I dread the day I require anything complicated that requires medical/insurance bureocracy in this country. I've had already ungodly share of issues with Aetna because they capitalized my surname.
I had my first serious medical procedure a year and a half ago, which required a rare specialist. My insurance, Anthem Blue Cross, covered everything, and called and mailed me ahead of time confirming my hospital stay at UCSF was approved and in network. So, YMMV.
Another avenue of escalation is also via your state congressional rep / federal congressional rep. Their offices should always have a constituent services function whose very purpose is to help their constituents navigate these bureaucratic mazes.
(Disclaimer: I’ve never had to exercise this personally.)
I take resource constrained over purposefully obtuse system. I can understand that people and medicine is expensive and inefficient(compared to farming and factories or tech). But at least these public systems seem to attempt to do stuff. And not be piled with bureaucracy to avoid paying out or increasing the prices.
An important metric in efficiency of systems is overhead. For health system, it would be how much money is spent on purposes other than the stated purpose of the system. Private insurance is never going to optimise for that, because low overhead means high utilisation of funds paid in, and low profits.
Commonly complained about polish NFZ (which, unlike NHS, operates through contracting to semi-private and private providers), has overhead IIRC of around 1%.
I don't have links on hand (maybe someone more recently versed on US insurance can check?), but I heard of common overhead levels in private insurers in USA being in range of 30%, mainly for claim acceptors/adjusters.
These days I am screening potential employers with who they use for their medical insurance plan. There's absolutely no way I'm ever going with United Healthcare Group ever again.
LOL, I had a phone screener three days ago and did the exact same thing. Asked which health plan they offered with the explicit purpose of filtering out UHC. They're the lowest of the low and even doctors hate them. (At least one of mine audibly groaned when I mentioned being on a UHC plan and then he said "Guess there's no point in trying <drug>."
Ha, I know Carelon! It's their pharmacy division for specialty (read: expensive) medication. Not a clue as to why they'd be involved in a CPAP claim, but this story does ring far too close to home.
I once spent months fighting United Healthcare to stop hounding me for a $2k bill that I categorically did not owe. Countless phone reps were unable to remove it from my account; I only solved the problem by making a big enough stink on Twitter for someone from corporate to get involved. Good times!
Carelon also does preauthorizations for various expensive procedures and such. I’ve had the displeasure of having to try to coordinate between my insurance provider and PCP’s insurance coordinator for authorizing some expensive blood tests. Insurance wanted the PCP to use Carelon, Carelon automatically denied it, the appeals process was designed to be as frustrating and opaque as possible.
(Unlike the OP, I didn’t have the patience to spend two years navigating the kafkaesque nightmare they did. I finally gave up after a couple months of being stonewalled by all the parties who would refuse to talk to one another and me trying to be the middle man. I never did get the blood work done. So much for preventative medicine.)
It’s surprising to me that not only in my home country is the process of having a CPAP machine covered by insurance a long and complicated one.
In my case, it took almost 12 months to receive my first CPAP machine, which then turned out to be refurbished. Initially, I had to visit a doctor, who had an available appointment in two months. He then referred me to a sleep laboratory (another two-month wait). After my sleep study, they sent me back to the doctor, who confirmed I had sleep apnea and said I needed to return to the sleep lab to test some settings—a further two months’ wait.
Then, after more than a month waiting for the next appointment, the doctor informed me that the settings they had tried were too low and wanted to send me back to the lab. I disagreed, but he gave me the prescription, and two months later, I received a CPAP machine with incorrect settings that didn’t help much.
Eventually, I purchased my own Philips Dreamstation Go because it automatically adjusts the pressure, and I’ve been sleeping well ever since.
After an initial round of bullshit with the local government insurance agency to get my CPAP including the multiple “two month wait for x”, then a 6 month wait to get the machine, and subsequently struggling to get it serviced, I bought my own for a few hundred EUR and been doing that for nearly 10 years now.
I don’t have much in the way of
“Means”, I just enjoy breathing and set my priorities accordingly. Also, where I live the most expensive CPAP costs like 1800 EUR. Mine costs 900 EUR
Just in case you missed the news about the recall and issues with Philips CPAP machines. You might want to check if there is anything that you can or need to do. The disintegrating foam seems like an unpleasant flaw in production.
Met someone coming from US to Australia to visit and was nicely surprised you can just go buy a CPAP, cheaply with no referral. Just like buying a dishwasher or something.
Makes me wonder if in the US a trip to mexico or canada or somewhere could make this easier.
As someone with multiple "pre-existing conditions" who cares for a stroke survivor (my wife) and a stage 4 chronic kidney disease patient (my mother-in-law,) I suggest we do the following:
1. make private health insurance illegal
2. pass a Constitutional amendment allowing every human the unlimited and absolute right to buy, make, modify, and sell medical things including importing and exporting those items.
It is cheaper just to buy things than to use insurance. The stock holders need to loose all of their equity then go to prison.
Typical libertarian strawman. You can pull all the foam you want out of _your_ device. No one cares. The government least of everybody. You are free to hurt yourself due to the consequences of your own actions.
You can't go modifying some types of medical devices and then sell them to _others_ without going through some sort regulatory process. Simple as that.
This is the typical libertarian insanity: "Regulations are bad, ergo there should be no regulations. And once we get rid of them everything will just work because somehow everyone will still abide by _some_ rules, although they are not required."
The problem is most Americans don’t have these types of chronic health issues, so it’s not an issue for them. I have a type 1 diabetic son, the amount of money we have spent on health insurance and medical equipment/supples is criminal.
I feel sorry for you, man. I have T1D as well, but pump supplies + CGM work out to something on the order of $200 a month in Poland. I am not even sure how much exactly, because I don't bother to count since it's not big money for me. Still a lot given the median pay, and you still have to buy the pump out of pocket, but nowhere near what's going on in the States.
Yep, I have a cousin in France who is also a T1D, he pays effectively nothing for his supplies (he tried pump+CGM but he's been doing injections for so long he found the pump to be a hassle.)
>pass a Constitutional amendment allowing every human the unlimited and absolute right to buy, make, modify, and sell medical things including importing and exporting those items.
I'm pretty sure I've never heard of a worse idea for a law. Removing any possibility of regulating the quality or efficacy of medicines and medical devices will injure and kill far more people than any resulting improved access would help.
Funnily enough, we have a constitutional amendment guaranteeing the right to own machines that are designed with the singular purpose of killing people. How could a “medical device second amendment” be worse?
The second amendment doesn't guarantee an unrestricted right to sell guns and isn't even really interpreted as an absolute and unlimited ability to own then these days. Furthermore, the abusive ways to use guns to the detriment of others are inherently illegal and don't scale. If the right to sell medicine were absolute, thalidomide couldn't have been barred from the US market or subsequently pulled and probably would've been laced with nicotine or heroin to make sure people keep buying it. But maybe that wouldn't have been a problem because it would be lost in a sea of snake oil.
The right to bear arms doesn't stipulate the right to buy any possible configuration of arms. The equal comparison is the right to use medical equipment as seen fit, not the right to purchase.
> pass a Constitutional amendment allowing every human the unlimited and absolute right to buy, make, modify, and sell medical things including importing and exporting those items.
I also have experienced various delays related to my cpap machine. I wonder how much of this debacle is because people in the know knew that this was coming, and therefore intentionally delayed anything to do with cpaps.
>How does that not demonstrate the ineffectiveness of the regulations?
The only reason there was a recall was because of the regulations and the gargantuan and slow bureaucratic apparatus surrounding Philips.
Philips tried, and would have succeeded without the regulations, to brush this off. They stalled, delated, cajoled, and lied.
Consumer protection laws (i.e. just sue after someone dies) are almost worthless in this case. No amount of rationally acting rational actor's next of kins bringing individual actions after the death of a loved one would have gotten Philips to move. Those wouldn't have even occurred because the only reason the link was made was because of a medical device monitoring system put in place by the FDA and government medical researchers looking into anomalous death statistics whose only common factor was Philips CPAP machines and the ensuing technical evaluation. Numerous deaths occurred, were attributed by some other cause because dissecting a deceased person and examining their alveoli for microscopic particles isn't an action typically performed after someone dies of what appears to be a stroke in their sleep.
Indeed, when this whole mess first started Philips deflected and delayed for years and their teams of lawyers would have annihilated each individually rationally acting rational actor's lawyers one by one to protect their bottom line drowning each litigant in delays, appeals, and litigation by financial attrition as the cases popped up one-by-one.
"Duh gubmint" is slow and often ineffective, but in this case the only reason anything happened at all and Philips CPAP machines aren't still out there literally and actually killing people is because of "a fat cat gubmint parasite" enforcing "onerous and burdensome" laws.
