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[CPAP] AUTO or not - Is the auto-CPAP machine inherently better than a CPAP?
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SuperSleeper Offline

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Post: #11
RE: AUTO or not - Is the auto-CPAP machine inherently better than a CPAP? [copied]
Steven Wrote:YEP, "Auto" CPAP (aka APAP) is ALWAYS the way to go - EVEN if you plan to always use it in straight CPAP mode.

In fact I feel so strongly about it, I just returned home with my brand spanking new ResMed S9 AutoSet.

I will post in a separate topic the steps I took to make certain that I got what "I" wanted.
02-25-2012 06:32 PM
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SuperSleeper Offline

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Machine: PR System One REMstar Auto (DS560)
Mask Type: Nasal pillows
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Humidifier: none
CPAP Pressure: 12.5 - 18.5 cmH20 (auto range)
CPAP Software: SleepyHead

Other Comments: Have diabetes Type II

Sex: Male
Location: Illinois, USA

Post: #12
RE: AUTO or not - Is the auto-CPAP machine inherently better than a CPAP? [copied]
Ltmedic66 Wrote:I'll just go on record as saying that I am not convinced that APAP is the way to go for everyone. The issue, I think, is far more complex, and so far we have been talking about it in relation to "single patients". In the context of the overall health care system, I do not think it is so cut and dried.

First, I would venture to say that the vast majority of patients are not really interested in tinkering with their CPAP pressures and are likely to follow their doctor's advice as issued. Second, there can be down sides to APAP, so it is clearly not for everyone. Third, if someone is not going to use the data, then there is no need to pay for that capability. Finally, not everyoneis sold of the accuracy of the data recorded by home CPAP machines.

The key point in my mind, however, is that getting a more expensive machine for someone who is not going to use the features is just wasteful. The simplest CPAPs are just a few hundred dollars, while most fully loaded APAPs tip out at around $1,200. I know it varies, but those are the round figures. It's inefficient for the health care system and wasteful for the patient to spend more than is needed or will be used. Additionally, it is probably a little disingenuous to expect the DME to "eat" the difference in the price difference between what is required and what is desired. They're not a charity. So, I'd say if CPAP is prescribed but you want APAP, it's fair to expect you to pay the difference, not the DME.

Following the logic in this thread, we should all get $4,000 VPAPs and set them to CPAP or APAP mode, on the off chance that we might need VPAP some day.

Don't get me wrong- I have no problem with someone buying all the bells and whistles they want. I have a straight, non-data CPAP that was almost as expensive as some APAPs. It serves my needs, I'm happy with it, and I paid a little extra to get something that met my requirements. So if you want to cover all the bases and pay a little extra for APAP or data, go for it! But it is not "always" the right answer, in this hosehead's opinion.
02-25-2012 06:32 PM
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SuperSleeper Offline

Administrators

Posts: 9,973
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Machine: PR System One REMstar Auto (DS560)
Mask Type: Nasal pillows
Mask Make & Model: ResMed Mirage Swift II
Humidifier: none
CPAP Pressure: 12.5 - 18.5 cmH20 (auto range)
CPAP Software: SleepyHead

Other Comments: Have diabetes Type II

Sex: Male
Location: Illinois, USA

Post: #13
RE: AUTO or not - Is the auto-CPAP machine inherently better than a CPAP? [copied]
Steven Wrote:
Ltmedic66,(time=1324689819) Wrote:I'll just go on record as saying that I am not convinced that APAP is the way to go for everyone.
I respectfully disagree.

I think that APAP would be the best for everyone.

But, I will also admit that if someone wants to dumb down their choice for the numerous reasons you stated, it is their decision. And if they are happy with it, I certainly won't be ridiculing them.

I now this is not a statistically reliable sample, but I have never seen someone say they bought an APAP & regretted it (unless that is what zimlich is saying). But, I have seen numerous postings of people who bought something other than an APAP & later regretted it. They were even more incensed when they learned that they were never told there were other options.

OK, OK, I know that the postings I am reading are from others who are just as anal about it as me, but that is all I have to go on.

