• Why does it take so long?

    Over the weekend, when I messaged Aaron about my obstructive sleep apnea (OSA) situation, his reply was, basically, “Why can’t they get you a CPAP machine right away?”

    Welcome to the U.S. health system. Here are the sources of delay, with time=0 the moment the doctor had a diagnosis and called me.

    • I was not available when the doctor called, though I would have picked up if the caller ID had indicated it was him. I called back within a day and got voice mail. I left a message. I never got a call back. (USA! USA! USA!) Meanwhile, I suspected I did not have OSA because (a) during my sleep study, nobody came in to fit me with a CPAP machine, as I was told would happen if they saw apnea events; (b) I assumed the doctor would express more urgency if I had that diagnosis. So, score this as a communication failure for which I am only partly responsible.
    • ~1 week later I remembered I hadn’t connected with the doctor and called back. This time I got him and my diagnosis. I can take some blame for this delay, but it was not without some justification (see above).
    • Knowing little more than what I could recall from the ICER report I was involved in, I told the doctor I was interested in an oral appliance. Once those words came out of my mouth, he decided not to put in a request for a CPAP machine. That made sense to me at the time, but now I think that was bad care. He trusted the patient too much. I’ve never had this diagnosis before! However, I also take some blame for my ignorance about CPAP and bias against it. A far better process would be an informed, shared decision-making one, perhaps starting with a referral to some instructional videos. I did all this work on my own this past weekend (as I’ve documented in prior “sleep apnea” posts), which reduced my fear of CPAP tremendously. Now I’m all for it.
    • This false assurance followed by self-education process cost me another week or so. But, the prescription for a CPAP is now in! I also have a dental appointment for an oral appliance (intake, not to actually make the thing). I can do both, at this stage, but will probably go with CPAP as my first treatment. If that fails me for some reason, I am that much further along in the oral appliance branch.
    • However, both branches (CPAP and getting the intake dental appointment) take about 4 weeks. The former is because of insurance delays. The latter because the dentist I want to see is busy. I’m sure I could find another dentist, but I don’t know how to judge them. Anyway, it doesn’t matter because I want to do CPAP first.
    • So, what is the insurance company doing for 4 weeks? Utilization management. It wants to make sure I have all the documentation to justify CPAP. This is somewhat reasonable. On one hand, nobody would get CPAP if they didn’t have some sleep problem, so wasteful utilization is somewhat bounded. On the other hand, we would not want docs just giving out prescriptions for the thing without being sure it was warranted, and the sleep problem wasn’t actually something else (like insomnia that can be cured very cheaply with CBT). CPAPs are not cheap!
    • Should this take 4 weeks? That’s a cost-benefit or marketing question. My insurer could certainly hire more claims processors. That’d boost admin costs, showing up in higher premiums. By the way, I’m being generous here, I was really told it could take 4-6 weeks, but could be faster. So, I figure 4 is about the average.

    So, there you have it. After an insurance-created, multi-month delay in getting my diagnosis, there’s about another ~1.5 months to treatment. And that’s just to start treatment. I expect an adjustment period. It won’t actually be working for me for several weeks after I start. So, let’s call it 2 months to treatment from diagnosis. I guess it could be worse. It sure as hell could be better, but that might cost us even more than we already pay.

    That’s a long time to have crappy sleep! Now you see why I’m working so hard at interim solutions. BITWMA!


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