If you have not read my blogs before, I am a family physician, who retired because doctors did not diagnose my sleep apnea. Once my husband (not a doctor) figured out what was wrong with me and I found treatment that was effective for me (I was a CPAP failure), I went back to work--something that is rare in a nation where disability usually means the end of productive life. While off work, I got a Masters Public Health and did several research projects and my thesis on sleep apnea. I have written about sleep apnea. I blog about it online. It is a special interest of mine in clinical practice, though I do not run or own a sleep lab. Indeed, by some odd twist of fate, I have ended up working the last five years at a "free clinic" that does not have enough money to pay for sleep studies or CPAP which has forced me to become creative---
And therefore, I was bit alarmed when I read this piece from 2012, about how a major health insurer appeared to be taking the position that sleep apnea was being overdiagnosed and over treated---and costing the nation too much money in the process, and therefore they want to limit the diagnostic and treatment options that are available to OSA patients who have insurance.
Dr. Fred Holt, an expert on fraud and abuse and a medical director of Blue Cross Blue Shield in North Carolina, says some patients aren't having basic exams done first and are therefore being prescribed expensive tests they don't need. Not everyone who snores has a chronic disorder, he says. In other cases, Holt says, the labs prescribe CPAP machines right away without first suggesting other strategies that could reduce apnea, such as losing weight or sleeping on your side.
http://www.npr.org/...
Don't health insurers know that if they don't fix the sleep disorder now, they will be paying for the CABG and the stroke rehab a few years from now? Maybe they don't look beyond the next quarter. Maybe they need a family doctor to help them see the big picture---the big health picture and the big financial picture.
Now, I happen to agree that sleep disorders treatment needs to be taken out of the (exclusive)hands of lung specialists and ENT specialists and put into the hands of family doctors, pediatricians, internists and other primary care providers who see the patients regularly. The American Academy of Family Medicine agrees and has started a Sleep Medicine subspecialty. Family Practice doctors, who treat the whole patient, not just the throat, not just the lung, are more likely to recognize that sleep disorders are multifactorial, and that treating them requires addressing each factor. It also requires a committed doctor, one who does not get frustrated reminding the patient time after time why it is important to treat that GERD, sleep on that side, stop smoking, take that thyroid medication, get those dogs out of the bedroom, use that CPAP, avoid that beer at bedtime, follow a diet, exercise---because people who are thinking about their fibromyalgia and migraines and ED and diabetes and chest pain may forget that their sleep plays a part in all these problems.
On the other hand, a doctor or a health insurer whose answer to OSA is "lose weight" is in denial. A recent study in which subjects were offered a wide variety of foods showed that the same people, when sleep deprived, chose higher calorie, higher fat, sugary foods.
Hogencamp et al. Acute sleep deprivation increases portion size and affects food choice in young men.
Source Psychoneuroendocrinology. 38(9):1668-74, 2013 Sep
From a survival of the species point of view, sleep deprivation was probably associated with times of stress for our ancestors. If your crops failed and your tribe was on the move, your body required that you binge eat whenever food was available. Now, we can be sleep deprived and have a full refrigerator down the hall---a recipe for an endless cycle of sleep deprivation, obesity and more sleep deprivation that only ends if you put someone on a desert island without food---or help that person get a good nights sleep.
Another study showed that sleep deprivation activates a part of the brain that makes people crave food more.
Benedict et al. Acute sleep deprivation enhances the brain's response to hedonic food stimuli: an fMRI study.
Source Journal of Clinical Endocrinology & Metabolism. 97(3):E443-7, 2012 Mar.
Sleep apnea is not caused by obesity. I have plenty of overweight patients who do not have sleep disorders. I have patients who are normal or underweight who have osa. I was underweight when I had OSA. OSA is caused by an inherited inability to keep the airway open in the deeper stages of sleep. Anything that makes the airway more narrow or increases the work of breathing or decreases the strength of the muscles of breathing will make OSA worse. You treat it by unraveling the various strands that contribute to each individual patient's sleep disorder. If you try a one size fits all approach--"Sleep study, CPAP, next"---you will fail to treat the patient and you will drive up medical costs and you will not prevent any disease. But that is the fault of the half assed approached to sleep disorders treatment that some people adopt. It is not a reason not to treat sleep disorders.
Health insurers, if you are out there somewhere, your goal and my goal as a family physician with a Masters Public Health in the area of Community Health are exactly the same. We both want to cut down on wasteful spending and prevent chronic diseases that take workers out of the labor force when they are most productive--after the age of 40. The way to do that is to develop better strategies for detecting the 8 out of 10 people with OSA---the ones who have not gotten so critical yet that anyone can see their sleep disorder from a mile away. Those are the ones that can be helped with a weight loss diet, sleep hygiene and smoking cessation. For the ones who are having hypoxic spells 50, 60, 70, 100 times an hour--yes, I know that last one sounds impossible, but I had one sleep study on one patient come back with that number---a sleep study and then CPAP/BIPAP is the only sensible treatment. Some of these people will be so badly affected already by their sleep disorder that they will die anyway from their heart problems. But others will pull back from the brink. I have seen it happen.
Please, whatever you do, health insurers of the nation, do not take a page out of the XYZ playbook---see Life Without CPAP, free at Amazon for two more days or send me a message and I will send you a free Word document---the story of a free clinic that could not afford to do sleep studies or CPAP) and try to throw up obstacles. Because if you do, your primary care doctors will become even worse than they already are at diagnosing sleep apnea (and they already miss 8 out of 10 cases) and you will find yourself treating more people for heart failure, renal failure, suicide attempts, stroke, car wrecks and all the other preventable, expensive problems that come from burying your head in the sand.
There is an epidemic of undiagnosed and untreated sleep apnea out there. Yes, the medical community as a whole is doing a piss poor job of taking care of it. Health insurance companies have a chance to make a meaningful intervention. If that intervention is to say "No" to sleep disorders diagnosis and treatment, the problem will just get worse--and you will hemorrhage money, since you will no longer be able to exclude those with medical conditions caused by failure to diagnose and treat a sleep disorder.
For those who like horror stories, here is some scary public health reading.
http://www.ncbi.nlm.nih.gov/...
Although the data are limited, the effect of sleep disorders, chronic sleep loss, and sleepiness on accident rates, performance deficits, and health care utilization on the American economy is significant. The high estimated costs to society of leaving the most prevalent sleep disorders untreated are far more than the costs that would be incurred by delivering adequate treatment. Hundreds of billions of dollars are spent and/or lost annually as a result of poor or limited sleep.
P.S. I mean what I wrote about sending free word documents to anyone who wants to learn more about OSA. Drop me an email at McCamyTaylor@earthlink.net and I will send you Life After CPAP---my story, designed to help people understand what failure to dx and treat OSA can do to the individual---and Life Without CPAP---my story, designed to help people understand what failure to dx and treat OSA can do to the community. Oh, and btw, an undiagnosed sleep disorder crippled my grandmother, the breadwinner of her family. She snored. She stopped breathing. She got up every night to use the bathroom---one of the most common symptoms of untreated osa. One night she fell head first down the stairs---dizzy, no doubt from that untreated sleep disorder, since this was before OSA was being diagnosed and treated. She bled into the part of her brain that controls vision. She spent the last decade of her life blind. Half her kids have OSA. A bunch of her grandkids have OSA. It is genetic. I still don't know why nature invented something like this. But I know that I don't want anyone else to end up like my dear, sweet grandmother. And anyone who demands a link or who says that she never existed is a very callous person---but that's ok. She was a good Catholic and she forgives you.