By Sree Roy

Many US health insurers refuse to cover CPAP for obstructive sleep apnea (OSA) unless adherence thresholds are met—but new data challenge that binary thinking. A large-scale actuarial analysis sponsored by EnsoData suggests that CPAP delivers measurable cost savings for Medicare beneficiaries, and it links simply starting the therapy to reduced healthcare utilization among people with OSA.

Among more than 28,000 beneficiaries studied who were diagnosed with OSA between 2016 and 2019, those who started CPAP but discontinued it within the first year still incurred significantly lower healthcare costs than those who never initiated treatment. The implication being that any CPAP use—regardless of adherence to a four-hour threshold—can lower the OSA-linked healthcare burden. In the study, the beneficiaries who met the adherence threshold had even greater healthcare cost savings per member per month. (Anytime a study analyzes retrospective data, such as Medicare claims, it is vital to remember that cause-and-effect cannot be determined; only an association can be noted.)

“Our economic study shows that diagnosing and treating obstructive sleep apnea is a healthcare economic winner for payors,” says study co-author Nathaniel F. Watson, MD, MSc, chief medical officer at EnsoData. “In other words, any costs associated with diagnosing and treating obstructive sleep apnea will be recouped by payors over time by reduced healthcare costs.”

In the patient population studied:

• 45% were CPAP adherers, meaning Medicare was charged at least four times for the patient’s device;
• 44% were non-initiators, meaning Medicare was never charged for a CPAP; and
• 10% were non-adherers, meaning Medicare was charged at least once for a CPAP but not more than three times—implying the person tried the device but did not stick with it in Medicare’s rent-to-own protocol.

Just Starting CPAP Might Matter

Study co-author Chris Fernandez, co-founder, executive chairman, and chief research officer at EnsoData, expresses surprise that the started-but-did-not-adhere cohort experienced significant cost savings, overall and when grouped by their comorbidities, compared to the people who did not try CPAP.

Over two years, people who started CPAP spent $153 less per month on healthcare costs versus those who did not give the therapy a try. The people who met the CPAP adherence threshold spent $196 less per month compared to the non-initiators—within the first two years on therapy. So the cost savings show up right away, Fernandez notes.

“This is motivating for the field,” Fernandez says. “Maybe it’s not binary, like above or below four hours. The more the better, and there’s a real benefit to supporting patients and trying to maximize and optimize their therapy.”

First author Emerson M. Wickwire, PhD, ABPP, CBSM, DBSM, says the findings make sense. “A number of studies have demonstrated that even partial [C]PAP adherence can lead to improved health outcomes,” he says. “It stands to reason that the same would also be true for economic costs.”

Cost Savings in People with OSA Comorbidities

Far from excluding OSA patients with comorbidities, the study leaned into them. The investigators further analyzed the cost differences in the three cohorts by separating them by seven common chronic conditions: chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), depression, hypertension, type 2 diabetes, obesity, and stroke.

The differences in per-member per-month costs for the people who were CPAP adherent versus those who did not try CPAP were:

• Stroke: $396
• CHF: $347
• COPD: $266
• Depression: $256
• Obesity: $225
• Hypertension: $205
• Diabetes: $181

“We want to try to make an economic argument about why treating sleep apnea is important beyond the improvements in quality of life, sleepiness, health, and well-being,” co-author Watson says. “We also want to highlight the economic opportunity here if we diagnose and treat sleep apnea across the board.”

Fernandez adds, “We hope that sleep physicians use these findings to promote more collaboration with other specialties,” including primary care, cardiology, and psychiatry. “It is something that can be immediately helpful,” he says. “Beyond that, part of why we did this work was, I think, that the health outcomes are better understood than the financial outcomes.

“We have a complex healthcare system with a lot of stakeholders…and being able to understand the benefits of the things that we do, both in health outcomes terms and in financial outcomes terms, can be really helpful to moving the whole system into a place that it would be better for all of us.”

Valuing Sleep within Healthcare

Co-author Wickwire, a professor and section chief (sleep medicine) at the University of Maryland School of Medicine and the University of Maryland Medical Center, says, “One of the key lessons is that to define, demonstrate, and maximize the value of sleep, we need to understand what matters to those stakeholders whom we serve—our patients, referring providers, payors, the public, and so on. 

“In the short term, OSA care increases costs: for physician visits, diagnostic sleep testing, [C]PAP machines (or oral appliances or medications), and so on. These costs are generally front-loaded in year one, then decrease over time. This is why time horizon is so important when considering economic aspects of OSA care. It makes a big difference whether we look one or five years out.”

Fernandez hopes studies like this will ultimately result in a greater healthcare investment in sleep. He says, “We hope this contributes to the appreciation [of the value] that sleep apnea treatment has not only for quality of life and longevity, but also for its hard dollars impact.”

Reference

Wickwire EM, Fernandez CR, Huynh N, et al. Association between positive airway pressure therapy and healthcare costs among older adults with comorbid obstructive sleep apnea and common chronic conditions: an actuarial analysis. Sleep. 2025 Jan 13:zsaf009. 

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