Of course I could be wrong. We all remember how magnanimous and ethical corporations were prior to all of these systems being put into place, don't we?
They went too extreme. Maybe let people buy the device but it still needs to be manufactured to regulations.
However I don’t know enough about CPAP to judge whether you should need a doctors cert or some kind of training cert on the device. Can a CPAP harm you if you incorrectly use it / use incorrect settings?
If a CPAP just did nothing, the users would be harmed. That's why they're using a CPAP machine in the first place. Or do you mean can the wrong settings be even more harmful?
Though it’d probably take 666 days to see a sleep specialist and get your first CPAP machine… (which I suspect you’d agree is part of the stealth dissolution plan)
Depending on how defunding worked so far in one's area, but NHS generally prioritised potentially dangerous issues.
Means it's easier to be frustrated waiting and then getting a 10 minute talk when it's flu or something similar, but get seen to in 10 minutes after arriving at a walk-in centre because you're worried of bine fissure in leg (turned out to be inflammation fortunately)
I went to A&E with symptoms of appendicitis. They took me in, put me in a bed, next day I was operated on, stayed one night and out the door. Everyone was great and seemed very competent.
This was on a three-day business trip to the UK, which was extremely unlucky, but the NHS was fantastic.
You got lucky. My father went to a&e recently with breathing problems due to some non COVID respiratory virus. He was struggling to breathe. They had zero free beds and he stayed overnight on the chairs waiting to be admitted. Eventually they found him a recliner.
And then of course you have the constant strikes and inability to even see a doctor at all unless you win the game of phone lottery.
The NHS may have a simple user interface, but it doesn't actually work when you need it so that's not very helpful. And the idea this is a Tory problem is propaganda. The NHS budget only ever goes higher yet service gets worse. Dumping ever more money into this third world system is never going to work.
Part of it is a Tory problem - when they changed how the funding gets distributed, so that overall bigger fund is divided now into smaller pieces that still have to cover the same population, but without the scaling benefits that previous allocation provided.
It's visible in other systems too, where for example you end up with local government politicians fighting for "prestige" or even perceived need to have a specific kind of hospital in their area, but they don't have a way to bring enough patients to support it, so you get a system too fragmented to sustain despite spending more and more money.
The NHS doesn't have a problem with too few patients anywhere. Just look at the chaos of the recently opened dentists that saw massive queues down the street, where police had to intervene to control the crowds. The reason: the dentist was new and accepting NHS patients.
A system that can't even provide dental slots without needing police to break up fights is a catastrophically failed system and it is a huge problem of the UK that people have loyalty to this dying corpse of a department.
It is a problem with funding when you need to break it down into smaller pieces because some very expensive things that are used by less patients now do not have support of budget for a larger area, and become an extra drain on the administrative region - because you still need to maintain neurosurgery units etc.
Suddenly there's less money for smaller, cheaper things.
Sure. Most parts of the world don't have the government run the entire healthcare system. It's an obviously bad idea everywhere
To everyone except Brits.
I have terrible news about systems built on private health insurance (USA): it will still take 666 days to see a specialist, and you will need a referral from your PCP who may also decide they want to see you in person first. This may be its own scheduling nightmare. Then you may find out that your preferred specialist is out of network for your private insurance. The waits are a generally a supply and demand issue more than a beurocracies issue, but I can assure you that multiplying the number of beurocracies involved in getting healthcare doesn't speed anything up.
That’ll depend heavily on location and specialty. Neurology and dermatology book 3-5 months out for new patient visits in my area, from personal experience.
I think it heavily depends. I know a friend who can only see her neurologist with a 3 month wait. Rheumatologists and specialized cardiologists are about the same issues. As an adult, trying to speak to a neurologist for an autism, ADHD, or learning disability evaluation is also a nightmare time-wise.
Last month, I tried to make an appointment with an endocrinologist. The first one I called had the earliest availability in July. The earliest one I could schedule was in March. and it's an hour and 15 minutes away from my home.
- ENT: 8 months (turned out to be a useless appointment too sadly)
According to my PCP last week, endocrinologists have stopped taking in patients that do not have urgent issues and even then it's a 6+ month wait. He said 9/10 of his referrals to endocrinologists in the last year have been denied.
Car accident, holding steering wheel, airbag goes off and hyperextends my wrist way back. Thankfully, no tears. But ER does their thing, and I follow up with PCP the next morning, both recommending, and PCP referring me to PT "to start immediately", because I have barely any grip strength in what was my dominant hand.
I couldn't find a PT within 30 miles that could see me within "12-14 weeks".
The NHS is a failed system that absolutely nobody is envious of, except brits because for some weird reason, they seem to think that the alternative is poor people dying in the streets.
Similar systems as the NHS have been introduced and subsequently canned in favor of more sane approaches in other European countries, which now have better (but still socialized) healthcare as a consequence.
There is no central european country with a similar amount of health care horror stories than the UK, and none where it plays a similarly important role in its identity. It boggles the mind.
If you think the problems of US healthcare are caused by too much „free market“ and could be solved or even marginally improved by an NHS-style socialized replacement with even more government interference, you have never seriously investigated the issue.
In my experience people in the US aren't envious of the NHS. Most of us are aware that the grass is not green on any side of that fence.
People in the US would like a system that works. That means not waiting 666 days for a CPAP. It also means not having the government strongly nudge you to off yourself with its assistance, as in Canada. And it means not having an ever-increasing number of deaths by waiting, as with the NHS, which typically don't happen here for most kinds of care.
Sadly, healthcare is expensive to provide regardless of who's paying. The NHS is able to provide even that troubled level of care because it pays its medical staff poorly by American standards, which it is able to do because it relies heavily on immigrants, which it is able to do in large part because those immigrants can't come to America and make 3x the salary since we make it incredibly difficult for foreign medical credentials to be recognized here. If we quit doing that tomorrow, the NHS would collapse by Friday.
I dunno, I’ve just spent 18 months in Dubai, where I had private insurance, and it was a breeze. See a UK-trained specialist for almost anything within a day or two, and hospital direct billing meant I almost never had to interact with the insurer directly.
I guess my point is that as reassuring (as a Brit) as it is to know the NHS is there, private insurance isn’t necessarily bad if regulated well (and that matches my experience of having private insurance in the UK too), it’s just America’s seems incredibly poorly regulated.
A consistent theme in responses here is that how long you just wait for a doctor depends on location, and the preponderance of evidence suggests that the differentiating factor between locations where it is easy to see a doctor vs waiting a long time is how many golf courses are around.
Correlation isn’t causation of course. Not suggesting golf courses cause doctors. But in general in this thread I see people from heavily golfed areas saying ‘I found a doctor really quickly’ and people from golf deserts talking about long waits.
I think the critical element in the UK hasn't been regulation, so much as the NHS putting a hard price floor under everything that private providers offer. The two systems worked symbiotically. As / if the NHS is killed, private medicine will enshittify as well.
I agree with this. The sleep apnea world is kind of a weird racket; in order to buy $150 worth of electronics, you need to pay a doctor $5000 to interpret the results of a sleep test. Insurance companies require this because they don't want to waste money on electronics if there is no disease that needs to be treated. But of course, the testing costs them more than the devices. (And the devices aren't $150, because they aren't marketed directly to consumers, they're marketed towards insurance companies. That means you get to jack up the price because people aren't using real money to buy them.)
There was probably some argument for requiring a prescription when someone needed to adjust the pressure, but now that the machines do that themselves, they should probably just be available at Wal-Mart next to the reading glasses.
> And the devices aren't $150, because they aren't marketed directly to consumers, they're marketed towards insurance companies
Apropos of anything else, the newest CPAP machines are relatively sophisticated. They may not be worth the $1,100 they sell for, but definitely more than $150. $500, maybe.
> The sleep apnea world is kind of a weird racket; in order to buy $150 worth of electronics, you need to pay a doctor $5000 to interpret the results of a sleep test.
ENT too. I had a deviated septum. Most (all?) of my life. Finally did something about it when I was 40. Went to an ENT, who was great. "Yup, right nostril, 90% occluded". "Makes sense. So when do we schedule the surgery?"
He sighs, and with a roll of his eyes (at the process, not me), "Welllll.... first I'm going to prescribe you these two nasal sprays so that you can come back in 30 days and tell me that, to our mutual shock, they didn't realign the cartilage in your nasal septum. At that point, insurance will approve the surgery and I can have it done within 3 days of getting that approval back."
