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The CPAP world is a microcosm of what's wrong in the medical world, i.e. why things cost so much. A CPAP machines costs about 10x as much as it should, and a p

by ars 7y ago

The CPAP world is a microcosm of what's wrong in the medical world, i.e. why things cost so much. A CPAP machines costs about 10x as much as it should, and a part of that is insurance companies wanting to make sure they are not paying for a device you are not using. Which then increases the price, which makes insurance companies even more worried about them. Then you are paternalism where only a Dr. is allowed to change the settings on the machine. So they lock them down, which adds even more to the cost. And then they are prescription only, so they have to go through specialized distributors because heaven forbid someone actually buy one without a Dr. letting them. The end result of all this is lots of people making money, and higher costs for the patient in the form of higher insurance premiums.

BurningFrog 7y ago
Maybe it's my bias, but I assume most of that 10x comes from the overly strict medical device regulations from the FDA.
- nx2059 7y ago
  Why was this downvoted? Do people here seriously believe that the US doesn't have a system of crony capitalism? Is it so implausible to believe that regulations, while created with the best intent, are not susceptible to corruption via lobbying by powerful corporations to keep competitors out of the market?
- xnyan 7y ago
  >overly strict Disclaimer: my opinions, not my company. I worked as a project engineer for a major testing company (underwriters laboratories). This is a vast simplification, but in essence the difference between medical device testing verses say, household electronics, is that in practice household electronics get evaluated with a "safety checklist" of all the serious and common problems to that kind of device (plus additional testing if deemed necessary which is not common) that UL and industry have seen over the years. In contrast, each and every kind medical device is torn apart and subject to a clean evaluation. There are still checklists and common issues they look out for of course, but in practice each device is considered novel while the same is not really true for more common devices. I think the latter type of testing is fundamentally more expensive, that said I think there are tons of regulatory issues that add to cost - I just want to argue that medical device testing will probably never be cheap.
  - BurningFrog 7y ago
    I don't disagree. Testing should be as strict as is needed. I'm arguing/assuming that US testing standards for medical devices is overly strict. I think* there is the same "maximum" standard for all medical devices. But what's appropriate for a pacemaker is overkill for a CPAP machine. * but am happy to be corrected (Cunningham's Law)
    - simplecto 7y ago
      Your are partly correct. There are multiple classifications for medical devices. CPAPs are class 2 devices whereas a pacemaker is class 3. I don’t want to over simplify, so I will link you to the FDAs entry point into the Byzantine maze of classifications. https://www.fda.gov/medical-devices/overview-device-regulation/classify-your-medical-device https://www.fda.gov/medical-devices/overview-device-regulati...
- ars 7y ago
  It doesn't. You can buy CPAP machines from manufacturers that don't work with insurance companies for far less (around 1/4 of the price). The machines are also not locked down, however they do still require a prescription so that part of the cost still exists.
  - favorited 7y ago
    You can also buy them used, which is perfectly legal. Insurance is nice because they pay for the supplies (some of which are supposed to be replaced pretty frequently). However, I've found that it's pretty easy to stretch the life of any component, as long as you clean it thoroughly each day.
SubiculumCode 7y ago
Its worse than that. Before receiving a CPAP machine ~$1,000, most doctor's require a sleep study, which costs many thousands of dollars, and many times wait months to get the appointment. CPAP machines are usually the ultimate solution to reported sleep problems involving repeatedly waking up, and I don't see why they can't be prescribed immediately to see if they solve the problem.
- favorited 7y ago
  My insurance wouldn't even pay for a monitored sleep study before I did an at-home study. Luckily, the at-home device showed moderate apnea, so I didn't have to do the lab study.
  - SubiculumCode 7y ago
    That's what they did for me as well, but not for other people I know living in a less affluent area of California. The take-home solution is much more cost-effective, it is a wonder that it hasn't been adopted universally. Also, I LOVE my CPAP.
    - favorited 7y ago
      That's fair, I only know what happened at Stanford. Side note to anyone reading this: don't go to the sleep clinic at Stanford. If your doctor refers to there, ask for another referral. There's a reason they have 1.5 stars on Yelp... And I totally agree about the CPAP – any morning after I accidentally take it off in my sleep (pretty rare, but happens especially as the seasons change), I feel like absolute garbage. It's amazing what actually breathing through the night can do for you.
- ars 7y ago
  Completely agree. And the worst part is sleep studies are medically unnecessary - an APAP machine (automatic machine) can auto-set the necessary pressure, and no sleep study is needed. Simply sleep with an APAP for a week, review the pressure graph and draw a line at the bottom of the values. Then set the minimum pressure to that number, or slightly less and done. Review every few months. If you ask a Dr. about this they'll talk about the 1% of less cases that will not be correctly adjusted by such a machine. But all you need to do is ask the patient after a week "do you feel better?". If they say no you can go for the more complicated options.
cpwright 7y ago
"A CPAP machines costs about 10x as much as it should, and a part of that is insurance companies wanting to make sure they are not paying for a device you are not using." If you look just at BOM, I am sure my insulin pump must seem the same way (about $3500); but the technical support from Medtronic is top notch and the devices are not mass market; probably only about 100,000 of them each year (just based on a 4 year warranty period, which is when your insurance covers them, and a quick google showing about 350,000 on them). I do think there is a bit of a razor blade model here though, given that the consumables will cost nearly as much as the pump over the course of a year.
hindsightbias 7y ago
One thing about Kaiser CA, they’re very proactive about OSA. Free take home test rig (must be back by 9am), and the sleep specialist pushed a higher end CPAP, 3 masks, 3 pillow types into my hands and said I’d get a 10% copay call. Followup on choosing right mask/pillow, and when my machine starting whistling after 4 years, doc emailed the sleep specialist and they gave me a new machine with no copay. No telemetry. Think I’ve spent $120 for the machines, the headgear costs (supplier) are overpriced. But you can look for one of those online shops and wait for 4-pack specials, got 16 pillows for $150. Not an expense I can complain about.

