What are the potential costs of alternative the Federal Motor Carrier Safety Administration (FMCSA) and Federal Railway Administration (FRA) regulatory actions that would restrict the safety sensitive activities of transportation workers diagnosed with moderate-to-severe OSA?
The main costs relate to evaluation, diagnosis and treatment of sleep apnea. Costs may vary, depending upon providers, payors, regions and the types of tests being implemented. However, approximate costs can be estimated by looking at Medicare physician reimbursement fees.1 According to these figures, the cost of diagnosis would range from $170 for an HST to $796 for a negative HST followed by a confirmatory PSG. CPAP titration studies would cost about $658. A CPAP machine and supplies for 1 year costs about $1,000.2 An MWT, which is used to identify subsets of excessively sleepy individuals, costs about $424. However, there is great variation in the contracted rates of providers and insurance companies, providing an opportunity to reduce overall costs for high-volume screening programs.
Costs related to treatment
The average annual cost for treatment for an individual found to have sleep apnea, including physician follow up, additional supplies, and an additional CPAP titration study every 5 years is estimated to cost around $1,200/year 2 Alternative treatments for OSA, such as an oral appliance or surgery, would cost around $1,500 and $10,000, respectively. Furthermore, costs can be increased by failure rates of modalities of treatment then leading to another modality being tried.
The majority of costs are generally highest in the first year. Average costs can be lowered by starting treatment with CPAP in all patients, advancing to an oral appliance only after therapy failure with CPAP, and only utilizing surgery as a last resort for treatment.
Who would incur those costs? What are the benefits of such actions and who would realize them?
The costs related to evaluation, diagnosis, treatment and continued management of sleep apnea are usually paid for by an individual’s health insurance. It is less clear if insurance companies would cover the MWT testing. While this is the “gold standard” for evaluation of the ability to stay awake, it is not routinely implemented in the evaluation of patients with sleep apnea, as the majority of patients do not work in sensitive positions such as driving a train. In general, all reimbursement would be subject to variability in individual plans, deductibles, co-payments and related individual/family healthcare utilization. The benefits of treating sleep apnea are well described and elaborated upon below. While healthcare costs might increase in the short-term for patients diagnosed with the disease, long-term health care costs of individuals treated with sleep apnea are expected to decrease over time. In general, patients with untreated OSA incur additional costs of $1950 to $3899 per year in comparison to those who do not have OSA 3 Therefore, the health and financial benefits would accrue to the individual, employer and to the public.
Health benefits of treatment
What are the potential improved health outcomes for individuals occupying safety sensitive transportation positions and would receive OSA treatment due to regulations?
There are well established relationships between untreated sleep apnea and the development or worsening of obesity, depression, hypertension, diabetes, stroke, coronary artery disease, and cardiac arrhythmia. Individuals with untreated sleep apnea have a reduced quality of life and a shorter life span.3 Treating OSA successfully mitigates or reverses most of these risks.
What models or empirical evidence is available to use to estimate potential costs and benefits of alternative restrictions?
Several of the tests suggested in this paper might be considered “alternatives” to the traditional evaluation of sleep apnea, such as the MWT, for which we have provided cost data (see “Medical Cost” above) that is available from the Centers for Medicare and Medicaid Services.
Paying for apnea
What costs would be imposed on transportation workers with safety sensitive duties by requiring screening, evaluation, and treatment of OSA?
In general, screening, evaluation, and treatment of OSA is paid for by health insurance companies. However, transportation workers or their employers would be responsible for deductibles, co-payments and uncovered screening, evaluation and treatment of OSA. If patients do not report snoring or excessive sleepiness, coverage for a sleep test from an insurance company could be denied. In the general population, there is no specific incentive to under-report symptoms. However, as discussed above, under-reporting is common in transportation workers. This could contribute to cost of testing being shifted towards the workers and employers in many cases.
Are there any private or governmental sources of financial assistance? Would health insurance cover costs for screening and/or treatment of OSA?
As discussed, reimbursement varies based on the insurer. It is likely that all screening and treatment of OSA would be paid for in the cases of transportation workers. It may also be a shared cost or one that might need special negotiation if the decision is made to test all workers rather than only testing individuals who meet the sleep testing criteria determined for the general population.
- The American Academy of Sleep Medicine. Sleep Services Payment Comparison 2014 National Payment vs. 2015 National Payment. (Link)
- McKinsey& Company. The price of fatigue: The surprising economic costs of unmanaged sleep apnea. 2010. (Link).
- Knauert, Melissa, et al. “Clinical consequences and economic costs of untreated obstructive sleep apnea syndrome.” World Journal of Otorhinolaryngology-Head and Neck Surgery1 (2015): 17-27. (Link)