FDA should focus some of its enforcement zeal toward those things that really matter. Perhaps the FDA has heard of the need for a national prescription drug monitoring database.

Unless, of course, I am mistaken, and rogue CPAPs are slaughtering more than the 20,000 people every year who die from prescription drug overdoses.

My solution to this dilemma will, I hope, be found through my primary care physician. I have made an appointment with him for the sole and single purpose of getting that magic prescription. It will cost me $30, and my insurance company significantly more, all to tell the good doc that I’m feeling fine and that there is nothing wrong. I just need one of those air-huffing, meth-cooking, chaos-reigning machines — but a small one to make my travel schedule easier to bear.

There is a chance that he will not be able to authorize one without another complete sleep study, in which event it will represent a colossal waste of resources.

In the absence of a logical explanation, this scenario simply serves to show the ridiculous waste of time, effort and resources in a system where common sense often struggles for its moment in the sun. In a world where we are trying to figure out how five or six remaining practicing physicians are going to treat 350 million people, is this really where we need to devote so much effort? It simply makes no sense to me.

But then again, there may be reasons of which I am not aware. I am sure some medical wizard out there, or a medical-equipment salesperson, should be able to enlighten me and remove my veil of ignorance on the matter. I encourage you to do so, and you don’t even need to be gentle about it.

It certainly won’t be my first time.

‘4-Lanes’ Approach to Work Comp Claims

Claims operations have ascended the value chain from an “island in the stream” technical function into a key facet of the customer value proposition. To handle the growing demands, it’s important to think about work comp claims in terms of four lanes.

The first lane is governed by compliance rules and requires not just compliance awareness, but the knowhow to optimally integrate compliance into the operation.

The second lane is focused on vendor management. This needs to go beyond simply outsourcing non-core competencies. Successful companies concentrate on ways to leverage vendors to achieve superior outcomes and competitive advantage.

The third lane is defined by business rules. This is where automation is fully deployed and constantly improved. This lane draws from rules-driven facets of each of the other three lanes.

The fourth lane is the “interpersonal, interpretative and professional judgment” perspective. It relies on the subjective application of knowledge and human interaction. This lane leverages engagement, training, technology and analytics to continuously accelerate accurate decision making, enhance performance and improve quality.

The four lanes represent perspectives and should not be confused with a company’s organogram. Indeed, each lane touches every facet of any organogram found in the insurance industry today.

The compliance, vendor management, business-rules and professional judgment lanes all benefit from a strong commitment to business process improvement (BPI). Data capture and analytics that support measurement of performance along the entire claims’ value chain is integral to BPI. The BPI discipline uses data to identify best practices, implement those practices, assess their effectiveness and uncover opportunity for further improvement.

Embracing the four-lane view and BPI model will help carriers make strong, data-based decisions as they reconfigure their claims departments to control costs, stabilize case reserving and improve outcomes of their claims operations.

Great tools, talented people and sound business practices are the timeless ingredients of success, as is operational adaptivity. Today’s workers’ compensation carriers are operating in an environment of increased uncertainty and complexity. Carriers face headwinds because of a shift into a healthcare-centric business, which has caught many carriers flat-footed. Medical costs are approaching 70% of the total claims spending in many jurisdictions. The utilization and cost of pharmaceuticals is rising at a rapid rate. According to the California Workers’ Compensation Institute, pharmacy and home-medical-equipment costs have risen by  more than 250% since 2004. Today’s companies must adapt their models to concentrate on effective and efficient delivery of care that improves patient outcomes, exudes customer value and underpins superior combined ratios.

The undeniable reality is that the nature of work comp claims has changed. Traditional ideas on the core competencies necessary to operate an effective claims operation need to be challenged and adjusted. Positive differentiation and sustainable market leadership depend on effectively incorporating the ingredients of success into a well-defined strategy that produces desired results and provides an agile framework for continual business evolution.