Utility of remote pacer checks

I am less than thrilled with the care I have gotten at my cardio office. Everything is "cookie-cutter" and when I ask why, I am told "that is our standard of care." I would switch providers, but this place is the only game in town, and then next closest is 80 miles away. I have asked to get my pacer adjusted so that I run without getting winded, but it has been trial and error, with little effect. At my last interogation, I saw a tech who said she was not able to give me a printed report on my episodes of atrial fib. She was willing to tell me I was in afib 9% of the time. She also hit the edge of my pacer, that hurt for the rest of the day. 

That being said, I see no good reason to do quarterly remote checks. When I go into afib, the rate is 70-80. I am not on any anti-arrhythmic nor do I want to be, and I do not have ventricular arrhythmias. My insurance has changed and I am charged $200 out of pocket for each interrogation. Can anyone explain why I should bother with remote checks when adjustments can't be made? I suppose I need to go in for the 6 month checks, but I still don't see the benefit versus the cost for the remote checks. 


6 Comments

Utility

by AgentX86 - 2021-02-07 23:00:53

I'd encourage you to find another cardiologist.  I know you said there aren't any others withing 80mi but there seems to be a few in Bellingham. In any case, it sounds like your cardiologists are pretty poor but it may be that they're not happy with what your insurance will cover (just a SWAG).

Pacemaker setting are somewhat of a trial and error sort of thing.  A good tech can get close with a few visits but it can take some time to get things right.  Of course, this all depends on your situation (chronotripic incompetency is the real problem case).  My PM techs have worked with me while I've been there.  Tweak this, walk the halls/staris, and report back how I felt.  Rinse/repeat.  It's possible to do this more formally on a treadmill but that would require the participation of your cardiologist, which doesn't seem to be in the cards.

You're one of the rare ones, like me, who's heart rate doesn't (didn't) spike up when in Afib.  Even later, when I was in AFL, I knew it was back when my heart rate went from the 50s only to the 80s.  I didn't bother going to the ER.  No point.  The ER cardiologist didn't believe me anyway.  He was so dumb that he couldn't even read an EKG. Probably why could only get a job in the ER.

Nothing can be changed during a remote session for security reasons.  The PM data can only be read out. It seems like a good idea to me.

$200?! If you're really as stable as you say, there probably isn't any need for the quarterly remote transmissions. Perhaps just "forget" sending them?  I have forgotten and no one said anything.  As long as you're on an anticoagulant, you're probably OK. If your PM is getting towards end-of-life, it would be more important. If anything unexpected happens you can initiate a transmission.

 

Remote monitoring

by Gemita - 2021-02-08 05:40:12

Julros,

Usefulness ?  When a patient experiences a serious arrhythmia or syncope and becomes unstable and with the help of a family member is able to do an immediate transmission to their pacing clinic for the arrhythmia to be assessed, I would imagine the usefulness of the facility would become obvious.  I certainly wouldn't be without my remote monitoring in the comfort and safety of my own home.

If you feel you don't need quarterly routine checks because your AF or other arrhythmias are stable at present, then I would speak to your team and just go back for your six monthly checks and do nothing else.  You could then keep the monitor plugged in and ready to transmit to your clinic just in case you need it one day to help diagnose a potential problem with pacing, with your health, with any potential future medication changes or with worsening arrhythmias since the nature of arrhythmias can change very very quickly.

As to your disappointment with your care, you seem to be stable at the moment, with no help required from anti arrhythmic meds, nor do you want to take them, and your heart rate seems well controlled (I presume without rate control meds?)  There is little therefore that they really need to do for you, particularly if you decide you do not wish to have any further treatment for your AF?

AF, even at slow rates can affect our ability to exercise as I well know so whatever setting changes they carry out by trial and error is fraught with difficulty while we are in AF.  Running in AF always makes me winded, even at low rates.  It is the irregularity of rhythm which so affects me and causes blood flow problems.  It is not the pacemaker that needs adjusting;  it is my AF that needs treating or eliminating (if only!) to prevent symptoms of breathlessness during exertion.  As we all know a pacemaker cannot treat AF although it can help many of us to feel less symptomatic during periods of AF.  This has been my personal experience so far.