Thankfully, that went like clockwork. I saw him on day 30, and they had an approval and 34 days after seeing him for the first time, it was taken care of.
Are there any studies estimating the cost of this kafakasque nightmare? End of the day users pay for this via higher premiums. I am sure doctor's offices also face something similar.
Well the kicker here, is that the process is not inefficient. It's just efficient for someone other than your average person. If anything, for the people that care and can do something about it, the process is inefficient in the opposite direction -- it's not bleeding as much money from the consumer as it could be.
Not to mention Aphyr spent lots of (expensive) time on the other side. I think Anthem should have to compensate him for all the time that he had to waste.
I move around a lot and have run into all kinds of weirdness when it comes to CPAP stuff. Any time you establish a new doc, if your CPAP prescription is more than 1-2 years old you need to do another sleep study, so I think I've done 6 different sleep studies over the years.
The other thing to remember about CPAP is that it's not just the machine, you have to get replaceable supplies - masks, air tubes, etc every so often.
While not nearly as bad as linked blog entry, my worst situation was with Kaiser in the SF Bay Area. I had gotten a CPAP through them and then a few years later moved to a different part of the Bay. I set up a new doc also with Kaiser, but the records don't easily transfer and since it's a different Kaiser respiratory team, I had to (of course) do another sleep study AND go through a CPAP orientation on how to use a CPAP despite me already owning and using a CPAP and just needing a new mask, etc.
I get my supplies from illegitimate sellers on amazon precisely because of this.
I also learned how to adjust my machine manually because it was taking way too long to schedule new sleep doctor appointments and then appointments with the DME provider…I shouldn’t have to wait 6 months to a year in order to to get quality sleep.
I will never understand why a prescription for my BiPAP or my glasses is required. It is all pointless bureaucracy.
This is too common. The author of the article asked for the wrong thing from the wrong people. He should have asked his sleep doctor (which he calls the sleep center) for a new CPAP. By asking for a repair from his insurance company, he caused himself lots of grief.
I doubt he has a list if his doctors that his insurance companies or doctors would agree with.
From the article:
> Listen, gobsmacked, as they explain that they decided your claim was in fact an appeal, and transferred it immediately to the appeals department. The appeals department examined the appeal and looked for the claim it was appealing. Finding none, they decided the appeal was moot, and rejected it.
Tell me why this is not fraud. Tell me why insurance company employees are not facing prison time.
This was a nightmarish read. I'm glad he was eventually able to get the replacement paid for.
On top of your state's DOI, there are a few agencies that can (typically) be used to bring insurance and other companies more swiftly into compliance with the laws they're meant to proactively follow:
* Many state AGs are responsive to well-documented problems and will send a warning on official letterhead.
* This won't work for insurance, but the CFPB[1] has a relatively smooth complaint process for financial issues, and (anecdotally) generally produces a rapid outcome.
Please folks remember that it isn't compulsory to use a companies byzantine process.
Instead, check your insurance policy wording that you are covered, spend the money on a new machine, send a single letter to the insurer asking to be reimbursed, and when they don't reimburse within 30 days file in small claims court.
They'll pay. They don't want to physically show up in court or have you send bailiffs to their HQ over $3000 that they probably owe you anyway.
Unfortunate that you cannot get additional damages against them. That sort of behaviour really needs to be heavily punished -- say, forcing them to cover every single CPAP prescribed for the next year for free, with the executives having to personally pay if the company can't afford to.
Byzantine processes when dealing with medical issues should be punished with Byzantine punishments.
Reminds me of the funniest Crusader Kings bug of all time—a performance issue where the game laboriously calculated over and over again whether or not every character in the Byzantine Empire wanted to blind every other character in the Byzantine Empire.
I loved that bug. To the point that I actually spent a (probably unnecessary) number of hours QC'ing it to try to figure out what was causing it. I didn't manage to figure out that it was the blinding check that was a problem, but I did discover that if you basically murdered all the people in the Byzantine empire, or you elimited the cultures that allowed blinding people, your game perf would go way up.
So I made a little personal mod that immediately castrated (if there was something to castrate) and blinded all characters of the Byzantine empire on game start, and it seemed to solve the problem.
In most places you can at least get back the court fees (which are typically a few hundred bucks).
Unfortunately sometimes you can't get back the court fees, and in situations like that, rather than spending $3000 on some new medical gear and battling insurance I would be very tempted to go to eBay, buy it 2nd hand from someone for $150, and just use that. Better time/effort/money/result tradeoff IMO.
eBay is pretty good at enforcing their policy banning sales of medical equipment requiring a prescription. They yank any listing for a CPAP very quickly.
I don't want to get back just my court fees. If I could have it, heads would roll, but in lieu of that, I will take severe personal penalties to all those involved. Their tunes will change really frakking quick if the consequence is being put out on the street (or worse) for frakking around with people's medical coverage.
Someone should start a SaaS that just automates this process.
Thinking about it, the only moderately difficult part would be compiling a list of small-claims courts and understanding the different paperwork each one requires.
After that, the whole thing could just be a single page with a few form fields (email, insurance company info, upload purchase receipt), a credit card form for the SaaS to collect its fee, and an API integration that uses one of those physical-mail APIs to send out the paperwork.
A use of AI/LMM I could support: read the policy documents and produce (or execute) the exact steps to get the insurance company to honor their obligations.
> the only moderately difficult part would be compiling a list of small-claims courts and understanding the different paperwork each one requires.
In reality the difficult part would actually be getting your service in front of people like OP at the right time. How do you imagine the guy in this post finds you and pays for your service? Have you ever looked for a similar service yourself when you faced similar issues?
I think this is where search engine ads would work. The keyword is Anthem. The message is "File Anthem claims through us. Get paid in no more than 60 days or we waive your $10 fee."
and this gets me wondering; what could we accomplish if we took 0.2% of the time we spent writing (let alone reading) internet comments, and instead used that time to engage in our state democratic processes, and help update our public school education standards to build a robust civil society!
my high school made sure I knew how to use both a band saw and a stand mixer; why not a courtroom? that's a systemic failure we could yet address
Does small claims court work in some states and not other ones? I'm assuming you are us based? And my understanding was that small claims courts are very different in each state.
They are, but the basic idea works pretty much everywhere.
In general, small claims courts aren't very strict on the correct procedure being followed - they are explicitly designed to be accessible to non-experts.
Thinking about that I really start to love the Swiss version of health insurance where (with most providers) you'll just provide your insurance card and they'll pay first and then decide whether to get reimbursement from you.
Much more easier to fight than if you'll have to bring them to pay something you paid first.
> and when they don't reimburse within 30 days file in small claims court
The very nature of having to be adversarial and “guard up” on everything is what exhausts people and sours a culture. It’s also inaccessible to many who are already exhausted and just don’t have another manual process and battle in them.
We lost my wife’s CPAP while traveling. Through insurance it would have been a month of paperwork, an exception made, and $600. Without insurance it was no wait and $650.
Guess which way we went…
I’m sorry the author had to deal with any of this. A lot of pandemic scarcity and multiple recalls made it hard to get supplies for a long time. My wife’s first CPAP is out of commission because the parts will simply never be made again. In between the pandemic start and the “well we all gave up” point three new models, recalls, and various mergers happened but not one replacement set of filters were delivered.
If it was any sort of other filter I’d just buy a replacement from Amazon and call it a day, but that doesn’t seem appropriate for this situation. Some people did and apparently (per doctors not my own research or anything I can verify) old OEM and new but improperly made third party filters can start flaking off while the machine runs due to how CPAPs work.
Now though? Apparently it’s easy to get a new model and all the components from a supplier… at least if you skip insurance.
If you need repairs done in the future, see if the local university’s biomedical engineering department has a student chapter of Project C.U.R.E. Students may volunteer to fix the device (off warranty of course). They work for free for needy families, and if you’re not in the former category, consider donating to their organization
However, your policy might also contain (more likely) an arbitration clause, requiring you to submit any dispute to arbitration or (sometimes) a form selection clause, requiring you to submit a dispute in a particular legal forum other than arbitration.
Note: some states do not allow forum selection clauses in insurance contracts, by statute or by case law. However, that will not stop a company from boilerplating it in. so, just because the policy might have the clause does not mean it’s necessarily enforceable.
On the other hand, I get the point that they may just pay the money rather than send it to legal to handle. YMMV.
Yeah try importing a CPAP from the states into Vietnam if you want a real adventure.
A $650 cpap machine costs well over $2K here. So I thought I'd import one. Apparently you need a prescription in the states? Ok, get a "prescription" from an online service that basically just asks you if you snore over a video call. Amazing.
