A Cost Minimization Analysis of Home versus Lab-based Diagnosis of Obstructive Sleep Apnea

Abstract

Importance: Insurers have adopted new reimbursement policies for diagnosing and treating obstructive sleep apnea (OSA) using home sleep testing (HST) instead of laboratory-based strategies. Objective: We conducted an economic analysis of the HomePAP study, a multi-center randomized clinical trial that compared home-based versus lab-based testing for the diagnosis and management of OSA. Design: A cost-minimization analysis from the payer and provider perspectives was performed, given that 3 month clinical outcomes (acceptance, adherence, and functional status) were equivalent for the home and laboratory arms. 2011 Medicare price weights were used for the payer perspective. HomePAP sites submitted itemized cost estimates for the provider perspective. Setting: Seven academic sleep centers. Participants: 373 subjects at high risk for moderate to severe OSA were randomized to either home-based limited channel portable monitoring followed by unattended auto-titration with continuous positive airway pressure (CPAP), versus a traditional pathway of in-laboratory sleep study and CPAP titration. Main outcome measure: Per-subject costs, as randomized, in US Dollars. Results: From the payer perspective, per subject costs for the lab-based pathway were $2,124 (95% C.I. $1,948, $2,308) compared to $1,874 (95% C.I. $1,724, $2,020) for the home-based pathway under the base case. Costs were $250 (95% C.I. $10, $494, p=0.04) in favor of the home arm. From the provider perspective, per subject costs for the lab arm were $1,940 (95% C.I. $1,801, $2,079) compared to $1,992 (95% C.I. $1,870, $2,123) in the home arm, for a difference of $51 (95% C.I. -$235, $142, p=0.59) in favor of the lab arm under the base case. Differences in payer and provider costs resulted in a provider operating margin of $184 (95% C.I. $126, $244, p<0.001) in the lab arm compared to a loss of $118 (95% C.I. -$159, -$77, p<0.001) in the home arm. Conclusions and Relevance: For payers, a home-based diagnostic pathway for OSA with robust patient support incurs fewer costs than a lab-based pathway, but has comparable if not higher costs for providers, resulting in a negative operating margin for providers. This analysis shows the need to ensure that cost savings under HST are sustainable without potentially compromising patient care.