Yesterday I had an angry patient arrive in the office who blamed the President for her troubles. The patient has a commercial driver's license and is required by the Department of Transportation here in New Hampshire to undergo a physical examination, which in her case led to concern, and later diagnosis of obstructive sleep apnea based on her neck size and a report of snoring. That sounds a bit arbitrary to me but the severe sleep apnea which was discovered would lead to health problems later in life if not close calls her accidents in the near future. Tfter the patient underwent a sleep study to diagnose the illness, she was set up on the therapy for sleep apnea. This therapy is called continuous positive airway pressure or CPAP.
The patient related to me the fact that the insurance paid for very little of this investigation and treatment and led to bills reaching into the thousands of dollars. I feel how railroaded she feels and, intruded upon. Her employer is now seeking reports of compliance to CPAP in return for allowing the patient to drive a large vehicle.
Since the regulation was implemented months ago, I have been faced with a half dozen patients with commercial driver's license who are livid about the reporting and the mounting bills associated with this diagnosis. Although her frustration is my frustration, the greater good is served by not allowing sleepy drivers behind the wheel of dump trucks, snowplows, or 18 wheel trucks.
The further misfortune that the patient faces is that the CPAP device is uncomfortable for her to the point of being intolerable. The device is intruding on sleep at home, she feels claustrophobic in he mask. And, each and every night the patient removes the device and disgust after four hours of use. The duration of four hours is not a coincidence because patients with sleep apnea are required by their insurance provider and the Department of Transportation to demonstrate sufficient use-- at least four hours each night for 70% of the nights in a 30-day period. This translates to 21 consecutive days. The machines are sophisticated enough to record the amount of use and know it is appropriate use.
She also has a $40 co-pay with each visit to me or any other specialist. The CPAP machine is being rented; therefore, the patient has little choice about finding cheaper alternatives. I have no wish to have any patient burdened by a large bill and an illness. By the way, CPAP.com is a potential supplier who has CPAP machines –bare-bones devices --for about $500. But the disadvantage of finding a machine on line is that the service his left up to the patient. Getting the right fit for a patient's CPAP therapy needs persistence and vigilance which only person to person service can provide. So the vast majority of patients with obstructive sleep apnea take advantage of commercial suppliers like Lincare, Apria, and Home Care Services.
I mentioned all this detail because the quagmire I just described is to me more a market phenomenon than a nuisance government regulation. Drowsy drivers have spectacular and deadly accidents. So when this angry patient and other angry patients seek to blame Obamacare for any failing to the system, I have limited patience. I have several patients with his level of anger in this exact same situation. The regulation is new and has been stringent. However, insurance was not facile or sufficient. everyone needs to know it is unusual for any insurance to cover any piece of medical equipment. Crutches, for instance, are often not covered under health insurance policies.
She went on to single out Obamacare as the future cause for these things to become more expensive and was convinced that her employer would rescind any health care benefits as a result of the health care reform act. I doubt that is true; her insurance was unusual for the cost of co-pays and how little they reimbursed. In fact, she also has bills for a recent mammography that were inordinate. We call it ‘bad insurance’. The patient made the unfortunate pledge never to have another mammography. I didn't know how to politely say—in an unpolitical way-- that I doubt anyone in America thinks that's fair. And I missed the moment to say in this new era mammographies would be performed at no extra cost.
I should mention at this point that the patient is working out a payment scheme for the bill with the insurance company and the hospital. I made a joke that fell flat was that this is New Hampshire not Philadelphia and we would not be sending a collection agency after her. . (That happened to me when I was in medical school: I was seen in the emergency room after hours for a needle stick exposure. Months later, I had a collection agency arrive at my door with a demand for $100s for a 20 minute ER visit.)
In previous diaries I have mentioned patients with similar animosity to obamacare, but after Tuesday night these complaints seem less threatening, quaint even, The health reform act is here to stay.
This got longer than I expected: in the next diary I will describe the efforts here in New Hampshire to establish a new medical system called an accountable care organization.