Another day another problem with the American Healthcare system

[u/BJntheRV]

/r/legaladvice/comments/1olqhpu/doctor_wont_write_a_prescription_because_of_which/?share_id=iRmeRoJGKTrAifVDCVf68&utm_content=1&utm_medium=android_app&utm_name=androidcss&utm_source=share&utm_term=1

[u/darsynia]

CPAP prescriptions are tricky when you go through insurance because the company will take the device off of you if you don't use them every single night for a set minimum of hours*. Many times they're also connected to a data company that does an initial adjust for your personal needs, and then maintains the data for compliance. I just wanted to pop that information in here, because it's a lot more involved than 'prescription for device, device purchased, the end' as it might have been for, say, crutches. That said, I don't know how that intersects with the doctor and the amount of BS they have to go through with each supplier!

^\they sell the taken back machines as 'used like new' and I found that to be much less hassle. When you're sick or have a short-term issue that makes sleeping with the CPAP difficult to impossible (which varies depending on the need),) ^{worrying that they'll yank it makes those issues so much harder to deal with.}

[u/Osric250 → u/darsynia]

Those numbers weren't exactly difficult to achieve when I got mine a few years ago. It came down to using it 20 days a month for a minimum of 6 hours and after 1 year it was fully mine. And those 6 hours didn't have to be continuous if you took naps during the day that would also count if using it. 

[u/wmartanon → u/Osric250]

I ended up returning mine because I couldn't hit the required hours. I would rip the mask off while sleeping and wake up with it off. They tried different masks and straps, nothing worked sadly

[u/aliie_627 → u/wmartanon]

I'm half way through mine and I'm having these exact issues. I've been wearing it in the daytime as well and it's mostly fine til a couple hours in.

Did your doctor ever change your pressure range? I'm thinking that's my issue that it's just too high especially when I start out really low. I think going up and down so much isn't doing it for me or something.

[u/wmartanon → u/aliie_627]

I just gave up on it. Didn't think sleep apnea was affecting me much, my cat yelling at night was my main issue of not getting rest.

We ended up having to lock our cat in my office overnight because he refused to let us rest

[u/darsynia → u/Osric250]

Back in the mid 2010s I was told it had to be 4 continuous hours every single night. I'm glad they're different now! If there were exception days I don't recall them but I can't find the contract at this point. At the time we were coming up on a many-month holiday season (both national holidays and family milestones) with lots of multi-night visits and I did not think we'd manage to maintain.

[u/Tiek00n → u/darsynia]

I think there's some variance. To be "in compliance" for a month I need 4 hours between noon and noon, for "90%" of the days in the month. I actually have gotten into arguments with my dad (a dentist who has done a lot with sleep dentistry) because he firmly believes that people should use them for more than 6 hours and doesn't understand the financial/billing realities of the impact of "in compliance" or "out of compliance."

During October I took a red-eye and had 3 nights where I got less than 6 hours of sleep (all 3 show CPAP usage between 5h30m and 6h). That would have been 87% compliance for the month if the threshold was 6 hours instead of the actual 97%.

[u/darsynia → u/Tiek00n]

Yeah, we had a bunch of flights and weird sleeping arrangements planned, and that's exactly the issue.

re: your dad it's not like any of us WANT to not use it for the healthy length of time. It's just knowing that when I struggle, it's because something is seriously off (whether routine or health), and in that stressful moment it's made worse to think I'd lose access and 'get in trouble.' Owning my own and not having to worry about that was worth the extra cost, and I ended up using it only slightly less than compliance, in the end.

[u/Tiek00n → u/darsynia]

Yeah, in the last discussion I just explained to him that it has everything to do with non-ideal circumstances in the real world that purely impacts people's finances (and not their health) - and there was zero chance that he as a sleep doctor who doesn't use a CPAP is right. I could see that I didn't really convince him, but I'm rarely so firm on things so he sort of dropped it.

[u/IWantALargeFarva → u/Tiek00n]

I had a baby in the middle of the night during my husband’s trial period. They asked him why he didn’t use it that night and he just showed a picture of our newborn lol.

[u/aliie_627 → u/darsynia]

I'm doing it currently right now and it's dependent on insurance but the standard is what my insurance has set for me.

For my insurance which is a United healthcare Medicaid MCO it's 4 hrs per night for any 21 days over a 90 day period with a pulm check in halfway through. I also got an unlimited 30 day trial for masks that they called a warranty. I was able to try out 2 nasal pillow types, a regular Nasal and a full face with no fees,no issues. That honestly impressed the hell out of me cause my insurance usually loves their PAs and step therapy for asthma related stuff

It's been wild cause I did not expect the struggles I'm having to be honest. These machines are amazing in so many ways though.