Also, the guy I dealt with at my DME provider asked why I had insisted on getting an APAP & specifically a ResMed APAP. My simple answer was "I just think it is better". I was surprised when he responded "So do I".

It was reassuring to me to hear that a tech at a DME provider that sells 99% Respironics with 99% of those being dataless bricks at the insistence of the Sleep Centers & Sleep Doctors would have such an opinion.

Now my DME provider is not the best in the world, but I have not been able to find anyone else locally who I consider to be better. I know because I visited 4 others before I made my purchase.

At every one (5 including the DME provider I continue to deal with) we discussed why Sleep Centers & Sleep Doctors in my area were Respironics fans & more specifically why they did not prescribe APAPs unless someone like me requested it (actually demanded it).

All of their answers were shockingly the same (as though I had talked to the same person 5 times).

The Sleep Centers & Sleep Doctors stick to only 1 brand & avoid APAPs because they just don't want to have to learn any others, nor do they want to have the software for those others. They just want to see how many hours you use it each night. They want to make their lives as simple as possible, even to the detriment of their patients.

How would you feel if your Doctor continued to prescribe X drug after it was determined that something else came out that was much better only because they were not willing to look at something new?
02-25-2012 06:33 PM
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SuperSleeper Offline

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Posts: 9,973
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Machine: PR System One REMstar Auto (DS560)
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CPAP Software: SleepyHead

Other Comments: Have diabetes Type II

Sex: Male
Location: Illinois, USA

Post: #14
RE: AUTO or not - Is the auto-CPAP machine inherently better than a CPAP? [copied]
Hi LT...

Let me first state that you all are my friends here, so this is in no way personal AT ALL, so please don't anyone take it that way. This is simply a friendly discussion.

I'd like to challenge your thoughts on this LT (and maybe my friend Mary's thoughts also)... you could be absolutely correct... I'm not sure... but I do have some thoughts and questions:

Quote:First, I would venture to say that the vast majority of patients are not really interested in tinkering with their CPAP pressures and are likely to follow their doctor's advice as issued.

I would agree on this. However, should these patients in the future decide to take a more active role in their own therapy, they will be restricted as to options if all they have is a non-data capable, standard CPAP. I personally think (as most people here seem to think also) that patients will have a much better chance at CPAP success if they take a personal role in their therapy, rather than simply following doctor's orders (and then when they have problems, they may decide to quit CPAP).

There are many folks here who have had problems, come here to Apnea Board to seek out solutions, and as a result, taken a much more active role in their therapy. Some of these folks are frustrated that their DME gave them a low-end non-data capable CPAP... after they become educated, they become angry with the DME for not giving them a data-capable CPAP or an Auto-CPAP in the first place, especially when the cost to Medicare or the insurance company would have been the exact same.

Quote:Second, there can be down sides to APAP, so it is clearly not for everyone.

Can you list what those downsides are? Are these professionally-researched downsides or simply personal opinion?

Quote:Third, if someone is not going to use the data, then there is no need to pay for that capability.

Again, you're assuming that most patients aren't going to be interested in the data. But I contend that a good number of them, if they became truly educated and informed as to what their AHI and other numbers mean to their treatment, would become very interested in following the data to obtain the best possible treatment.

For folks who are ignorant when first prescribed CPAP, they might be given a non-data capable machine... and LATER, after reading more on forums like this, decide to take a more active role. They must then go out and purchase a data-capable CPAP or Auto-CPAP from their own funds. This is paying for two machines, when if the right one would have been prescribed first, the overall cost would have been greatly reduced.

Quote:Finally, not everyoneis sold of the accuracy of the data recorded by home CPAP machines.

Again, when it comes to AHI and other data recorded by home CPAP machines, it is not the accuracy of that data that is most important. For instance, one machine may record an AHI during the night of 1.5, while another machine may record that very same night's AHI as 2.8. This difference in AHI calibration is not really that important when it comes to being useful to the patient. These numbers are used to show trends only. For instance, on most machines, they will accurately record overall trends (whether a particular adjustment caused the AHI to go up or down over time).

