LAST month, the Obama administration announced that the Centers for Medicare and Medicaid Services would make much greater use of competitive bidding to buy medical equipment for Medicare patients. Because of Medicare’s size and position in the health care market, it is likely that this policy will be quickly adopted by Medicaid and private insurers.
On the face of it, competitive bidding sounds like a very good idea. If one supplier can provide power wheelchairs or oxygen masks for 30 percent less than another, it’s hard to argue for contracting with the more expensive supplier, especially at a time when everyone is looking for ways to save money. A one-year experiment with expanded competitive bidding that was recently conducted by Medicare yielded cost savings of 42 percent, without reducing the quality of care, and was hailed as a great success.
But as a doctor working with patients on the ground, I have doubts about that quality-of-care measure, and I worry that those savings obscure a potentially serious problem.
I care for many children with obstructive sleep apnea, a condition that causes the throat to collapse during sleep, preventing air from getting into the lungs. It is associated with cognitive impairment, as well as hypertension and heart disease. Some of these children need to be treated with continuous positive airway pressure, or CPAP, a machine that blows air through a mask at a fixed pressure, which props the throat open and prevents the child from choking.
Using CPAP, or any medical device, is complicated, and the machines work only if you know how to use them properly. If the CPAP mask doesn’t fit snugly, it can be uncomfortable and cause skin abrasion or even scarring. If moisture condenses in the tubing and splashes into the mask while the child is asleep, it can be very frightening and unpleasant. And there are many important adjustable features, for instance for the humidifier and the rate at which the air pressure increases. If used incorrectly, CPAP will not do what it is supposed to. The obstructive sleep apnea will remain untreated, and if a child’s blood oxygen levels drop too low, or if heart disease develops or worsens, the child could even land in the hospital.
The same is true for other devices. Patients who aren’t properly taught how to operate home IV pumps can wind up staying in the hospital instead of being treated as outpatients. Patients on home oxygen can stop breathing if they’re accidentally given too high a concentration of oxygen.
To make sure this sort of thing doesn’t happen, medical-equipment suppliers send a technician to the patients’ homes to explain what can go wrong and to show them and their families how to use the device properly. But I know from experience that some suppliers are better at this than others. Some CPAP suppliers’ technicians will spend an hour making sure the families understand everything. Others (whom I no longer use) spend no more than 15 minutes. I found this out after patients showed up in my clinic, days after their machines had been delivered, still unable to use them.
This extra care takes time, and time costs money. But sicker patients and unnecessary hospital visits cost far more. And competitive bidding doesn’t take these subsequent costs into account.
If competitive bidding is predicated on supplying equipment at the lowest possible price, something has to give. And more likely than not, that something will be patient care. Medical-equipment providers will have no incentive to do a better job of making sure the equipment is being used properly. And that, in turn, will lead to poorer outcomes.
Only by comparing these outcomes can one supplier be demonstrated to be truly more effective than another. And as someone working with real patients and their families, I know that without ensuring that patients who are prescribed medical devices know how to use them, the total cost to our society will only rise.
Dennis Rosen is a pediatric pulmonologist and sleep specialist at Children’s Hospital Boston.