title: Medicare long-term CPAP coverage policy: a cost-utility analysis.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  Cost-utility and cost-effectiveness analysis.
  
  
  METHODS
  U.S. Medicare Population.
  
  
  METHODS
  N/A.
  
  
  METHODS
  N/A.
  
  
  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.
authors.affiliation: UW Medicine Sleep Center, University of Washington, Seattle, WA.
authors.forename: Martha E
authors.initials: ME
authors.lastname: Billings
authors.forename: Vishesh K
authors.initials: VK
authors.lastname: Kapur
mesh_terms: D000368:Aged; D045422:Continuous Positive Airway Pressure / Q000191:economics* / Q000379:methods; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D003663:Decision Trees; D005260:Female; D017048:Health Care Costs; D006291:Health Policy; D006801:Humans; D008134:Long-Term Care; D008297:Male; D006278:Medicare / Q000191:economics*; D011050:Policy Making; D017286:Polysomnography; D019057:Quality-Adjusted Life Years; D012720:Severity of Illness Index; D020181:Sleep Apnea, Obstructive / Q000175:diagnosis / Q000191:economics / Q000628:therapy*; D014481:United States
keywords: CPAP; Cost-Utility Analysis; Medicare