Redesigning payment models to sustain OSA therapy

Flexible, longitudinal obstructive sleep apnea (OSA) care is both clinically sound and economically sustainable. As OSA gains recognition as a chronic condition, payers must redesign reimbursement models that undermine sustained therapy.

Clinicians today operate under significant resource constraints and payment models tied to short-term adherence metrics. In this environment, payers risk letting a payer’s prediction of who will comply with therapy versus a patient’s actual motivation gatekeep access to OSA care. This perceived “willingness to adhere" approach may seem pragmatic, but in reality, it systematically excludes patients who could benefit from treatment and deepens health inequities.

The consequences extend far beyond individual patients. Coverage frameworks that restrict OSA therapy based on projected adherence will ultimately drive up long-term system costs from untreated cardiovascular conditions, workplace accidents and emergency interventions, while sidelining opportunities for proactive care that could reduce overall healthcare utilization.

How reimbursement rules hard-code patient drop-off

In many markets, payers shape what care patients receive. Reimbursement structures built around short-term compliance thresholds effectively bake attrition into the care pathway. Adherence criteria like the U.S. CMS 90‑day rule are financial instruments, not evidence-based standards, and create incentives that reward early compliance while penalizing the gradual, individualized progress necessary for chronic disease care.

These pressures cascade downstream. In response to policies that make long-term support financially unsustainable, home care and medical equipment providers have no choice but to prioritize patients who appear more likely to meet short-term targets.¹

Why perceived ‘willingness’ is a moving target shaped by policy

When coverage hinges on short-term adherence, “willingness to adhere” becomes a proxy for rationing care. It reflects the system patients move through, not their personality.

Evidence shows that adherence is driven by factors modifiable through policy, such as confidence to continue their therapy, digital engagement and health system support. A real-world study of over 13,000 U.S. PAP users found that confidence at initiation was the strongest predictor of both short- and long-term adherence. Patients who reported high confidence were 3x more likely to be compliant at three months and 5x more likely to remain on therapy at one year.²

Motivation itself varies by context. Internal motivators (e.g., wanting better sleep, not disturbing a partner) support adherence while external motivators (e.g., pressure from family) had the opposite effect. Support also had layers: regular data monitoring by healthcare providers improved outcomes, but passive check-ins had little effect.²

The takeaway is clear. Instead of letting “perceived willingness” be a precondition for access, it should be treated as a design outcome. Reimbursement frameworks must evolve to increase self-efficacy, sustain engagement and allow for therapy re-entry.

Real-world payer reforms for sustained OSA care

Some countries are moving beyond perceived willingness-based rationing toward payment models that maintain quality while expanding equitable access to care.

France offers a leading example through its national telemonitoring and reimbursement framework, which allows CPAP homecare providers to remotely track patient usage and receive performance-based payments.

This pay-for-performance model does more than reward outcomes: It incentivizes sustained, personalized support. Providers receive higher weekly fees when patients increase their nightly CPAP usage. National data shows that this strategy directs resources toward lower-adherence patients and boosts the number who achieve >4 h nightly usage.³

Across Europe, governments are increasingly embedding telehealth and digital care within reimbursement structures. In Germany, digital health apps can be prescribed for sleep disorders and reimbursed by statutory health insurances. While currently limited to insomnia treatment, researchers are exploring expansion to OSA care.⁴ The country’s Somnolink Project, established in 2024, is also working towards building a well-connected digital healthcare system and integrating machine learning-based clinical decision support and personal device monitoring into the OSA treatment pathway.⁵

While these reforms vary in maturity, they share a central theme: aligning payment with sustained support rather than front-loaded compliance thresholds. But their eventual success depends on infrastructure, regulatory design, provider buy-in and safeguarding against digital exclusion.

Who is being excluded, and why does it matter?

Long-term adherence to continuous positive airway pressure (CPAP) therapy is a global challenge. Data shows that 22.9% of patients in Japan discontinue therapy by the end of the first year and 33.5% by year three. Similar one-year discontinuation rates have been observed in large-scale studies from the U.S. (18.9%) and France (23.1%).⁶

A French nationwide analysis of 480,000 patients further shows that certain populations are systematically at higher risk for PAP therapy discontinuation:

• Age: Both younger (18–40 years) and older groups (>80 years) show elevated dropout.
• Gender: Females are more likely to terminate therapy compared to males.
• Comorbidities: Diabetes and COPD substantially raise the risk of stopping PAP treatment.
• Socioeconomic factors: Social context (marital status, education) and parental origin also influence adherence.⁷

These patterns reflect social determinants of health, not valid medical contraindications. By tying reimbursement to short-term adherence metrics, payers systematically disadvantage groups least likely to meet these early compliance thresholds. And in doing so, they deepen existing disparities rather than correct them.

Making equity actionable

To move beyond perceived willingness as a gate, health systems must adopt flexible, data-driven care models. Three priorities stand out:

1. Redesign reimbursement for long-term outcomes

   Healthcare payers must replace models that reward short-term adherence with chronic disease reimbursement frameworks and criteria that facilitate continued engagement, therapy reinitiations and health outcome. A chronic care lens to reimbursement design allows for iterative treatment and patient-centered pacing, especially for populations that face greater structural barriers to early adherence.

2. Fund digital infrastructure for monitoring and follow-up

   Payers need to invest in infrastructure that sustains engagement beyond therapy initiation by covering mechanisms like remote monitoring, EHR triggers and patient-reported outcome (PRO) tracking. Remotely monitored CPAP has been associated with 23% lower total costs, largely by reducing in‑office visits and improving adherence monitoring.⁸

   In the U.S., the American Academy of Sleep Medicine’s (AASM) newly released PRO tool, PLATO, offers a validated framework for longitudinal symptom tracking that integrates with EHR platforms.⁹

   But as payers expand telemonitoring coverage, they must also account for the digital divide. Patients with poor internet access, limited digital literacy, or complex social circumstances risk being left behind unless programs include alternate support paths.

3. Codify longitudinal nature in coverage policies

   Payer policies must formally reflect OSA’s status as a chronic condition requiring adaptive, long-term management. This includes establishing coverage provisions for multiple treatment modalities, re-entry opportunities, and equity-focused eligibility criteria. Regular reassessment (such as every five years or following major health events) should also be covered to ensure that treatment stays aligned with patient needs.

   Examples of such payer policy evolution already exist. In Germany, statutory health insurance historically restricted coverage to CPAP therapy only. But in 2021, the Federal Joint Committee approved coverage for mandibular advancement devices (MADs), demonstrating how targeted payment reform can expand therapeutic flexibility.¹⁰

National reimbursement frameworks must evolve to reflect OSA’s chronic nature. This means shifting from short-term adherence gating to flexible, longitudinal payment models that facilitate patient engagement and improved outcomes over time. France’s national telemonitoring model shows this transition is possible at scale, without increasing system burden.