Buy machine and have it sent to a freight forwarding service. They fuck up the paperwork.
It gets held in Vietnamese customs for almost 4 months. Go down to customs once a week to argue with the guy. One week you can't have it because it looks used. It doesn't look used.
Next week you can't have it because they think I'm importing to resell it. Yes it's a very hot market right now.
Repeat same processes with different people next successive weeks.
Finally someone says to bring prescription. But they don't write prescriptions for CPAPs here. A lot of hand waving when you tell them that. Go back to cardiologist who told me to get the CPAP and ask for a prescription. Oh no, he says, we don't write prescriptions for that. Can you write a letter saying that you don't write prescriptions and that I need the machine? Oh no, he says, I can't do that.
A couple of weeks later finally get someone at customs to agree that my sleep apnea test is proof enough. Bring the test in. Nobody looks at it. They still release the machine to me.
I would still take this random bureaucracy over American insurance any day of the week though.
I learned recently that you want a fixer that knows and bribes people where it's customary and expected. Going through lengthy processes deaf to the trigger phrases will make your life, which could be incredibly easy, unbearably hard in many countries.
Honestly I don't think most people need a "fixer" - just any local friend. Either they will know the expected bribe amount or they can figure it out. Also you might be able to get them to do stuff for you where all of the sudden the bribe is 1/10 the amount because they are local.
Maybe if you are doing more serious stuff like business or real estate it makes sense.
In specific countries, like Brazil, “fixer” is a real job (it’s called “despachante” there) and it’s supposedly someone that knows the bureaucracy and how to navigate it.
Most of the time when you need to deal with a government agency you’d go through one of them. They don’t advertise that they’ll bribe people to get it done but that’s how it works.
It is worth pointing out that (at least according to the corporate training I have to take every year) this is considered illegal by the US government for a US citizen to do even not on US soil; if the Feds get wind of it and feel like making a point they could throw you in jail, even with an intermediary "fixer".
In my experience, they are more professional. I engage with a firm who offers "customs brokerage" and "agent" services. They take care of any local payments necessary. I get a proper invoice that I pay with a wire transfer.
As a consultant, I have to take FCPA training an average of 3 times a year. So although I’m not a lawyer, my take is that it’s only allowed if you can point to official documentation that lays out an expedited action fee schedule.
Paying a third party is just as illegal. However, unless you’re expecting to run for Congress, nobody is going to care that you bribed some low level foreign customs agent to get your ink cartridges released.
There were some massive bribery scandals in the late 70s where pretty much entire governments were coopted by US corporates that these laws arose in response to.
Where we get the term "Banana Republic!" for such dispicibles as the DOLE family - who, we only know the white-washed name by their offspring Bob Dole charading as a nice ol' grampa type but a good ol' corporate boy.
--
One of the major scandals associated with the Dole family is the overthrow of the Hawaiian monarchy. Sanford Ballard Dole used his government influence and self-appointed position in Hawaii to push the US toward taking over the islands in the late 1890s. The Dole fruit company in Hawaii rose out of the bloodless Hawaiian coup staged by the Dole and the US government in 1893. Another scandal involved the Dole Food Company, where a jury found that Dole should pay $2.5 million in punitive damages to five workers who claimed they were made sterile by use of a pesticide on Nicaraguan banana plantations in the 1970s.
You didn't pay close enough attention in class. The US FCPA [0] explicitly allows "grease payments" (which is what we are talking about here) so long as they're not illegal in the country in question.
Grease payments are paid for the purpose of expediting a task that a low-level official is required to do anyway as part of their job, e.g. release a package from customs hell.
The FCPA prohibits bribes which are payments intended to influence high-level decision-makers to make a decision in your favor when they are not otherwise required to do so.
I've dealt with this many times as a South Asian person and it is very possible they still do actually want money. Most people will not ask in a straightforward manner for money and when you offer to pay them, they act all offended. This is a stupid game that I have no idea how it started where they will pretend to not want the money but will still very obviously want it. This has stumped me, being mildly autistic, for the decades of my existence and also stumps foreigners a lot. I cannot proffer a solution. Sometimes asking works, most of the time it doesn't and the other party feels unhappy about it and then when you decide enough is enough and want to pay, another guessing game begins where you need to gauge what amount satisfies them. It's incredibly goddamn annoying and I wish they just told you they want a bribe or money instead of engaging with these weird, obtuse, coy behaviours and then I have to obsess over whether I made a faux pas by paying/not paying them
It's their culture of saving face. The solution is extremely simple.
You tell the person "I was told I had to pay this <X fee> to release my package but I don't know who or where I pay" while waving the cash around cluelessly. The person will 100% then offer to take it and "handle it from there" under the stupid guise of plausibility.
Asian culture never ceases to confuse me. Nothing is ever straightforward.
I tried giving a gift to some, as thanks for letting me sleep on their couch. They told me no no no. I asked my friends about it, they told me it's about face.
Omg, I get that honor is a big thing, but it makes normal interactions way more complicated.
Yes when I first moved to the US, people would greet me with "How ya doing?" and I thought they really did want to know. It took a while to understand that it was just a way of saying hello.
I'm told that, in China, a way to greet someone is to say: "Have you eaten yet?" 你吃了吗
You are not supposed to provide a detailed answer such as: "Yes I ate a breakfast sandwich this morning at 8 am".
Instead you simply say "I ate" (吃了) or "Nope" (没呢)
Working in Singapore, I encounter this often (but in English). It took me a few months before I realised that I did not need to provide a detailed answer.
There are concepts though shared by the area. Piety. Face culture. Ancestry worship. Conservative values.
Some areas may have it to a lesser extent (China were the cultural revolution steam rolled everything and only left superstition) but the concepts shared remain the same,the expression of the pattern varies widely.
This. I bribed my way out of many traffic tickets in Southeast Asia by suggesting that because I’m so busy, I’ll pay the cop directly and then he can pay the ticket on my behalf. Worked every time except once, where the guy was a real stickler
Often they’re afraid they’re being recorded. So the conversation should be more like asking for unrelated advice and then making some type of friendship, maybe asking for their contact if you needed any more clarification, etc. Also, they might have a trust network, like you get to them through their friends. So you should ask your friends if they know someone working in this department etc, and get an intro. That way they feel safer. You don’t have to pay them monthly, but yeah, do occasionally compensate them for no reason.
Regarding money, you should start with cash. Have an amount you think is fair on your pocket. Tell them this is what you have and thank for their help. If they don’t look happy or they reject/ask for more, tell them it though, but that you need check if you have more in your car. If the difference is a lot, say you need to ask friend for help. Go back to your car, pretend to talk to someone and come back with more. If they really want a lot more, ask for they’re bank account and tell them you’ll need to transfer (throughout make sure to show them that they asking for a lot and this is very hard for you, you have kids, need to eat, get a cab, pay a loan, etc). Also if you tell them you’ll transfer from a different bank than theirs, they might settle on the cash because interbank transfers are not same day.
All this varies by country and what methods of payment are available.
My friend does export/import into SEA. You don’t just have to know who/when to bribe, you have to have an insider set up already. They used to have a guy in customs who would take a monthly payment to forward all her packages through without a second look. He disappeared and then trying to find the next one took months. Nothing was getting through customs, and showing up at the office they would deny any attempts to bribe. It is definitely a very coded art finding the right person, price, and parameters to get something set up like that.
It's always a guy with a gun. Fact of life. Border crossings? Find the guy with the biggest gun and bribe him. South America, Eastern Europe, etc. Import/exports have armed security too.
I recently read the book "Gaming Behind the Iron Curtain." It's about the former Soviet satellite states trying to play video games inside the Czech Republicb in the late 80s. They had to smuggle in computers hidden inside suitcases from England. This feels almost like the same thing.
I'm stuck in thinking that someone smart could break apart these CPAP machines and bring in necessary parts, then find other parts from China and hand carry those in. Then reassemble them inside Vietnam. A price differential of $1500 seems like an interesting arbitrage opportunity, maybe better than drug dealing. And there aren't chip sniffing dogs in the airport.
If you need to do this again, fly to Bangkok, they have ResMed and Philips authorised resellers with machines already in country, although incredibly enough you can also just order them off Lazada
My CPAP machine was held by customs, they asked me to provide some extra paperwork from another department, which boiles down to a form and a "prescription". Fortunately they accept american prescriptions. I emailed all of the docs to the department, and they told me since I'm physically in Japan, I have to do what Japanese would do - send a physical mail in an envolope. A week later I got the approval mailed back to me, scanned them and emailed them back to the customs, they released my package.
