November 10, 2013

Why sometimes I feel like Jimmy Stewart....

A couple years back I had the good fortune to attend and present at the annual meeting of one of our sister organizations - the Sleep Apnoea Trust. My talk was on OSA in the USA - clever title, I thought anyway. One of the images I used was of Jimmy Stewart from the Hitchcock film Rear Window.
The point I made in the presentation was that I am an observer of the practice of sleep medicine as respects the diagnosis and treatment of sleep apnea.

Lately, I am reminded of the Jimmy Stewart and the film for another more disturbing reason. I feel like Jimmy as I watch powerlessly through the rear window as a crime is being committed against an innocent and unsuspecting victim.

The crime - diagnostic and treatment for sleep apnea is not being provided based on a care management model as opposed to episodes of care. The sleep apnea patient is now even more on their own than they were earlier. While home sleep testing is more efficient and will get many more people into the treatment pipeline - without the intervention of a qualified sleep medicine physician to provide guidance or at a minimum, consult on the appropriate treatment pathway - the patient is more likely to get lost - go without effective treatment.

Who is the Raymond Burr character, the villain, in this thriller? You could say the healthcare system is to blame - with its focus on sick care and payment for procedure versus payment for improved outcomes. But the payors starting with Medicare can also be faulted for not fully understanding the condition they are trying to address with their reimbursement model.

The use of Positive Airway Pressure as a non-surgical intervention for the treatment of obstructive sleep apnea is still relatively new. Dr. Colin E. Sullivan published his landmark paper in the journal The Lancet on April 18, 1981, barely a generation ago. 

At the time, it was not clearly understood what the prevalence of the disease was, nor was there a conscious effort made to understand the best way to dispense the therapy. The default was to use the channel used to dispense the therapy used for other pulmonary disorders - durable medical equipment companies that dispense oxygen therapy. 

Positive Airway Pressure therapy has evolved rapidly in the past 30 years. Evolved beyond the basic understanding of many of the people who prescribe it and many of those who dispense it. It fact, I heard a lecturer say that the technology is outpacing the science when it comes to treatment - scary thought. 

As things stand now, especially with how insurers are viewing diagnosis and treatment - everyone involved in this condition - clinicians, suppliers and patients are suffering. 

Calling for a "do-over" is not possible - but asking for a thoughtful examination of how this disease is diagnosed, treated and managed is - particularly as we here in the United States transition to a more patient-centered (read patient-financed) system of health care delivery. 

It is time for those patients, who have "come out on the other side", to help those who are struggling to examine current practices and the basis of that assessment recommend a care model that is efficient, cost-effective and sustainable going forward.

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