RE: Medical policy and standards
Thanks everyone for the thoughtful and interesting responses.
My point with the examples of other devices is that the plans don't require re-diagnosis for other conditions. I can't think of any other condition that a plan will require the member to resubmit to diagnostic tests in order to continue providing treatment that a previous plan was covering. There are a lot conditions that need monitored with ongoing tests to monitor progression of the condition, but that is a different purpose than just proving the condition exists. The plan may need to put an authorization in place for a new member to receive ongoing treatment/supplies, but, at least where I live, there are legally mandated continuity of care requirements for people who are new to a plan and are in the middle of a course of care. The treating physician may need to provide information on the diagnosis and treatment history to the plan, but I can't think of any other conditions that the plan will require the member to submit to diagnostic testing all over again to prove the condition exists. I find that a problem and unnecessary obstacle to care for people with sleep apnea.
Also, why does the diagnostic test have to be a formal sleep study, and why is a test always necessary? Kaiser uses another method. And for many conditions, there are diagnostic tests available, but a doctor doesn't need to do them to diagnose. It seems that for people who fit certain criteria and appear likely to have OSA at least, a home trial of an auto cpap could be sufficient.
Health plans are under pressure to keep costs lower and find more efficient ways to manage health of members. I think the newer technology (auto cpaps) and methods for identifying and directing treatment for sleep apnea hasn't been on plans' radars, but I suspect the plans will catch up in the upcoming years. Kaiser uses a more efficient method as an alternative to sleep studies (home oximeter followed by home trial of auto cpap), and patients get treatment faster than they do with other plans. If the plans could promote better screening in primary care (rather than cardiac wards) and diagnose some of the 90% undiagnosed people with sleep apnea before they have heart attacks or strokes, and provide treatment without the difficult and expensive hoops to jump through, the plans could better manage the health of their populations and save money in the long run. It seems this area is ripe for the plans to review and reconsider current policy. If the plans change their policies, the doctors are going to be more likely to consider options other than formal sleep studies.
Thank you Zonk for the links! I've shared the info with some plan contacts I have, and one plan has asked their medical director to review it and the plan's policy. (This wasn't my plan, however, but it is a plan that currently requires sleep study.) With the pressure on plans to retain costs and better manage health of its members, I think this is important information for plans to consider. If Kaiser can do it, the other plans should be able, too.
I haven't seen stats on % of sleep apnea patients that have OSA, central apnea, or mixed, but various info says OSA is most common. With estimated 90% undiagnosed, and with the very bad outcomes and complications that can arise from untreated sleep apnea, it seems that a system that has more efficient screening and treats quicker would be better. What would the harm be in putting people who suspect they have sleep apnea and/or are likely to have sleep apnea on a voluntary trial of auto cpap immediately, followed by formal sleep study if data and experience with auto cpap indicates something more is going on? Would we be able to treat a larger number of people sooner and more successfully and efficiently than requiring the wait for sleep study diagnosis to begin treatment? Could we reduce the need for (expensive) sleep studies in some,maybe even most, patients?
I will be doing what I can to raise awareness of the inefficiencies in healthcare for sleep apnea patients and the options that plans and doctors might consider. I'm just one voice, but I'll try to use my voice...