Then, the shipper messed up with my address, they use a local partner for delivery, but failed to pass them my phone number and the second line in my address. Apparently the poor delivery guy attempted to deliver for a week, I found it out in the tracking page, called the customer service, they figured out and eventually have it delivered.
Back in the day I remember reading patio11 posts on navigating the Japanese bureaucracy and he described this as "doing SQL JOINs" across different departments by filling out forms and visiting each one.
Japanese customs is a special thing. I had a plastic Christmas tree held in quarantine for 9 months because the box said "tree", and all attempts to point out that the tree was in fact fake, and probably not of serious biological concern feel on deaf ears.
>Go down to customs once a week to argue with the guy. One week you can't have it because it looks used. It doesn't look used. Next week you can't have it because they think I'm importing to resell it.
Cousin Eddie: I'm real glad that things are going good for you, Clark.
Clark: Mm-hm.
Cousin Eddie: I got laid off when they closed that asbestos factory.
Clark: Ahem.
Cousin Eddie: And now, wouldn't you know it...
...the Army cut my disability pension...
...because they said the plate in my head wasn't big enough.
Clark: Shoo.
Catherine: Eddie, Clark and Ellen don't want to hear about our troubles.
Clark: No, no. It's very interesting.
Aunt Edna: Why don't you just ask him for the money, Eddie? He sure as hell can't take a hint.
I had a business trying to get an institutional trading account, and all these compliance officers kept the application in limbo for a year
finally the exchange’s general counsel or someone maybe even the CFO said I needed to show my company’s AML/KYC policy.
I have my lawyer draft a comprehensive AML/KYC policy.
I told the financial institution that my legal counsel had prepared our "ANTI-MONEY LAUNDERING AND “KNOW YOUR CUSTOMER” PROCEDURES Which should fulfill all of your company’s compliance goals”
And apparently that contained the magic words because they approved the account instantly, after being in account creation limbo for an entire year, they never even asked for or looked at the document
It isn't good to argue that way in this part of the world, I hope you didn't raise your voice - not 100% sure about Vietnam but in any of its surrounding countries - they would lose face and become uncooperative.
I learned the hard way after a few experiences like yours to telegraph as little frustration or anger as humanly possible. Reasoning also only goes so far.
But if you appeal on some technicality, even a rule of your own invention..
Your mistake was not bringing an envelope full of USD as evidence to be submitted to the relevant authority to expedite the service. Guess why it costs over $2k? Additional administrative taxes included. Also, you are supposed to do this through somebody that knows somebody that works somewhere.
Medical, and especially medical related insurance stuff, is one of the few things that drives me up a wall enough to add to my 'burn this chickenshit outfit down' list.
Alternatively, try a low histamine diet. Many people who have been told they need surgery to correct "deviated septum" or need cpap have found their problems go away.
I was not able to find any paper on Google Scholar about a study on the effect of a low-histamine diet on obstructive sleep apnea. How many is "many" and where is this documented?
The few matches for low-histamine diet and apnea come from what I would consider fringe and untrustworth research, often suggesting a low-histamine diet helps a large number of medical issues, but not pointing to study giving numbers, describing the severity of the apnea, and other things I would expect.
I was able to find papers which studied the effect of anti-histamine drugs on obstructive sleep apnea, like https://journals.sagepub.com/doi/abs/10.2500/ajra.2013.27.39... for when people also have allergic rhinitis. "adding [anti-histimines] to this treatment did not show improved effects compared with placebo treatment". I presume people taking anti-histamines would have a lower amount of histamines in their body, so if there were a correlation it would have been seen. (Alternatively, it says that a low-histamine diet is not effective for CPAP when suffering from allergic rhinitis.)
It is apparently quite hard to identify what "low-histamine diet" means. In "Low-histamine diets: is the exclusion of foods justified by their histamine content?" at https://www.mdpi.com/2072-6643/13/5/1395 , which specifically concerns "the symptomatology of histamine intolerance", notes the "great heterogenicity in the type of foods that are advised against for histamine intolerant individuals. Excluded foods were, in most cases, different depending on the considered diet. Only fermented foods were unanimously excluded."
> The design of a low-histamine diet is challenging due to different handicaps. One of these is the lack of consensus on the histamine level below which a food is said to be considered low in histamine. Thus, variable histamine levels in food ranging between 5–50 mg/kg have been pointed out as potential thresholds, while other authors are much more demanding and consider foods with low histamine concentrations to be those that contain amounts below 1 mg/kg [ 12 ,26 –28 ]. Moreover, there is no specific regulation for the food industry to declare the occurrence or absence of histamine in food labelling, which could help histamine intolerant individuals to make suitable and informed choices.
> Overall, providing dietary recommendations and guidelines in the frame of a low-histamine diet is difficult for healthcare professionals.
If it's difficult for healthcare professionals to even determine what is low-histamine - and that's for people who are specifically histamine intolerance - and no studies to back up your suggestion ... why should anyone think your proposal has merit?
There is a long history of using the "why the closed mind?" argument to sell snake oil treatments, so I would not advise using argument and instead point to supporting evidence.
Unsolicited medical advice is not appropriate. It suggests that the people suffering from the condition in question have put literally zero effort into solving their problem, when in reality they likely have already heard about and tried every "trick" or "alternative treatment" you're going to suggest.
Other common scenarios:
* Telling a chronic pain sufferer to "just try cannabis, it works better than pharmaceutical pain killers!"
* Suggesting [common behavioral quirk] is a very obvious sign of ADHD, and encouraging them to take Adderall.
* A whole host of "x supplement fixes y chronic condition" suggestions.
Let's not conflate "medical advice" with the suggestion on HN that you might want to look into a dietary change. That seems like a form of catastrophization.
If you can fix a problem by changing your diet, is it really a medical problem? Just because it relates to your health or body doesn't mean it's medical.
I know people who have made this diet change and it has changed their lives. They don't snore anymore. They don't need cpap.
If you're curious, look into it. If you're not, you're not.
> If you can fix a problem by changing your diet, is it really a medical problem?
Yes, without doubt.
Scurvy is a medical problem (very often) fixed by changing your diet to include vitamin C.
Beriberi is a medical problem (very often) fixed by changing your diet to include more thiamine.
Quite a few people have allergic reactions to the content of their food, like celiac disease due to an allergic reaction to gluten, which is resolved by switching to a diet without that component.
Some young children got lead poisoning because they would eat paint chips which tasted sweet due to the lead content. Their medical problem is helped by switching to a non-lead paint diet, often by removing the old paint from where they live and repainting, or by moving somewhere without lead paint.
> I know people who have made this diet change and it has changed their lives. They don't snore anymore. They don't need cpap.
Snoring does not mean someone needs a CPAP machine. How were they diagnosed? How severe was it?
Was the food actually low in histamines? How low was it? Did it affect histamine levels in the blood? As I pointed out elsewhere here, the histamine variability in foods is quite high, and hard even for nutrition professionals to get right.
Is there a response curve between the amount of histamine and the amount of obstructive sleep apnea?
How do you know the cause was due to low histamine vs some other dietary change? For example, it seems excluding citrus fruits is part of a low histamine diet even though they do not contain histamine because they are thought to "trigger the release of endogenous histamine" (quoting that paper). But perhaps there is something else in the citrus - the acid content, for example - which causes the problem.
How does an low histamine diet compare to taking anti-histamines? Why should we expect the former to work if the latter does not? What is the proposed method of action?
We have only to look at the history of scurvy and vitamin C treatment to learn how important it is to understand the details of why a treatment works!
How long does it take for the change in diet to affect people? 1 day? 1 month? 1 year?
Does it work for everyone with obstructive sleep apena or only a sub-population?
> If you're curious, look into it. If you're not, you're not.
I was curious. I looked into it. There appears to be no substance behind the idea.
It is interesting to see how CPAP is used and covered by insurance in different countries. In my country, South Korea, CPAP is available for rent if you have certain medical conditions, and the rental price is fixed. I pay 15 USD (20K KRW), and the Korea NHS pays 60 USD (80K KRW) per month. I've been using Löwenstein's CPAP, and it works great without any problems.
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[ 0.16 ms ] story [ 267 ms ] threadIn any other industry, this would be called "fraud."
I dread the day I require anything complicated that requires medical/insurance bureocracy in this country. I've had already ungodly share of issues with Aetna because they capitalized my surname.
(Disclaimer: I’ve never had to exercise this personally.)
Every healthcare system has issues, but universal healthcare beats the pants off the US system any day of the week.
Commonly complained about polish NFZ (which, unlike NHS, operates through contracting to semi-private and private providers), has overhead IIRC of around 1%.