As you know, on our page on How to Find the Optimum CPAP Pressure, we always caution when making pressure adjustments that patients should make "small, incremental changes", "give it time to work", and "don't make additional changes for a week or two". The fact that a patient's AHI went from 1.5 to 1.0 or from 2.8 to 2.0 is basically irrelevant... these numbers are not set in stone (not even at the sleep center) and should only be used for trend analysis (to show whether a change in pressure raised or lowered overall AHI).

Quote:The key point in my mind, however, is that getting a more expensive machine for someone who is not going to use the features is just wasteful.

Is it not also wasteful to give a patient a low-end, non-data capable, non-Auto CPAP and have them keep coming into the doctor, RT or sleep center way too often to answer questions about their treatment or make minor adjustments every time something changes in their lifestyle, overall health, etc.? That is going to cost money... this waste might have been avoided if they were given a data-capable Auto-CPAP and also informed as to make small changes themselves to improve their treatment.

Quote:The simplest CPAPs are just a few hundred dollars, while most fully loaded APAPs tip out at around $1,200.

Yes, but those are the extremes. Seldom does a DME give a patient a $300 CPAP, and seldom to they give out a $1200 machine. They are usually given one that is between $700-800 in cost, when the DME could have given them an Auto-CPAP that is about $90 more (the cost of an average doctor's office visit). Again, the DME is reimbursed the exact same amount by insurance/Medicare, whether or not the machine dispensed is a low-end standard CPAP or a data-capable Auto-CPAP.

Quote:It's inefficient for the health care system and wasteful for the patient to spend more than is needed or will be used.

I agree. It is totally inefficient for the health care system and wasteful to keep having to spend $90 for an office visit 2-3 times a year every time a pressure or setting needs to be adjusted. It would be much less expensive to spend the extra $80 and given them a shiny new data-capable Auto-CPAP right off the bat, along with a bit more initial patient instruction to help them take control of their own therapy. Far too often, patients are handed a machine and mask, given 10 minutes of instruction, and then they never hear from their health care professional again (unless they can create a billable event - $$).

Quote:Additionally, it is probably a little disingenuous to expect the DME to "eat" the difference in the price difference between what is required and what is desired. They're not a charity.

It's supposed to be a free market. We're talking about a DME making a few bucks less on the average CPAP sale. If they can't be profitable by handing out Auto-CPAPs to patients, then there is always going to be another DME down the street that will find a way to distribute Autos and still remain profitable. No one is "stealing money" from anyone here... DMEs are not being forced to distribute Auto-CPAPs anywhere that I know of. If I had insurance, and I knew that my DME would get $1500 from the insurance company no matter what CPAP they gave me... I would always insist upon a data-recording Auto-CPAP. Why? Because I am an informed customer. Likewise, I want all CPAP users to be informed customers. If my DME can't see fit to give me what I want, I will go to one who will. Free market, 'ya know.

Quote:So, I'd say if CPAP is prescribed but you want APAP, it's fair to expect you to pay the difference, not the DME.

So it's "fair" for DMEs to screw with me, giving me a low-end, piece of junk non-data capable CPAP instead of a good quality, data-capable auto? All because they want to make more profit? If that's considered "fair", then why is it not also "fair" when I choose to walk out from that DME and go to another DME who is willing to provide me with what I want?

I don't pay any more money by going to another DME for an auto, the government pays no more money for that, neither does insurance pay more for that. The only one who doesn't make as much money is the DME that I left. In my opinion, if they can't provide a quality product for a competitive price, they deserve to lose my business.

Quote:Following the logic in this thread, we should all get $4,000 VPAPs and set them to CPAP or APAP mode, on the off chance that we might need VPAP some day.

Inaccurate analysis and comparison there, LT... We're not talking about VPAPs, we are talking about data-capable Auto-CPAPs vs. standard, non-data CPAPs. The medical coding for Medicare and insurance is the exact same whether the patient gets an Auto-CPAP or standard CPAP. The cost to Medicare or insurance is the same. VPAPs are not billed under the same code as standard CPAPs and Autos.

If, however, someone (like me) does not have Medicare coverage or any kind of health care insurance, I am free to purchase with my own cash whichever machine I can afford between the two (CPAP and Auto-CPAP). (or even VPAP if I have a prescription for it).

