Although both insurance companies and government regulators would appear the unlikeliest of sources to promote further awareness and acceptance of RERAs and UARS, they may end up serving that purpose for paradoxical reasons. Right now and for a long time, both institutions have shown resistance and created barriers to the use of evidence-based data regarding RERAs and UARS. However, among private insurance carriers, several major ones such as United and Blue Cross have covered patients diagnosed with UARS, although the frequency of coverage probably varies according to regional or state policies. Strangely, many physicians in sleep medicine do not know or appreciate that UARS coverage has been documented, and many insurance carriers even list the concept of UARS in their policies and procedures. Sadly, many sleep medicine specialists seem to be under the impression that all insurance carriers strictly follow Medicare rules. As Medicare has demonstrated the most intransigence on the subject of UARS, and as medical professionals fear Medicare for its penchant for audits, it is no surprise many sleep physicians would choose an easy path away from recognition of UARS and RERAs. The “why bother” approach is not uncommon in all fields of medicine when butting heads with Medicare.
In the long-run, it’s possible Medicare would never elect to cover a UARS diagnosis. Yet, this scenario may herald a confluence of forces leading to the preference cascade. Think back to our original example. People fear something because of an authoritative power structure (sure, Joseph Stalin’s a lot more menacing than Medicare, but you get the point!); then, because these people (sleep doctors) are not communicating at a high frequency with each other on the value of UARS, there is no push back against Medicare to gain coverage for UARS. Clinically, however, as more information surfaces on the importance of RERAs and UARS, primarily by epidemiological research that links this variant of sleep apnea with all sorts of co-morbidities as well as treatment research demonstrating outcomes such as fewer traffic accidents, lower blood pressure and reduced insomnia severity, at that point, more sleep professionals become aware of the clinical relevance of RERAs/UARS, and they begin pushing back against insurers, including Medicare. Eventually, as more sleep doctors become aware and gain practical experience dealing with UARS, the sleep medicine community revises its own conventional wisdom that would then be in direct conflict with any remaining insurance carrier who resisted identifying and treating RERAs/UARS. When this confluence of forces builds, patients will also be getting involved in the effort as well. Reaching critical mass, so to speak, the cascade preference will unleash itself, and the insurance carriers will fold, as they finally recognize their previous policies were flawed or outdated.
Right now, despite the anecdotal evidence of numerous insurance carriers and their medical directors approving coverage for UARS, we do not know if these outcomes reflect the opening that will eventually lead to the preference cascade or whether it is just a fleeting window of opportunity, soon to be a fading ray of light.
With all of the above in mind, I want to finish the post by focusing on the two more institutions in this mix of medical professional resources. We’ll continue with the insurance carriers to try to see into their workings on such processes. And, then we’ll close with the low man on the totem pole, durable medical equipment companies (or DMEs or HMEs).
What happens in insurance carrier policy-making is clearly a mystery to most people, but one thing is clear: the insurer’s business model must promote coverage criteria to provide for high quality care while at the same time serving the bottom line as efficiently as possible. While treating UARS is certainly likely to save money for an insurance carrier by decreasing symptoms related to insomnia, hypertension and depression, it is not clear how much of this information is known by the insurer’s decision-makers. Arguably, it is more likely that some insurance medical directors, being MDs, are increasingly exposed to newer or more evolving ideas in various fields of sleep medicine. On this point, I can categorically state that in my conversations with medical directors, for example, at United Health Care, it is rare that the physician on the other end of the line would not know about UARS. Yet, 10 years ago awareness of UAR would not have been the norm. In fact, 10 years ago, in dealing with our UHC medical directors who were located in Colorado, I was fortunate to engage with two physicians who were very receptive to discussing the concepts of UARS, and they were willing to receive peer-reviewed articles on UARS. Shortly thereafter, I noticed that UHC’s policies and procedures actually included wording about UARS and continues to do so in some limited fashion as far as I know.
Thus, some contact with insurer’s may make a difference over time, which means a limited cascade preference would occur if a sizeable proportion of sleep doctors made it a point to discuss UARS with medical directors of a particularly receptive insurance carrier. If the medical directors of said insurer repeatedly found themselves in dialogue on the topic of UARS, and if a steady current of research papers flowed in their direction, then eventually coverage criteria would most likely state definitively the need to cover UARS.
Finally, the DME or HME companies often function as both gatekeeper and scapegoat when it comes to UARS. As they want to be reimbursed for PAP devices and supplies sold, they must be very careful about knowing whether or not a particular patient’s insurance covers UARS. Thus, the administrative side of the DME company must be fastidious in its record-keeping to confirms they are monitoring the actual data provided from the diagnostic study. On the other hand, when the DME is caught napping, so to speak, they may get stuck with no reimbursement if they did not follow the rules of an insurance carrier. Now, sometimes, a sleep doctor will go to bat for both the patient and the DME company by explaining that the patient not only suffers from UARS, but the patient is also a truck driver who suffers from daytime sleepiness. Next thing you know, the PAP device is covered. There really are exceptions to some rules!
Still, DME companies are not likely to play proactive roles, because they have so little influence. They would like to think that the sleep doctors with whom they work would always be taking the initiative for their patients, but as described in earlier posts, these medical professionals may be easily steered away from any interests in UARS. So, the DME companies can educate their UARS patients of the importance of treatment, and this positive step would always be encouraged, but unfortunately, it may have little bearing on insurance coverage, unless enough patients complain about the lack of reimbursement.
Considering the low level of respect for sleep medicine in the current medical landscape, it would not be surprising that the legal profession will eventually be the final pathway through which the UARS preference cascade is triggered. Though it is a sad commentary on how scientific evidence finds its way into the minds of the powers-that-be, a poor medical practice, such as ignoring UARS or not treating UARS, clearly goes against current scientific evidence. Nevertheless, the fact that so many medical institutions and professionals have even less interest or respect for (not to mention awareness or knowledge of) UARS than sleep medicine itself tells us the preference cascade is not necessarily close at hand. Efforts to educate individuals in all these areas of medicine and healthcare, though, are certainly worthwhile, which is one of the main rationales for these three posts.