I don't have links on hand (maybe someone more recently versed on US insurance can check?), but I heard of common overhead levels in private insurers in USA being in range of 30%, mainly for claim acceptors/adjusters.
(Not saying that's the right number, health care in the US is out of control).
I once spent months fighting United Healthcare to stop hounding me for a $2k bill that I categorically did not owe. Countless phone reps were unable to remove it from my account; I only solved the problem by making a big enough stink on Twitter for someone from corporate to get involved. Good times!
(Unlike the OP, I didn’t have the patience to spend two years navigating the kafkaesque nightmare they did. I finally gave up after a couple months of being stonewalled by all the parties who would refuse to talk to one another and me trying to be the middle man. I never did get the blood work done. So much for preventative medicine.)
In my case, it took almost 12 months to receive my first CPAP machine, which then turned out to be refurbished. Initially, I had to visit a doctor, who had an available appointment in two months. He then referred me to a sleep laboratory (another two-month wait). After my sleep study, they sent me back to the doctor, who confirmed I had sleep apnea and said I needed to return to the sleep lab to test some settings—a further two months’ wait.
Then, after more than a month waiting for the next appointment, the doctor informed me that the settings they had tried were too low and wanted to send me back to the lab. I disagreed, but he gave me the prescription, and two months later, I received a CPAP machine with incorrect settings that didn’t help much.
Eventually, I purchased my own Philips Dreamstation Go because it automatically adjusts the pressure, and I’ve been sleeping well ever since.
https://www.fda.gov/medical-devices/safety-communications/up...
https://en.m.wikipedia.org/wiki/Continuous_positive_airway_p...
I worry that, some day, tech companies will be under a regulating agency like insurance is today. If that happens, we’ll probably deserve it.
Makes me wonder if in the US a trip to mexico or canada or somewhere could make this easier.
As someone with multiple "pre-existing conditions" who cares for a stroke survivor (my wife) and a stage 4 chronic kidney disease patient (my mother-in-law,) I suggest we do the following: 1. make private health insurance illegal 2. pass a Constitutional amendment allowing every human the unlimited and absolute right to buy, make, modify, and sell medical things including importing and exporting those items.
It is cheaper just to buy things than to use insurance. The stock holders need to loose all of their equity then go to prison.
The idea that the law prevents me from pulling defective foam out of a device I own is terrifying.
You can't go modifying some types of medical devices and then sell them to _others_ without going through some sort regulatory process. Simple as that.
I'm pretty sure I've never heard of a worse idea for a law. Removing any possibility of regulating the quality or efficacy of medicines and medical devices will injure and kill far more people than any resulting improved access would help.
People uses faulty medical device, however....
https://www.independent.co.uk/news/world/americas/toddler-sh...
https://apnews.com/article/toddler-shot-kenton-county-parent...
The ironically terrifying evidence about what a horrible idea this is is that it was just in the news that the FDA said that recalled CPAP machines made by Philips killed 561 people: https://www.cbsnews.com/news/fda-sleep-apnea-philips-recall-...
Plain old consumer device safety stuff would apply here.
The only reason there was a recall was because of the regulations and the gargantuan and slow bureaucratic apparatus surrounding Philips.
Philips tried, and would have succeeded without the regulations, to brush this off. They stalled, delated, cajoled, and lied.
Consumer protection laws (i.e. just sue after someone dies) are almost worthless in this case. No amount of rationally acting rational actor's next of kins bringing individual actions after the death of a loved one would have gotten Philips to move. Those wouldn't have even occurred because the only reason the link was made was because of a medical device monitoring system put in place by the FDA and government medical researchers looking into anomalous death statistics whose only common factor was Philips CPAP machines and the ensuing technical evaluation. Numerous deaths occurred, were attributed by some other cause because dissecting a deceased person and examining their alveoli for microscopic particles isn't an action typically performed after someone dies of what appears to be a stroke in their sleep.
Indeed, when this whole mess first started Philips deflected and delayed for years and their teams of lawyers would have annihilated each individually rationally acting rational actor's lawyers one by one to protect their bottom line drowning each litigant in delays, appeals, and litigation by financial attrition as the cases popped up one-by-one.
"Duh gubmint" is slow and often ineffective, but in this case the only reason anything happened at all and Philips CPAP machines aren't still out there literally and actually killing people is because of "a fat cat gubmint parasite" enforcing "onerous and burdensome" laws.
Of course I could be wrong. We all remember how magnanimous and ethical corporations were prior to all of these systems being put into place, don't we?
Wait. We don't?
Second, this comment would have been better without the final three paragraphs, which amounted to flame bait.
Dunking on libertarians is the moral, ethical, and honorable duty of all sentient beings.
However I don’t know enough about CPAP to judge whether you should need a doctors cert or some kind of training cert on the device. Can a CPAP harm you if you incorrectly use it / use incorrect settings?
Means it's easier to be frustrated waiting and then getting a 10 minute talk when it's flu or something similar, but get seen to in 10 minutes after arriving at a walk-in centre because you're worried of bine fissure in leg (turned out to be inflammation fortunately)
This was on a three-day business trip to the UK, which was extremely unlucky, but the NHS was fantastic.
And then of course you have the constant strikes and inability to even see a doctor at all unless you win the game of phone lottery.
The NHS may have a simple user interface, but it doesn't actually work when you need it so that's not very helpful. And the idea this is a Tory problem is propaganda. The NHS budget only ever goes higher yet service gets worse. Dumping ever more money into this third world system is never going to work.
It's visible in other systems too, where for example you end up with local government politicians fighting for "prestige" or even perceived need to have a specific kind of hospital in their area, but they don't have a way to bring enough patients to support it, so you get a system too fragmented to sustain despite spending more and more money.
A system that can't even provide dental slots without needing police to break up fights is a catastrophically failed system and it is a huge problem of the UK that people have loyalty to this dying corpse of a department.
Suddenly there's less money for smaller, cheaper things.
And what is the alternative? For-profit systems?
that is not typical
They have figured out the right time in the morning to call every day to try to grab a canceled appointment slot but it takes dedication.
This sort of thing depends heavily on where you live, what your insurance coverage is, and the specific condition you're seeking care for.
- Dermatologist: 5 months
- Cardiologist: 3 months
- ENT: 8 months (turned out to be a useless appointment too sadly)
According to my PCP last week, endocrinologists have stopped taking in patients that do not have urgent issues and even then it's a 6+ month wait. He said 9/10 of his referrals to endocrinologists in the last year have been denied.
I couldn't find a PT within 30 miles that could see me within "12-14 weeks".
This includes multiple consultations with sleep specialists and zero chasing from me.
I suffer from sleep apnea and I too had an issue with my CPAP machine. The NHS fixed it within a week.
I can’t imagine spending 2 years chasing different health providers to sort a simple repair.
Similar systems as the NHS have been introduced and subsequently canned in favor of more sane approaches in other European countries, which now have better (but still socialized) healthcare as a consequence.
There is no central european country with a similar amount of health care horror stories than the UK, and none where it plays a similarly important role in its identity. It boggles the mind.
...except people in the US.
People in the US would like a system that works. That means not waiting 666 days for a CPAP. It also means not having the government strongly nudge you to off yourself with its assistance, as in Canada. And it means not having an ever-increasing number of deaths by waiting, as with the NHS, which typically don't happen here for most kinds of care.
https://www.theguardian.com/society/2023/aug/30/national-tra...
Sadly, healthcare is expensive to provide regardless of who's paying. The NHS is able to provide even that troubled level of care because it pays its medical staff poorly by American standards, which it is able to do because it relies heavily on immigrants, which it is able to do in large part because those immigrants can't come to America and make 3x the salary since we make it incredibly difficult for foreign medical credentials to be recognized here. If we quit doing that tomorrow, the NHS would collapse by Friday.
I guess my point is that as reassuring (as a Brit) as it is to know the NHS is there, private insurance isn’t necessarily bad if regulated well (and that matches my experience of having private insurance in the UK too), it’s just America’s seems incredibly poorly regulated.
Correlation isn’t causation of course. Not suggesting golf courses cause doctors. But in general in this thread I see people from heavily golfed areas saying ‘I found a doctor really quickly’ and people from golf deserts talking about long waits.
There was probably some argument for requiring a prescription when someone needed to adjust the pressure, but now that the machines do that themselves, they should probably just be available at Wal-Mart next to the reading glasses.
Apropos of anything else, the newest CPAP machines are relatively sophisticated. They may not be worth the $1,100 they sell for, but definitely more than $150. $500, maybe.
> The sleep apnea world is kind of a weird racket; in order to buy $150 worth of electronics, you need to pay a doctor $5000 to interpret the results of a sleep test.