Mary's original thread title was "AUTO or not; is the auto machine inherently better than a CPAP". To that I think the obvious answer is "yes, Auto is inherently better because it can be operated in both CPAP and Auto modes".

As to cost when it comes to Medicare/Insurance, that isn't an issue since they both pay the DME the same amount for both types of machines. As for properly adjusted Auto-CPAPs being "harmful" to some patients, I'm not sure any professional studies have ever concluded anything like that, and even if they did, the machine (again) could be operated in straight CPAP mode, avoiding the "harm".

The DMEs have a vested financial interest in promoting the view that "Auto-CPAPs can be worse than than standard CPAP"... DMEs get richer at the expense of decreased patient options when they dispense a non-data capable standard CPAP.

Again, just my humble opinion on all this... and I'm willing to listen to differing views and change my mind if convincing enough evidence can be posted.

Coffee

SuperSleeper
Apnea Board Administrator
www.ApneaBoard.com


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.

02-25-2012 06:34 PM
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SuperSleeper Offline

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Machine: PR System One REMstar Auto (DS560)
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Post: #15
RE: AUTO or not - Is the auto-CPAP machine inherently better than a CPAP? [copied]
archangle Wrote:
Ltmedic66,(time=1324689819) Wrote:First, I would venture to say that the vast majority of patients are not really interested in tinkering with their CPAP pressures and are likely to follow their doctor's advice as issued. Second, there can be down sides to APAP, so it is clearly not for everyone. Third, if someone is not going to use the data, then there is no need to pay for that capability. Finally, not everyoneis sold of the accuracy of the data recorded by home CPAP machines.
First - If the patient's doctor is not interested in tinkering with their CPAP pressure in order to get the correct pressure to properly treat a life threatening, he should find another line of work.

Second - If the doctor is not capable of setting the upper and lower pressure settings on an APAP machine to make it work better for anyone than a manual CPAP, he's probably going to do a worse job selecting a manual CPAP pressure than the APAP will do manually.

Third - Even if the patient or doctor is not planning to look at the detailed data from the CPAP machine, if the patient has problems with CPAP, a competent sleep doctor will look at the data recorded by his machine and look for problems. Even if it doesn't give "THE" answer, it may give the doctor a clue.

Without data, what is the doctor going to do with a patient who doesn't seem to be getting better? Tell him "let's take a stab in the dark and change your pressure with no data to go on?" Tell him, "let's send you back to the lab for another expensive PSG that your insurance is probably not going to pay for?"

Four - "It might not be accurate" is one of the most stupid statements used by the medical establishment against data capable CPAP machines. I think it's beyond stupidity, it's part of the mindset to generate extra doctor visits and expensive sleep tests.

Suppose a patient came into the doctors office and said "My wife says I snore all the time and stop breathing for long periods of time. She timed it last night and I stopped breathing every five minutes or so and stopped breathing for around a minute every time." If the doctor said "don't worry about it, your wife probably didn't measure it accurately," and didn't bother to investigate, we'd want take his license away.

The doctor should consider this information and decide if further investigation is needed.

Now, suppose a multi billion dollar medical equipment company comes to the doctor and says "our FDA approved medical device indicates the patient seems to be stopping breathing 30 times an hour with apneas up to 80 seconds in duration. Here's data of what we measured." Suppose the doctor said "I'm not interested." and didn't bother to investigate further. Wouldn't we want his license taken a way too?

There's yet another reason data logging should be mandatory. Consider what happens when the patient gets a non-data capable machine. Here's a very common scenario.

1) The patient isn't reporting any sleep problems, but for some reason, a sleep test gets ordered.

2) The test indicates severe apnea.

3) The patient gets a CPAP machine and uses it faithfully.

4) The patient doesn't report any problems using the CPAP, but he didn't realize he was having any problems before. The patient notices no difference between treated and untreated sleep.

Realize that there is NO monitoring whatsoever of actual results of the CPAP therapy if the patient has a dataless machine. The only feedback the doctor has is if the patient feels better or worse, or if the doctor orders another sleep test.