by ars 7y ago

BurningFrog 7y ago

Maybe it's my bias, but I assume most of that 10x comes from the overly strict medical device regulations from the FDA.

nx2059 7y ago
Why was this downvoted? Do people here seriously believe that the US doesn't have a system of crony capitalism? Is it so implausible to believe that regulations, while created with the best intent, are not susceptible to corruption via lobbying by powerful corporations to keep competitors out of the market?
xnyan 7y ago
>overly strict Disclaimer: my opinions, not my company. I worked as a project engineer for a major testing company (underwriters laboratories). This is a vast simplification, but in essence the difference between medical device testing verses say, household electronics, is that in practice household electronics get evaluated with a "safety checklist" of all the serious and common problems to that kind of device (plus additional testing if deemed necessary which is not common) that UL and industry have seen over the years. In contrast, each and every kind medical device is torn apart and subject to a clean evaluation. There are still checklists and common issues they look out for of course, but in practice each device is considered novel while the same is not really true for more common devices. I think the latter type of testing is fundamentally more expensive, that said I think there are tons of regulatory issues that add to cost - I just want to argue that medical device testing will probably never be cheap.
- BurningFrog 7y ago
  I don't disagree. Testing should be as strict as is needed. I'm arguing/assuming that US testing standards for medical devices is overly strict. I think* there is the same "maximum" standard for all medical devices. But what's appropriate for a pacemaker is overkill for a CPAP machine. * but am happy to be corrected (Cunningham's Law)
  - simplecto 7y ago
    Your are partly correct. There are multiple classifications for medical devices. CPAPs are class 2 devices whereas a pacemaker is class 3. I don’t want to over simplify, so I will link you to the FDAs entry point into the Byzantine maze of classifications. https://www.fda.gov/medical-devices/overview-device-regulation/classify-your-medical-device https://www.fda.gov/medical-devices/overview-device-regulati...
ars 7y ago
It doesn't. You can buy CPAP machines from manufacturers that don't work with insurance companies for far less (around 1/4 of the price). The machines are also not locked down, however they do still require a prescription so that part of the cost still exists.
- favorited 7y ago
  You can also buy them used, which is perfectly legal. Insurance is nice because they pay for the supplies (some of which are supposed to be replaced pretty frequently). However, I've found that it's pretty easy to stretch the life of any component, as long as you clean it thoroughly each day.

SubiculumCode 7y ago

Its worse than that. Before receiving a CPAP machine ~$1,000, most doctor's require a sleep study, which costs many thousands of dollars, and many times wait months to get the appointment. CPAP machines are usually the ultimate solution to reported sleep problems involving repeatedly waking up, and I don't see why they can't be prescribed immediately to see if they solve the problem.

favorited 7y ago
My insurance wouldn't even pay for a monitored sleep study before I did an at-home study. Luckily, the at-home device showed moderate apnea, so I didn't have to do the lab study.
- SubiculumCode 7y ago
  That's what they did for me as well, but not for other people I know living in a less affluent area of California. The take-home solution is much more cost-effective, it is a wonder that it hasn't been adopted universally. Also, I LOVE my CPAP.
  - favorited 7y ago
    That's fair, I only know what happened at Stanford. Side note to anyone reading this: don't go to the sleep clinic at Stanford. If your doctor refers to there, ask for another referral. There's a reason they have 1.5 stars on Yelp... And I totally agree about the CPAP – any morning after I accidentally take it off in my sleep (pretty rare, but happens especially as the seasons change), I feel like absolute garbage. It's amazing what actually breathing through the night can do for you.
ars 7y ago
Completely agree. And the worst part is sleep studies are medically unnecessary - an APAP machine (automatic machine) can auto-set the necessary pressure, and no sleep study is needed. Simply sleep with an APAP for a week, review the pressure graph and draw a line at the bottom of the values. Then set the minimum pressure to that number, or slightly less and done. Review every few months. If you ask a Dr. about this they'll talk about the 1% of less cases that will not be correctly adjusted by such a machine. But all you need to do is ask the patient after a week "do you feel better?". If they say no you can go for the more complicated options.

cpwright 7y ago

"A CPAP machines costs about 10x as much as it should, and a part of that is insurance companies wanting to make sure they are not paying for a device you are not using." If you look just at BOM, I am sure my insulin pump must seem the same way (about $3500); but the technical support from Medtronic is top notch and the devices are not mass market; probably only about 100,000 of them each year (just based on a 4 year warranty period, which is when your insurance covers them, and a quick google showing about 350,000 on them). I do think there is a bit of a razor blade model here though, given that the consumables will cost nearly as much as the pump over the course of a year.

hindsightbias 7y ago

One thing about Kaiser CA, they’re very proactive about OSA. Free take home test rig (must be back by 9am), and the sleep specialist pushed a higher end CPAP, 3 masks, 3 pillow types into my hands and said I’d get a 10% copay call. Followup on choosing right mask/pillow, and when my machine starting whistling after 4 years, doc emailed the sleep specialist and they gave me a new machine with no copay. No telemetry. Think I’ve spent $120 for the machines, the headgear costs (supplier) are overpriced. But you can look for one of those online shops and wait for 4-pack specials, got 16 pillows for $150. Not an expense I can complain about.