Many clinics (here in the UK) will not give printed copies of pacemaker downloads to their patients, but we can request access to our pacemaker records which can be sent to us on a password protected disc.  Some patients take a USB stick with them and their clinic may be able to download the data onto this for them, but they don’t usually like to print off data for us at the time of our pacemaker interrogation.  A “paper copy” of the full report or any part of the report in any event here in the UK would likely incur a fee.

The way forward?  Ask about better treatment for your AF.  9% of the time spent in AF doesn’t sound much but AF can quickly progress if it is not firmly controlled.  If it is causing you to get winded during exercise and affecting your quality of life I would push for better treatment.  An ablation offers the best chance of an effective treatment for AF (I see you have already had one for Atrial Flutter).  It would certainly be more effective than tweaking pacemaker settings, taking anti-arrhythmic or rate control meds.  I presume if you need it for AF stroke protection, you are taking an anticoagulant?

So why should you bother with remote transmissions when no immediate adjustments can be made you ask?  I would reply, the benefits of being able to transmit an immediate transmission to your doctors seems obvious to me.  Transmissions could reveal the presence of a potentially serious arrhythmia, it could pick up a problem with any medication, an electrolyte problem or point to another health problem, it could reveal a pacing problem and so on, all requiring immediate treatment or follow up by your doctors.  With timely treatment, the patient will be better protected. 

Remote Pace maker checks

by Selwyn - 2021-02-08 12:34:16

Firstly, I hope you are anti-coagulated for your atrial fibrillation. You should be unless you have some bleeding disorder. There is a risk of blood clots ( thrombosis) and embolism ( there movement into other areas of your body) .

Speaking from the UK, I am amazed that you are charged $200 for the pleasure of someone checking your PM every three months. Whilst I appreciate the wisdom of having remote monitoring (as Gemita has outlined), I question the interval of 3 months. 

Here in the UK the norm is a yearly check up providing they know the PM is working OK, you are happy, and there is plenty of battery left. Medicine should be evidence based. Why 3 monthly? Can't understand it myself- unless you look at the $200 they make!!!!

Even with a battery power left of <18 months, I am not on 3 monthly check ups ( though I was ) as they have worked out the rate of power usage and know I am OK for 6 months. 

Challenge them for the evidence of their decision!  I think it is a money making exercise. Here, where the NHS provides for free, we are seen once a year. In all my years of looking after pacemaker patients I have never seen (or heard of) anyone coming to grief with this check up system. If they think you are having a problem they may wish to see you sooner ( as in my case). Having a pacemaker is hardly like flying an aircraft- you should not need adjustments every three months.  

It is important to have a telephone number for contact so that if you wish to speak with someone with knowledge and the hardware, you can do so. 

Thank you all for your feedback!

by Julros - 2021-02-08 14:07:10

A little more background on me: I have a masters degree in cardiovascular nursing, so I feel like a have a good grasp on arrhythmias. I can probably read an EKG better than Agent X86's ER doc, lol. Yes, I am on anti-coaguation: Eliquis. I experienced a small stroke which sort of kicked off my diagnosis of a flutter, leading to an ablation and a CRT-P. The rationale was that my EF was 50%, and the wish to avoid pacermaker induced heart failure. 

I agree that the pacing checks are a money making exercise. Quarterly  interogations are probably the maximum that insurance will reimburse for. With my new insurance, I must fulfill the deductible before they will pay, and that would just cover a year of pacer checks. Cardiology office doesn't care about insurance but I am responsible for what isn't covered. 

 From my search for evidence the frequency of pacer interrogations, most point to detecting ventricular arrhythmias and worsing heart failure, neither of which I am at risk for. Yes, I "forgot" to do the remote check in October and got no feed back. So I will likely "forget" the one in April. 

Yes, I do get a little more winded when I run during Afib, but at least according to previous checks, they usually occur at night. I am doing what I can to minimize episodes: limited alcohol, BP control, weight loss, antiinflammatory diet. I do know that afib is generally a progressive condiion, but I can feel when I am in it and would seek care if it was intolerable. 