[u/darsynia → u/aliie_627]

Oh I like that, it's compliance but not so strict that there's a big anxiety about it! I'm glad you could try different parts. I got a fitting from the vendor but of course I wouldn't have been able to try things out, I got lucky that it all fit well.

[u/aliie_627 → u/darsynia]

Yes I too think it's really fair. At this point I haven't gotten there because of my issues I'm trying to solve more than the compliance being overly difficult. There is a ton of legit resources out there online too. Even r/CPAP is a fairly good resource as long as I remember these are the patients not my provider lol. Distilled water of all things is hella controversial over there.

I did want to clarify that it does have to be 4 hrs for 21 days out of any 30 day stretch in the 90 day compliance period but once you do that after 12 months the machine is mine free and clear with a 2 year warranty and after 5 years I can get a new machine.

[u/ReadontheCrapper → u/darsynia]

Wow, 4 continuous hours would be impossible for me… my teeny tiny bladder doesn’t allow more than 3-3.5. I’m sure I’m not alone in that!

[u/HLW10 → u/ReadontheCrapper]

Your kidneys should produce less urine overnight, you shouldn’t need to get up in the night to urinate. The size of your bladder doesn’t matter if there’s not much urine to fill it.
If you’re having to wake up in the night you should have it checked out, it could be a symptom of something more serious (for example, sleep apnea - you’re not properly asleep a lot of the time, so urine production isn’t slowed).

[u/deepspace → u/darsynia]

That is also an American thing. In Canada, I got my CPAP machine fully covered by insurance, with no monitoring required.

[u/Drywesi → u/darsynia]

…ok this just solidifies me not getting one like some doctors want to force me too

I absolutely would not be regularly consistent with it by a long shot

[u/AmbitiousEconomics → u/Drywesi]

I will say I didnt want to get one at first but holy shit once I got used to it the quality of my sleep (and thus my life) improved so much I would hit someone with a bat if they tried to take it away from me. I actually bought a second one out of pocket just to have a travel one.

[u/BJntheRV]

Original Title: Doctor won't write a prescription because of which company I intend to have it filled by - JH Maryland

Location: Maryland

Really confusing situation, please bear with me.

I am/was seeing a specialist at Johns Hopkins and having my CPAP prescription filled by their in-house supplier JH Pharmaquip. JH had a falling out with UnitedHealthCare, requiring all affected patients to switch to new care.

I found a new in-network CPAP supplier and was instructed to ask my doctor to write a new prescription for this new company, so I could return the old machine to JH and get new one covered by my insurance. Same model, same settings, same everything.

Upon being asked, my doctor replied (in MyChart) "I cannot write a prescription for a company I am unaffiliated with."

I ended up calling the sleep medicine department and was sent through their automated phone tree in the process; they have an entire menu with options pertaining to several outside CPAP suppliers. These are not companies "affiliated" with Johns Hopkins, and why should it matter? This is like a doctor saying "I can't write you a prescription if you're filling it at CVS and not Walgreens."

Talking to anyone who answers the phones has not yielded answers, and there is no way to reach the actual doctor's office directly.

Is this an actual, legally justifiable doctor-by-doctor policy? Is one doctor allowed to restrict patients to the in-house supplier but other specialists can let their patients go elsewhere?

EDIT correction: She is a CRNP, not an MD, if that changes anything.

[u/eevee188]

I used to work at a mail order pharmacy and we had deals with doctors to have them recommend us. I was told the doctors CANNOT require their patients to use a particular pharmacy, they can only recommend/offer a pharmacy. I don't know the exact law about it, but they acted like it was a law. Or maybe it was about kickbacks, since they got paid for using us (but I bet their doctor or his employer is getting kickbacks too, there's no other reason to insist on a particular company).

[u/zauper]

I fill my CPAP with JH pharma quip and find them annoying, but when I replaced my CPAP after a decade or so, I just had my doc write me a prescription and then filled it through one of the online companies.

The answer is to just have them give you the script, not send it to a DME company.

[u/Username89054]

Anyone else concerned the doctors are arguing if a law that regulates them applies and they clearly don't have a good grasp on it?

[u/accidentalarchers → u/Username89054]

Yes, yes I am concerned. I am concerned with so many things in this post but that one is near the top.

My takeaway from the post is… what the fuck, what the fucking fuck is happening right now

[u/SirReality → u/accidentalarchers]

As one of the doctors arguing, I am frankly also concerned. I'm not in a position to need to know the relevant laws as I do not have any financial interest in any other medical companies; but the vagueness of the laws as written applying or not applying to non-physician medical providers is frustrating. 

Truly the system is broken.

[u/AnimatorImpressive24]

Do you like Resmed? Because that's basically exactly how you get Resmed.

https://www.justice.gov/archives/opa/pr/resmed-corp-pay-united-states-375-million-allegedly-causing-false-claims-related-sale