Remember that the patient didn't notice any problems even when he was untreated and suffering severe apnea. A correct titration is often very difficult. Quite a few patients don't sleep well in the lab. Quite a few patients find their pressure needs change in the first few weeks of CPAP. Quite a few patients only have apneas during REM sleep or part of the night. They may not reach REM or whatever condition gives them the worst apnea during a PSG.

The patient could still be suffering from severe apnea despite the CPAP machine, and the doctor will have no clue. If the doctor would get up off his fat wallet and check the (possibly inaccurate) data from the CPAP machine, he might get a clue that his patient is still suffering from a life threatening condition.

A data capable CPAP machine usually only costs $100 more than a non-data machine. (Check online prices to verify.) A single doctor's visit will probably cost more than that. A new PSG sleep test will cost $1000 or more.

Let's consider the options.


Dataless CPAP

"Accurate" PSG data from before treatment started. (Maybe accurate, if the patient has the same apnea in a strange place, bothered by probes all over his body, maybe being forced to sleep on his back instead of his normal sleeping position, maybe not sleeping much at all, with unfamiliar, possibly leaky mask strapped on his face, etc.)

Feedback from how the patient feels and how he says he sleeps.

Feedback if the patient's health, BP, etc. improves or deteriorates.

Costs over $1000 to get more accurate data, with the very likely possibility that the insurance won't pay for it. Requires the patient to go through another horrid night in the sleep lab.

If you're lucky, you can get another dose of "accurate" data once a year or so.

Your patient may be in just as much danger as before, but you have NO accurate data to check his treatment.

Data Capable CPAP

You have all the data available for a non-data capable CPAP.

Costs about $100 more, maybe less. The only cost is a one-time cost when a new CPAP machine is purchased.

It requires very little extra effort on the part of the patient.

The machine gives you an AHI number every night.

It records every apnea through the night.

If you're interested it gives you data from every night. It can show you a breath by breath waveform of the patient's breathing.

If the patient has a particularly bad night, you can look at the data, including waveform data for that night. You can do this even if the bad night was several days in the past. The patient doesn't even need to come into the office, he can mail in the data card.

You can argue data isn't accurate, but you can look at the waveforms. If the patient is having bad apneas, it will usually be abundantly clear from the waveforms. In many cases, you will see that the patient is absolutely, positively not breathing for 30 seconds or more. This IS a problem. Some of the apneas will be "borderline" and will require a judgement call. This is true even in a PSG.

More importantly, if the CPAP machine says "no apneas," it's almost certain he isn't having significant apneas. If the machine says everything is good, it probably is.

Even if the patient says he doesn't feel any better, you can tell him, "You stopped breathing 120 times an hour for up to 45 seconds. Wearing the CPAP, you only stop breathing 3 times an hour and never more than 20 seconds. This is doing you good."

Even if the primary sleep doctor isn't trained to read data from a CPAP machine, he may refer or consult with another doctor who can look at the data and pinpoint or fix a problem without having to subject the patient to another expensive and inconvenient PSG.

Central apneas often show up or go away some time after treatment starts. The machine can't definitively tell a central from obstructive, but it makes a good guess in many cases and will show it as an apnea of some kind. Remember that a central apnea is no more dangerous than an obstructive apnea, it's just harder to treat. A data capable machine may tell you if the patient develops a need for an ASV. It may also tell you a patient who you thought might need an ASV doesn't actually need one after doing CPAP for a while.

There's just NO downside to a data capable machine other than a small initial cost difference, less than the cost of a physician visit or two.


OK enough ranting. I just hate to see people getting treated badly by our medical system.

Ho Ho Ho, Merry Christmas to all, and to all a low AHI.
02-25-2012 06:35 PM
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SuperSleeper Offline

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Machine: PR System One REMstar Auto (DS560)
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CPAP Software: SleepyHead

Other Comments: Have diabetes Type II

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Post: #16
RE: AUTO or not - Is the auto-CPAP machine inherently better than a CPAP? [copied]
Ltmedic66 Wrote:
Steven,(time=1324741680) Wrote:I now this is not a statistically reliable sample, but I have never seen someone say they bought an APAP & regretted it (unless that is what zimlich is saying). But, I have seen numerous postings of people who bought something other than an APAP & later regretted it. They were even more incensed when they learned that they were never told there were other options.