ENT too. I had a deviated septum. Most (all?) of my life. Finally did something about it when I was 40. Went to an ENT, who was great. "Yup, right nostril, 90% occluded". "Makes sense. So when do we schedule the surgery?"
He sighs, and with a roll of his eyes (at the process, not me), "Welllll.... first I'm going to prescribe you these two nasal sprays so that you can come back in 30 days and tell me that, to our mutual shock, they didn't realign the cartilage in your nasal septum. At that point, insurance will approve the surgery and I can have it done within 3 days of getting that approval back."
Thankfully, that went like clockwork. I saw him on day 30, and they had an approval and 34 days after seeing him for the first time, it was taken care of.
But what a fuckshow.
I'd question the "by stealth" part of this.
If only.
The other thing to remember about CPAP is that it's not just the machine, you have to get replaceable supplies - masks, air tubes, etc every so often.
While not nearly as bad as linked blog entry, my worst situation was with Kaiser in the SF Bay Area. I had gotten a CPAP through them and then a few years later moved to a different part of the Bay. I set up a new doc also with Kaiser, but the records don't easily transfer and since it's a different Kaiser respiratory team, I had to (of course) do another sleep study AND go through a CPAP orientation on how to use a CPAP despite me already owning and using a CPAP and just needing a new mask, etc.
I also learned how to adjust my machine manually because it was taking way too long to schedule new sleep doctor appointments and then appointments with the DME provider…I shouldn’t have to wait 6 months to a year in order to to get quality sleep.
I will never understand why a prescription for my BiPAP or my glasses is required. It is all pointless bureaucracy.
I doubt he has a list if his doctors that his insurance companies or doctors would agree with.
Tell me why this is not fraud. Tell me why insurance company employees are not facing prison time.
On top of your state's DOI, there are a few agencies that can (typically) be used to bring insurance and other companies more swiftly into compliance with the laws they're meant to proactively follow:
* Many state AGs are responsive to well-documented problems and will send a warning on official letterhead.
* This won't work for insurance, but the CFPB[1] has a relatively smooth complaint process for financial issues, and (anecdotally) generally produces a rapid outcome.
[1]: https://www.consumerfinance.gov/
Instead, check your insurance policy wording that you are covered, spend the money on a new machine, send a single letter to the insurer asking to be reimbursed, and when they don't reimburse within 30 days file in small claims court.
They'll pay. They don't want to physically show up in court or have you send bailiffs to their HQ over $3000 that they probably owe you anyway.
Byzantine processes when dealing with medical issues should be punished with Byzantine punishments.
Little late for the new year's stuff, but let's party like it's 499!
So I made a little personal mod that immediately castrated (if there was something to castrate) and blinded all characters of the Byzantine empire on game start, and it seemed to solve the problem.
Unfortunately sometimes you can't get back the court fees, and in situations like that, rather than spending $3000 on some new medical gear and battling insurance I would be very tempted to go to eBay, buy it 2nd hand from someone for $150, and just use that. Better time/effort/money/result tradeoff IMO.
https://www.ebay.com/itm/404778680293
They even have a category for "Medical equipment > ventilators". If they do have such a policy, they enforce it very poorly.
Policy: https://www.ebay.com/help/policies/prohibited-restricted-ite...
Thinking about it, the only moderately difficult part would be compiling a list of small-claims courts and understanding the different paperwork each one requires.
After that, the whole thing could just be a single page with a few form fields (email, insurance company info, upload purchase receipt), a credit card form for the SaaS to collect its fee, and an API integration that uses one of those physical-mail APIs to send out the paperwork.
In reality the difficult part would actually be getting your service in front of people like OP at the right time. How do you imagine the guy in this post finds you and pays for your service? Have you ever looked for a similar service yourself when you faced similar issues?
my high school made sure I knew how to use both a band saw and a stand mixer; why not a courtroom? that's a systemic failure we could yet address
In general, small claims courts aren't very strict on the correct procedure being followed - they are explicitly designed to be accessible to non-experts.
Much more easier to fight than if you'll have to bring them to pay something you paid first.
The very nature of having to be adversarial and “guard up” on everything is what exhausts people and sours a culture. It’s also inaccessible to many who are already exhausted and just don’t have another manual process and battle in them.
Guess which way we went…
I’m sorry the author had to deal with any of this. A lot of pandemic scarcity and multiple recalls made it hard to get supplies for a long time. My wife’s first CPAP is out of commission because the parts will simply never be made again. In between the pandemic start and the “well we all gave up” point three new models, recalls, and various mergers happened but not one replacement set of filters were delivered.
If it was any sort of other filter I’d just buy a replacement from Amazon and call it a day, but that doesn’t seem appropriate for this situation. Some people did and apparently (per doctors not my own research or anything I can verify) old OEM and new but improperly made third party filters can start flaking off while the machine runs due to how CPAPs work.
Now though? Apparently it’s easy to get a new model and all the components from a supplier… at least if you skip insurance.
https://projectcure.org/
Note: some states do not allow forum selection clauses in insurance contracts, by statute or by case law. However, that will not stop a company from boilerplating it in. so, just because the policy might have the clause does not mean it’s necessarily enforceable.
On the other hand, I get the point that they may just pay the money rather than send it to legal to handle. YMMV.
A $650 cpap machine costs well over $2K here. So I thought I'd import one. Apparently you need a prescription in the states? Ok, get a "prescription" from an online service that basically just asks you if you snore over a video call. Amazing.
Buy machine and have it sent to a freight forwarding service. They fuck up the paperwork.
It gets held in Vietnamese customs for almost 4 months. Go down to customs once a week to argue with the guy. One week you can't have it because it looks used. It doesn't look used.
Next week you can't have it because they think I'm importing to resell it. Yes it's a very hot market right now.
Repeat same processes with different people next successive weeks.
Finally someone says to bring prescription. But they don't write prescriptions for CPAPs here. A lot of hand waving when you tell them that. Go back to cardiologist who told me to get the CPAP and ask for a prescription. Oh no, he says, we don't write prescriptions for that. Can you write a letter saying that you don't write prescriptions and that I need the machine? Oh no, he says, I can't do that.
A couple of weeks later finally get someone at customs to agree that my sleep apnea test is proof enough. Bring the test in. Nobody looks at it. They still release the machine to me.
I would still take this random bureaucracy over American insurance any day of the week though.
Maybe if you are doing more serious stuff like business or real estate it makes sense.
Most of the time when you need to deal with a government agency you’d go through one of them. They don’t advertise that they’ll bribe people to get it done but that’s how it works.
At least people in Vietnam don't kid themselves and call a bribe a bribe.
Paying a third party is just as illegal. However, unless you’re expecting to run for Congress, nobody is going to care that you bribed some low level foreign customs agent to get your ink cartridges released.
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One of the major scandals associated with the Dole family is the overthrow of the Hawaiian monarchy. Sanford Ballard Dole used his government influence and self-appointed position in Hawaii to push the US toward taking over the islands in the late 1890s. The Dole fruit company in Hawaii rose out of the bloodless Hawaiian coup staged by the Dole and the US government in 1893. Another scandal involved the Dole Food Company, where a jury found that Dole should pay $2.5 million in punitive damages to five workers who claimed they were made sterile by use of a pesticide on Nicaraguan banana plantations in the 1970s.
Grease payments are paid for the purpose of expediting a task that a low-level official is required to do anyway as part of their job, e.g. release a package from customs hell.
The FCPA prohibits bribes which are payments intended to influence high-level decision-makers to make a decision in your favor when they are not otherwise required to do so.
[0] https://en.m.wikipedia.org/wiki/Foreign_Corrupt_Practices_Ac...
You tell the person "I was told I had to pay this <X fee> to release my package but I don't know who or where I pay" while waving the cash around cluelessly. The person will 100% then offer to take it and "handle it from there" under the stupid guise of plausibility.
I tried giving a gift to some, as thanks for letting me sleep on their couch. They told me no no no. I asked my friends about it, they told me it's about face.
Omg, I get that honor is a big thing, but it makes normal interactions way more complicated.
"You'll have to pop in next time you're in the area!" does NOT mean "turn up at my house unannounced". Even if it sounds like it.
Or "How are you going?" is not a prompt to actually tell them how you're going.
I'm told that, in China, a way to greet someone is to say: "Have you eaten yet?" 你吃了吗
You are not supposed to provide a detailed answer such as: "Yes I ate a breakfast sandwich this morning at 8 am".
Instead you simply say "I ate" (吃了) or "Nope" (没呢)
Some areas may have it to a lesser extent (China were the cultural revolution steam rolled everything and only left superstition) but the concepts shared remain the same,the expression of the pattern varies widely.
