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Wednesday, September 15, 2010

Treatment of Sleep Apnea--the cost of a good night sleep

Obstructive sleep apnea (OSA), that is snoring with episodes of not breathing, probably affects more than 1 in 20 people.  It is most common in older men, though certainly not limited to this group. Risk factors include obesity, large neck size and limited room for air passage in the back of the throat.  When a person has OSA he or she may wake up hundreds of times a night as breathing is stopped by floppy tissue in the airway and the drive to breathe arouses them enough to take an effective breath.  This loud irregular snoring and snorting also interrupts the sleep of a partner in the same bed. People with sleep apnea have a lousy quality of sleep, rarely reaching the lower sleep levels and are less productive during the day than healthy sleepers and often fall asleep in meetings, movies and while driving. Years ago we discovered that application of a mask to the nose which applies a constant air pressure to the breathing passages can improve nighttime breathing and nighttime sleep. These are called CPAP (constant positive airway pressure) devices and are now commonly used in the treatment of OSA. People who use these devices have better oxygen levels during sleep, which benefits their hearts and brains, and usually feel more rested during the day.

This sounds really good so far. Treatment of sleep apnea is a success of modern medicine. Using CPAP is pretty easy, causes no major side effects and relieves suffering. A slam dunk. Unfortunately the process of getting tested for sleep apnea plus the CPAP machine and supplies is tremendously expensive. In order for an insurance company to cover their bit of the CPAP equipment, a sleep study must be completed and if OSA is diagnosed, another sleep study must be done to see what settings to use for optimal treatment.  This involves the patient spending the night in the hospital while hooked up to a machine that measures brain waves, limb movements and oxygen levels. At our hospital a sleep study costs over $2500, the physicians reading of the data costs nearly $600 and those costs are usually multiplied by 2.  The evaluation can be done with one night and that is a bit cheaper but still no great deal.  At our local durable medical supplier the CPAP machine and supplies cost close to $2000 and some of those supplies need to be replaced several times a year. With good evaluation and a good medical equipment supplier who follows up regularly, about half of the people who are diagnosed with sleep apnea can tolerate CPAP.

There is another option, though, that appears to work for some people.  A device that is quite a bit like a boxer's mouth guard can be made which places the lower jaw in a jutted position and improves breathing without the mask and tubes and such.  These oral appliances are carefully fitted and are amazingly expensive.  One of these things costs around $1200-$5000.  Why? All I can figure out is that the cost is competitive with CPAP and is the only viable option for people who can't stand a tight mask on their faces. Why doesn't someone make one that seriously undercuts the rest? I'm not sure. Perhaps because the market is small.  It sure seems like an insurer or an uninsured consumer could take a look at this not very complex piece of rubber and refuse to pay more than it is actually worth. Apparently that is not how things work.

It is definitely true that people feel better with better sleep. It is wonderful that the treatment of sleep apnea is such an active field, but none of this stuff needs to be this expensive.  This is yet another case of the free market system not acting to lower costs because the actual consumer rarely pays for the product. Insurers pay for most of these costs, and why they agree to do so is beyond me. A sleep study should not cost $3000. In fact, most people who have sleep apnea have really pretty classic symptoms and could get by with a test called an autotitration, in which the CPAP device is set up to adjust itself and a less expensive data set is gathered by a simple device that measures oxygen levels.  I asked the durable medical supplier how much they charge for an autotitration and they said that there is no charge.

What about the machines themselves? Many people with sleep apnea eventually quit using their CPAP machines because they are too uncomfortable or too inconvenient, or because they lose weight or die.  What happens to these expensive machines? Usually they go to a garage or basement somewhere and become a home for spiders. Because they are regulated as a medication would be, they cannot be sold without a doctor's prescription and durable medical suppliers do not refurbish them.  E-bay doesn't sell them, but there are companies that refurbish old ones and sell them online.  These machines can cost as little as $100-$200. I'm not sure how these companies get around these regulations.  Occasionally a person can pick up one of these things at a garage sale or Goodwill, but this is illegal and it is not straightforward to adjust them. Certainly a motivated medical profession could manage to make use of all of these wasted machines.

A reasonable conservative estimate of the number of treated patients with sleep apnea in the US would be about half a million, and the cost to treat per person at the very least $6000 each.  If the cost of evaluation were reduced to the cost of a heavily discounted CPAP machine which could do an autotitration for diagnosis (we will call this cost $1000 for simplicity sake) the cost savings without sacrificing quality would be over $2 billion.  

1 comment:

Anonymous said...

It's all just part of the ripoff cost of modern medicine. Obozocare explains why prices won't go down. If a company can charge the government $3000 for a machine that costs less than $50 to manufacture, and people can get the equipment "free" (because taxpayers are paying for it), why wouldn't a company charge the higher price?

CPAP masks have perhaps $3 worth of material in them and in quantity could be made for less than $5. So why are they $100? $200? Same reason.

Making the items "prescription" is just icing on the cake. It makes it harder for someone to obtain a CPAP machine except with the blessing of a doctor - which usually means insurance is involved.

But CPAP is just the tip of the iceberg. There are countless drugs that are "prescription only", which have virtually no side effects and no potential for abuse. Metformin, a drug for diabetics, is one such. Research indicates that it may have benefits far beyond its original use, and having gone beyond the patent period, it sells for as little as $3 for a month's supply. Yet one must have a prescription - so the cost explodes. Assuming a prescription is good for a year and costs $200 for the doctors visit, the cost for a 1 year supply goes from $40 to $240 just so the doctor can "bless" the use of the drug.

This is insane - and a violation of the hippocratic oath because the doctors are first doing harm to their patients by causing the cost of treatment to go up by a factor of six!