How would you feel if your Doctor continued to prescribe X drug after it was determined that something else came out that was much better only because they were not willing to look at something new?
Steven,

All very good points. For those who are inclined to really get invovled with their therapy, I would agree that all the bells and whistles are important. However, for the patient that is just going to strap on the CPAP and go to sleep, (and certainly for the ones who are either incapable or not interested in participating) I think that the cheapest machine that gets the job done is most appropriate.

I just disagree with the "buy the APAP in case you'll need it some day" approach.

Of course, I think the whole system is out of whack. I, like most people, had no clue what I was doing when I picked up my CPAP. Luckily, I got one that I liked, but is was really a crap shoot. The "system" was not set up to make me successful.

To me, it seems the best thing would involve the DME explaining the difference in the three main appraoches to PAP (CPAP, APAP, BiPAP), the price differences of each, and a realistic appraisal of the differences between manufacturers and features. Then, the patient would be able to decide which machine to buy, and if any features are desired above what was prescrived, then the pt would be able to choose to pay for them.

Of course, the real issue is that it takes quite some time to get used to CPAP, so it's really hard to figures these things out right after being diagnosed.
02-25-2012 06:36 PM
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SuperSleeper Offline

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Posts: 9,973
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Machine: PR System One REMstar Auto (DS560)
Mask Type: Nasal pillows
Mask Make & Model: ResMed Mirage Swift II
Humidifier: none
CPAP Pressure: 12.5 - 18.5 cmH20 (auto range)
CPAP Software: SleepyHead

Other Comments: Have diabetes Type II

Sex: Male
Location: Illinois, USA

Post: #17
RE: AUTO or not - Is the auto-CPAP machine inherently better than a CPAP? [copied]
archangle Wrote:Sorry for the double dipping on the same post, but I think these two points are extremely important.

Ltmedic66,(time=1324689819) Wrote:I'll just go on record as saying that I am not convinced that APAP is the way to go for everyone. The issue, I think, is far more complex, and so far we have been talking about it in relation to "single patients". In the context of the overall health care system, I do not think it is so cut and dried.

It IS cut and dried.

The cost difference to the supplier is small. Check the online pricing. The cost to the patient is usually zero with insurance.

Even if you don't initially use the auto function or the data capability, there is NO downside. You don't have to set it to auto, and you don't have to use the data.

Either feature can save your life later if your manual CPAP with no data collection isn't satisfactory. Even if your current doctor doesn't believe in it, maybe the specialist he refers you to if your CPAP fails will.

Ltmedic66,(time=1324689819) Wrote:it is probably a little disingenuous to expect the DME to "eat" the difference in the price difference

In most cases, the DME is being paid handsomely for a fully data capable CPAP. We know roughly what the price of a machine is. We know what the DMEs charge the insurance. The DME has been paid for a data capable CPAP. He's making unearned extra profit at the customers' expense when he gives out a cheaper machine.

It's probably a little disingenuous to pretend that it's not dishonest for the DME to take the amount of money that he charges for a top of the line APAP and dispense a model with lesser capabilities and not charge less money. :-/
02-25-2012 06:39 PM
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Machine: PR System One REMstar Auto (DS560)
Mask Type: Nasal pillows
Mask Make & Model: ResMed Mirage Swift II
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CPAP Pressure: 12.5 - 18.5 cmH20 (auto range)
CPAP Software: SleepyHead

Other Comments: Have diabetes Type II

Sex: Male
Location: Illinois, USA

Post: #18
RE: AUTO or not - Is the auto-CPAP machine inherently better than a CPAP? [copied]
cbramsey Wrote:I have had straight CPAP. I have also had APAP.

I prefer APAP. My doctor was willing to allow me the opportunity to use APAP. Everyone is happy. Especially my partner!!! Thinking-about
02-25-2012 06:40 PM
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Machine: PR System One REMstar Auto (DS560)
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CPAP Software: SleepyHead

Other Comments: Have diabetes Type II

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Post: #19
RE: AUTO or not - Is the auto-CPAP machine inherently better than a CPAP? [copied]
Ltmedic66 Wrote:SuperSleeper...No need for the disclaimers. People disagreeing and talking through an issue is how we get a better understanding of things! And I certainly respects your opinion on all things CPAP! Agreed, we're all friends, and it's a friendly discussion.