Sounds like they thought they caught a reseller endangering somebodies sales friendship.
Regarding money, you should start with cash. Have an amount you think is fair on your pocket. Tell them this is what you have and thank for their help. If they don’t look happy or they reject/ask for more, tell them it though, but that you need check if you have more in your car. If the difference is a lot, say you need to ask friend for help. Go back to your car, pretend to talk to someone and come back with more. If they really want a lot more, ask for they’re bank account and tell them you’ll need to transfer (throughout make sure to show them that they asking for a lot and this is very hard for you, you have kids, need to eat, get a cab, pay a loan, etc). Also if you tell them you’ll transfer from a different bank than theirs, they might settle on the cash because interbank transfers are not same day.
All this varies by country and what methods of payment are available.
I'm stuck in thinking that someone smart could break apart these CPAP machines and bring in necessary parts, then find other parts from China and hand carry those in. Then reassemble them inside Vietnam. A price differential of $1500 seems like an interesting arbitrage opportunity, maybe better than drug dealing. And there aren't chip sniffing dogs in the airport.
What a nightmare.
https://en.wikipedia.org/wiki/Hobbit_(computer)
Seems like something you could have paid 500-1000k (20-40USD) and been done with.
I've lived here for 12 years, I know how it works.
My CPAP machine was held by customs, they asked me to provide some extra paperwork from another department, which boiles down to a form and a "prescription". Fortunately they accept american prescriptions. I emailed all of the docs to the department, and they told me since I'm physically in Japan, I have to do what Japanese would do - send a physical mail in an envolope. A week later I got the approval mailed back to me, scanned them and emailed them back to the customs, they released my package.
Then, the shipper messed up with my address, they use a local partner for delivery, but failed to pass them my phone number and the second line in my address. Apparently the poor delivery guy attempted to deliver for a week, I found it out in the tracking page, called the customer service, they figured out and eventually have it delivered.
I thought it was terrible, but now.
Cousin Eddie: I'm real glad that things are going good for you, Clark.
Clark: Mm-hm.
Cousin Eddie: I got laid off when they closed that asbestos factory.
Clark: Ahem.
Cousin Eddie: And now, wouldn't you know it... ...the Army cut my disability pension... ...because they said the plate in my head wasn't big enough.
Clark: Shoo.
Catherine: Eddie, Clark and Ellen don't want to hear about our troubles.
Clark: No, no. It's very interesting.
Aunt Edna: Why don't you just ask him for the money, Eddie? He sure as hell can't take a hint.
I had a business trying to get an institutional trading account, and all these compliance officers kept the application in limbo for a year
finally the exchange’s general counsel or someone maybe even the CFO said I needed to show my company’s AML/KYC policy.
I have my lawyer draft a comprehensive AML/KYC policy.
I told the financial institution that my legal counsel had prepared our "ANTI-MONEY LAUNDERING AND “KNOW YOUR CUSTOMER” PROCEDURES Which should fulfill all of your company’s compliance goals”
And apparently that contained the magic words because they approved the account instantly, after being in account creation limbo for an entire year, they never even asked for or looked at the document
I learned the hard way after a few experiences like yours to telegraph as little frustration or anger as humanly possible. Reasoning also only goes so far.
But if you appeal on some technicality, even a rule of your own invention..
Carol Beer presents differently across cultures (https://www.youtube.com/watch?v=1pw8m_NTJ_0).
With all the "free trade" agreements Vietnam is party to [1], you'd think this would be perfectly fine. Funny how that works, isn't it?
[1] https://en.wikipedia.org/wiki/Free_trade_agreements_of_Vietn...
This is a great example of why.
I think one thing I would have done different when i switched primary I would have gotten a new Rx.
Not sure how much trouble that would have saved in the end but that is just what I tend to do.
Edit: to downvoters - why the closed mind?
The few matches for low-histamine diet and apnea come from what I would consider fringe and untrustworth research, often suggesting a low-histamine diet helps a large number of medical issues, but not pointing to study giving numbers, describing the severity of the apnea, and other things I would expect.
I was able to find papers which studied the effect of anti-histamine drugs on obstructive sleep apnea, like https://journals.sagepub.com/doi/abs/10.2500/ajra.2013.27.39... for when people also have allergic rhinitis. "adding [anti-histimines] to this treatment did not show improved effects compared with placebo treatment". I presume people taking anti-histamines would have a lower amount of histamines in their body, so if there were a correlation it would have been seen. (Alternatively, it says that a low-histamine diet is not effective for CPAP when suffering from allergic rhinitis.)
It is apparently quite hard to identify what "low-histamine diet" means. In "Low-histamine diets: is the exclusion of foods justified by their histamine content?" at https://www.mdpi.com/2072-6643/13/5/1395 , which specifically concerns "the symptomatology of histamine intolerance", notes the "great heterogenicity in the type of foods that are advised against for histamine intolerant individuals. Excluded foods were, in most cases, different depending on the considered diet. Only fermented foods were unanimously excluded."
> The design of a low-histamine diet is challenging due to different handicaps. One of these is the lack of consensus on the histamine level below which a food is said to be considered low in histamine. Thus, variable histamine levels in food ranging between 5–50 mg/kg have been pointed out as potential thresholds, while other authors are much more demanding and consider foods with low histamine concentrations to be those that contain amounts below 1 mg/kg [ 12 ,26 –28 ]. Moreover, there is no specific regulation for the food industry to declare the occurrence or absence of histamine in food labelling, which could help histamine intolerant individuals to make suitable and informed choices.
> Overall, providing dietary recommendations and guidelines in the frame of a low-histamine diet is difficult for healthcare professionals.
If it's difficult for healthcare professionals to even determine what is low-histamine - and that's for people who are specifically histamine intolerance - and no studies to back up your suggestion ... why should anyone think your proposal has merit?
There is a long history of using the "why the closed mind?" argument to sell snake oil treatments, so I would not advise using argument and instead point to supporting evidence.
Unsolicited medical advice is not appropriate. It suggests that the people suffering from the condition in question have put literally zero effort into solving their problem, when in reality they likely have already heard about and tried every "trick" or "alternative treatment" you're going to suggest.
Other common scenarios:
* Telling a chronic pain sufferer to "just try cannabis, it works better than pharmaceutical pain killers!"
* Suggesting [common behavioral quirk] is a very obvious sign of ADHD, and encouraging them to take Adderall.
* A whole host of "x supplement fixes y chronic condition" suggestions.
If you can fix a problem by changing your diet, is it really a medical problem? Just because it relates to your health or body doesn't mean it's medical.
I know people who have made this diet change and it has changed their lives. They don't snore anymore. They don't need cpap.
If you're curious, look into it. If you're not, you're not.
Yes, without doubt.
Scurvy is a medical problem (very often) fixed by changing your diet to include vitamin C.
Beriberi is a medical problem (very often) fixed by changing your diet to include more thiamine.
Quite a few people have allergic reactions to the content of their food, like celiac disease due to an allergic reaction to gluten, which is resolved by switching to a diet without that component.
Some young children got lead poisoning because they would eat paint chips which tasted sweet due to the lead content. Their medical problem is helped by switching to a non-lead paint diet, often by removing the old paint from where they live and repainting, or by moving somewhere without lead paint.
> I know people who have made this diet change and it has changed their lives. They don't snore anymore. They don't need cpap.
Snoring does not mean someone needs a CPAP machine. How were they diagnosed? How severe was it?
Was the food actually low in histamines? How low was it? Did it affect histamine levels in the blood? As I pointed out elsewhere here, the histamine variability in foods is quite high, and hard even for nutrition professionals to get right.
Is there a response curve between the amount of histamine and the amount of obstructive sleep apnea?
How do you know the cause was due to low histamine vs some other dietary change? For example, it seems excluding citrus fruits is part of a low histamine diet even though they do not contain histamine because they are thought to "trigger the release of endogenous histamine" (quoting that paper). But perhaps there is something else in the citrus - the acid content, for example - which causes the problem.
How does an low histamine diet compare to taking anti-histamines? Why should we expect the former to work if the latter does not? What is the proposed method of action?
We have only to look at the history of scurvy and vitamin C treatment to learn how important it is to understand the details of why a treatment works!
How long does it take for the change in diet to affect people? 1 day? 1 month? 1 year?
Does it work for everyone with obstructive sleep apena or only a sub-population?
> If you're curious, look into it. If you're not, you're not.
I was curious. I looked into it. There appears to be no substance behind the idea.
No diet is fixing that cartilage.