Remote Monitoring

by Marybird - 2021-02-08 14:18:02

Having looked at the Medicare reimbursement figures, as well as a few third party insurance sites here in the US for remote pacemaker interrogations, looks to me as though the $200 they're charging Julros is excessive. I'm looking at an explanation of benefits from my secondary insurance carrier ( primary is Medicare), and see that my cardiologist billed around $42 for the last remote pacemaker reading/interpretation, Medicare approved $32 and change, paid 80% of that and the secondary insurance paid the other 20% ( of the approved Medicare amount. For other insurances I have seen amounts around the $30-40 range ( depending on the location) So I don't know, $200  seems like a lot, unless that is what your physician is billing your insurance and expecting the reimbursement to be a lot less? And the insurance is passing that cost along to you? 

I'e be unhappy at paying that much for remote monitoring, let alone having to do it 3x a year and questioning the need to do it. In your shoes I'd talk to your doctor about adjustments to the costs, or the schedule for the remote monitoring, limiting monitoring to in-office visits, or let them explain to you why all those remote monitorings are needed.

I don't know if this is the standard of care in the US, but I'm on a 3 month remote monitoring schedule, as is my sister, and a couple of others we know with pacemakers or ICD's. Perhaps that's a sort of default monitor frequency with the wireless pacemakers/ monitors and "automatic" transmissions, but less frequent ( with specific instructions from one's doctor ) for the manual setups? Maybe providers set up remote transmissions every 3 months because they can, and they know they will be reimbursed by third party insurance carriers that often ( or more so if there is a problem). 

Maybe every 3 months is excessive if everything is stable, but seems to me that one of the ways to know that all is stable is to check the systems as frequently as needed. I just don't think it can hurt to have that sense of security ( especially if there are some medical, arrhythmia, or other pacemaker related issues) that all's been checked and ok. 

As I have recently had occasion to find out. I was recently informed, during a visit to my cardiologist's PA, that they were monitoring my remote transmissions, and had discovered the presence of a small amount of a-fib in those reports. I've had a long history of atrial tachycardias, one event of a- flutter, but this a-fib is new to me. The PA said that they never would have known about that afib without those remote reports- they're not all that frequent, they're short- lived, and I ignored the palpitations I got as insignificant. But their plans are to increase the metoprolol I take ( which seems to work well for me) depending on what's on those monitor reports, and go from there. Thanks to those monitor reports, they know exactly how much a-fib is there, can increase the meds as needed, and avoid the need for anticoagulation for now. 

I guess you just never know. 

Remote monitoring

by AgentX86 - 2021-02-08 19:43:05

I never got winded from either my Afib or the flutter after.  The AF felt horrible but I probably wouldn't have done much about it (other than the obvious).  Since I was having the CABG anyway, my cardiologist put a Maze and LAA clip on the menu as a side order.  The Maze failed miserably.  Well, it fixed the AF but left me in permanent AFL.  That, I couldn't stand.  No SOB or anything like that but awful palpatations, so bad that sleep was impossible.  Drugs sorta worked but ended up damaging my thyroid (ameoderone) and SI node (sotalol).

I looked up my insurance billing information for the remote monitoring.  My cardiologist's EP (not mine but the one reading the information) charged $112, which my insurance company has a contract for $55.  The monitor charge (don't know where that's going) was $136, with a contract price of $67.  So that's a total of $248 charged, the insurance' contract price was $122, of which I paid a $35 co-pay.

The ratio of billed to paid is about normal.  Of the $250,000ish my CSABG cost, my isurance paid about $120K and I paid about $1,000, only because I had two ER visits ($250 each). 

I paid nothing out of pocket for my PM because I'd already paid my annual maximum, even though it was in mid February (wow!  it's been three years).  I'd paid the annual maximum on January 9th (ablation).

Complicated?  Absolutely but we have the best congress that money can buy.  No, I don't want them messing with my health care more.  They've done enough damage to the insurance system (those with money can buy).

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I just want to share about the quality of life after my pacemaker, and hopefully increase awareness that lifestyles do not have to be drastically modified just because we are pacemaker recipients.