Quote:I would agree on this. However, should these patients in the future decide to take a more active role in their own therapy, they will be restricted as to options if all they have is a non-data capable, standard CPAP. I personally think (as most people here seem to think also) that patients will have a much better chance at CPAP success if they take a personal role in their therapy, rather than simply following doctor's orders (and then when they have problems, they may decide to quit CPAP).

True, but when considering the cost of the overall health care system, at what price does this flexibilty come? I've got nothing to go on other than my own hunch, but I still maintain that the vast majority of patients either will not or can not analyze data, change pressures, changes modes, or otherwise manipulate their machines. Which is why I maintain that for the vast majority of patients, the extra expense is wasted. Why use IV morphine for a headache when a couple of aspirin will do?

Quote:Can you list what those downsides are? Are these professionally-researched downsides or simply personal opinion?

Yes, I have read peer-reviewed journal articles that raised concern with APAP for some patients. I've also read many board posting from people who simply did not like the changing pressures of APAP. As for the professional concerns, I recall them mostly relating to increased arrousals in some patients, a lack of proven clinical benefits of APAP, a tendency to set lower limits below theraputic levels, and the stimulation of centrals through pressure changes. I've also read about concerns of "run away" pressure increases, but those seem to mostly be from older articles, probably when APAP was not as sopisticated as it is now. However, what I focus on is that there is no real consesus on if APAP really has true benefits for the average patient. Some researchers say there are benefits, others are not convinced. For the record, no, I'm not going to spend a lot of time quoting or looking up those sources, so you'll just have to trust that I've actually done the reading Wink

Quote:Again, you're assuming that most patients aren't going to be interested in the data. But I contend that a good number of them, if they became truly educated and informed as to what their AHI and other numbers mean to their treatment, would become very interested in following the data to obtain the best possible treatment.

For folks who are ignorant when first prescribed CPAP, they might be given a non-data capable machine... and LATER, after reading more on forums like this, decide to take a more active role. They must then go out and purchase a data-capable CPAP or Auto-CPAP from their own funds. This is paying for two machines, when if the right one would have been prescribed first, the overall cost would have been greatly reduced.

Yup, agreed, "IF". Again, I say most of them will not. I know a pretty good number of people on PAP. Few of them know a darned thing about it. Few of them want to. And these are people with above average medical knowledge and above average education. The average person is just no going to do it (my opinion).

Quote:Again, when it comes to AHI and other data recorded by home CPAP machines, it is not the accuracy of that data that is most important. For instance, one machine may record an AHI during the night of 1.5, while another machine may record that very same night's AHI as 2.8. This difference in AHI calibration is not really that important when it comes to being useful to the patient. These numbers are used to show trends only. For instance, on most machines, they will accurately record overall trends (whether a particular adjustment caused the AHI to go up or down over time).

Yes, you and I have discussed this before, and we agree. Home data is good for keeping track of trends and changes in day-to-day numbers. However (and I see it all the time, even here), people make the mistake of thinking that the numbers of a home machine relate to the numbers of another machine or the numbers in the sleep lab. Heck, one of the most common quotes I see from a proud new S9 APAP owner is "my AHI dropped X points after switching from my old machine". They think it's because the S9 (or any other machine) is giving better treatment. I think the reality is that the S9 (or whatever machine they switched to ) uses a different method to calculate AHI, which is what really accounts for the difference.

Quote:Is it not also wasteful to give a patient a low-end, non-data capable, non-Auto CPAP and have them keep coming into the doctor, RT or sleep center way too often to answer questions about their treatment or make minor adjustments every time something changes in their lifestyle, overall health, etc.? That is going to cost money... this waste might have been avoided if they were given a data-capable Auto-CPAP and also informed as to make small changes themselves to improve their treatment.

