Reimbursement must support continuity, not just short-term compliance

Obstructive sleep apnea (OSA) is a chronic condition affecting millions¹, with significant consequences for cardiovascular health, neurocognitive function and quality of life. The standard of care, continuous positive airway pressure (CPAP) therapy, demonstrates clear benefits, yet long-term adherence remains a major challenge. Up to 50% of patients discontinue CPAP within five years², and only a minority transition to alternative therapies.

As highlighted in recent work, effective OSA management must focus on minimizing “time to effective therapy” and maximizing “time on effective therapy” across the patient’s lifespan. Structured and dynamic follow-up, including regular evaluation cycles and a multi-layered assessment of therapy effectiveness (e.g., the S-O-S criteria)³, are essential for identifying patients who require therapy optimization or alternative treatment early and providing prompt, effective care.

How reimbursement models shape adherence

Current reimbursement structures in many countries are built around short-term compliance thresholds. For example, the U.S. Centers for Medicare and Medicaid Services (CMS) 90-day rule and similar policies in other health care systems incentivize early adherence but may inadvertently penalize gradual, individualized progress.⁴ These frameworks risk excluding patients who could benefit from therapy and reinforce health inequities.

As shown in recent analysis, only 1–2% of patients who discontinue CPAP are transitioned to second-line therapies, despite high dropout rates.⁵ This gap highlights the need for structured, dynamic follow-up and payment models that support therapy optimization and alternative treatment pathways.

Practical implications for clinicians

• Structured follow-up: Implement regular evaluation cycles (e.g., every 3 months) to assess patient satisfaction, therapy effectiveness (e.g., AHI reduction, usage hours) and symptom improvement. Use standardized tools such as the S-O-S questionnaire to guide decisions on therapy continuation, optimization or change.
• Early identification of suboptimal therapy: Proactively identify patients with inadequate adherence or unsatisfactory outcomes and consider alternative therapies (e.g., mandibular advancement devices, hypoglossal nerve stimulation) as recommended by guidelines.
• Patient-centered care: Recognize that adherence is influenced by modifiable factors such as patient confidence⁶, digital engagement and system support.⁷ Tailor interventions to individual needs and provide opportunities for therapy re-entry.
• Advocate for policy change: Engage with payers and policymakers to promote reimbursement models that reflect OSA’s chronic nature, support long-term management and reduce barriers to therapy optimization.

International models and future directions

Countries such as France have implemented telemonitoring and pay-for-performance models that incentivize sustained CPAP usage and direct resources toward patients at risk of discontinuation. In Germany, digital health applications and expanded coverage for alternative therapies are steps toward more flexible, patient-centered care.⁸

However, successful implementation depends on robust digital infrastructure, interdisciplinary collaboration and ongoing evaluation of care models. Disease management programs (DMPs) for OSA, as proposed in recent literature, should integrate digital tools and may further enhance long-term outcomes.⁵

A recent statement from a European Respiratory Society (ERS) task force reviewed the evidence and efficacy of telemonitoring in OSA. The group concluded that telemonitoring could improve the access to care and increase adherence. However, they also noted that cost and possible compliance challenges need consideration.⁹ More research is required to explore not just the integration of digital solutions into current pathways, but also the implementation of actual changes to those pathways.

Conclusion

Adherence to OSA therapy is a function of system design, not just patient motivation. To improve long-term outcomes, reimbursement frameworks must evolve from short-term adherence gating to models that support flexible, individualized and sustainable care. Structured follow-up, early identification of suboptimal therapy and integration of alternative treatment options are essential. This requires close collaboration between professional societies, payers and industry stakeholders with a shared focus on improving outcomes. As demonstrated in recent studies, including our own, these strategies can extend “time on effective therapy” and reduce the burden of untreated OSA across the lifespan.