Medicare long-term CPAP coverage policy: a cost-utility analysis

J Clin Sleep Med. 2013 Oct 15;9(10):1023-9. doi: 10.5664/jcsm.3074.


Study objectives: CPAP is an effective treatment for OSA that may reduce health care utilization and costs. Medicare currently reimburses the costs of long-term CPAP therapy only if the patient is adherent during a 90-day trial. If not, Medicare requires a repeat polysomnogram (PSG) and another trial which seems empirically not cost-effective. We modeled the cost-effectiveness of current Medicare policy compared to an alternative policy (clinic-only) without the adherence criterion and repeat PSG.

Design: Cost-utility and cost-effectiveness analysis.

Setting: U.S. Medicare Population.

Patients or participants: N/A.

Interventions: N/A.

Measurements and results: We created a decision tree modeling (1) clinic only follow-up vs. (2) current Medicare policy. Costs were assigned based on Medicare reimbursement rates in 2012. Sensitivity analyses were conducted to test our assumptions. We estimated cumulative costs, overall adherence, and QALY gained for a 5-year time horizon from the perspective of Medicare as the payer. Current Medicare policy is more costly than the clinic-only policy but has higher net adherence and improved utility. Current Medicare policy compared to clinic-only policy costs $30,544 more per QALY.

Conclusions: Current CMS policy promotes early identification of those more likely to adhere to CPAP therapy by requiring strict adherence standards. The policy effect is to deny coverage to those unlikely to use CPAP long-term and prevent wasted resources. Future studies are needed to measure long-term adherence in an elderly population with and without current adherence requirements to verify the cost-effectiveness of a policy change.

Keywords: CPAP; Cost-Utility Analysis; Medicare.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Continuous Positive Airway Pressure / economics*
  • Continuous Positive Airway Pressure / methods
  • Cost-Benefit Analysis
  • Costs and Cost Analysis
  • Decision Trees
  • Female
  • Health Care Costs*
  • Health Policy
  • Humans
  • Long-Term Care
  • Male
  • Medicare / economics*
  • Policy Making
  • Polysomnography
  • Quality-Adjusted Life Years
  • Severity of Illness Index
  • Sleep Apnea, Obstructive / diagnosis
  • Sleep Apnea, Obstructive / economics
  • Sleep Apnea, Obstructive / therapy*
  • United States