Well, yes. But that is because our health care system is stupid. I think that a patient starting CPAP therapy should be provided an opportunity to try a number of different machines and modes. They should receive a good degree of accurate education and adequate followup so that the proper machine, settings, and options are achieved. Instead, our system most often forces the patient to make a half-baked guess at which machine they want (if they have a choice at all) with a DME that is more interested in profit than service. Then, we send them home, usually with no support, so that many patients just give up and put their CPAP in the closet.

Quote:Yes, but those are the extremes. Seldom does a DME give a patient a $300 CPAP, and seldom to they give out a $1200 machine. They are usually given one that is between $700-800 in cost, when the DME could have given them an Auto-CPAP that is about $90 more (the cost of an average doctor's office visit). Again, the DME is reimbursed the exact same amount by insurance/Medicare, whether or not the machine dispensed is a low-end standard CPAP or a data-capable Auto-CPAP.

Yes, the DME gets the same money from insurance or medicare. So, as a for-profit company, isn't it in their interest to sell the cheapest machine possible that meets the script? That's really the free market. There is reallt little incentive for the DME or lower their profit, even $90.

Quote:It's supposed to be a free market. We're talking about a DME making a few bucks less on the average CPAP sale. If they can't be profitable by handing out Auto-CPAPs to patients, then there is always going to be another DME down the street that will find a way to distribute Autos and still remain profitable. No one is "stealing money" from anyone here... DMEs are not being forced to distribute Auto-CPAPs anywhere that I know of. If I had insurance, and I knew that my DME would get $1500 from the insurance company no matter what CPAP they gave me... I would always insist upon a data-recording Auto-CPAP. Why? Because I am an informed customer. Likewise, I want all CPAP users to be informed customers. If my DME can't see fit to give me what I want, I will go to one who will. Free market, 'ya know

Except it's not really a free market because most patients have to use a particular DME for their insurance (so there's no shopping around) or they do not have enough knowledge to make an informed choice. Additioanlly, the is little real competition because most DMEs play exactly the same game. Finally, unlike fast food joints, usually there are not DMEs "around the next corner. I live in a pretty big town- I have 2 to choose from. Most importantly, when it comes to something as complicated as medical care, I would submit that most of the requirements for free market activity cannot be met. The average consumer cannot possibley be knowlegable in the product, there are restrictions on the consumer's choices (many imposed by insurance), and there are not many sources of competition.

Thanks for the interesting discussion! I'm not looking to change your mind. We already know that you and I come from opposite ends of the spectrum, so to speak. However, you bring up many good points to ponder and I always learn something each time we discuss :-)
02-25-2012 06:41 PM
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Post: #20
RE: AUTO or not - Is the auto-CPAP machine inherently better than a CPAP? [copied]
Ltmedic66 Wrote:
archangle,(time=1324780381) Wrote:
Ltmedic66,(time=1324689819) Wrote:it is probably a little disingenuous to expect the DME to "eat" the difference in the price difference

In most cases, the DME is being paid handsomely for a fully data capable CPAP. We know roughly what the price of a machine is. We know what the DMEs charge the insurance. The DME has been paid for a data capable CPAP. He's making unearned extra profit at the customers' expense when he gives out a cheaper machine.

It's probably a little disingenuous to pretend that it's not dishonest for the DME to take the amount of money that he charges for a top of the line APAP and dispense a model with lesser capabilities and not charge less money. :-/
Hi Arch,

I'm just wondering why ANY business would reduce their profit unless forced to do so. The incentive for any business is to sell you the product that costs them the least, and charge you the most they can get away with. That's true for cars, soup, cereal, and CPAPs. I'm not saying I like it, but that kind of is how the market works. Why would we ever expect a DME to "give away" profit?

I'm not sure I agree that a DME is being paid for an APAP. A DME is generally reimbursed a flat rate to supply a CPAP, BiPAP, or APAP, if I understand correctly for the other posts. If that is the case, and the order is for a CPAP, I really don't see why they would give you a more expensive APAP (unless it was ordered by the doc). It would be like the car salesman just giving you leather seats because they're better than cloth. Markets don't work like that. The DME is in it to make the most money in the transaction that they can. For those that want a market-based health care system, I guess that's a little taste of it.

Of course, I have not problem with a patient paying the difference to get more features, or negotiating to get more.
02-25-2012 06:43 PM
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