The gap between how sleep medicine is practiced and how it’s paid for

Sleep disorders remain some of the most under-diagnosed conditions in medicine, and the way health plans pay for sleep care hasn't always kept pace with how the field actually treats patients.

To dig into that gap, Managed Healthcare Executive spoke with Fariha Abbasi-Feinberg, MD, FAASM, FAAN, president of the American Academy of Sleep Medicine (AASM) and former chair of the organization's Alternative Payment Models Task Force.

Abbasi-Feinberg discussed with us where reimbursement models fall short, which sleep disorders are most likely to go unrecognized, how payers should weigh a recent study linking insomnia to higher stroke and hospitalization risk and what she'd want health plan medical directors to understand about sleep medicine if she had their attention for five minutes.

MHE: From where you sit — both as a practicing sleep physician and as former chair of AASM's Alternative Payment Models Task Force — how well do current reimbursement models actually match how sleep medicine is practiced today?

Abbasi-Feinberg: Sleep disorders are often chronic conditions that require evaluation, treatment, and ongoing follow-up, but reimbursement models do not always reflect that continuum of care. We need models that support evidence-based diagnosis and treatment while also recognizing the value of longitudinal care, patient education, remote monitoring when appropriate, and coordination with other clinicians. Ultimately, reimbursement should support high-quality, patient-centered care, and improved outcomes.

MHE: Which sleep disorders do you think are most underdiagnosed in the general population, and how much of that is a screening problem versus a coverage/access problem?

Abbasi-Feinberg: Obstructive sleep apnea is an important example because untreated OSA is associated with serious health consequences, including cardiovascular and metabolic conditions. Data suggests that 80% of individuals with sleep apnea have not been diagnosed. That is clearly a very large number of people that need to be evaluated and treated.

Insomnia also can go unrecognized or untreated, particularly when patients assume that difficulty sleeping is simply something they have to live with.

Hypersomnias also pose a significant challenge as most are misdiagnosed as other medical issues.

Therefore, I think most sleep disorders are underdiagnosed at this time. There are challenges at several points in the process. Patients may not recognize their symptoms as signs of a sleep disorder, sleep may not always be discussed during routine medical visits, and access to sleep specialists and evidence-based treatment can vary. Improving recognition is important, but it also needs to be paired with appropriate evaluation and access to care.

MHE: A recent review found insomnia linked to a 26% higher stroke risk and 28% higher likelihood of hospitalization. Does that surprise you clinically, or does it confirm something you've already seen in practice?

Abbasi-Feinberg: These findings reinforce the importance of taking chronic insomnia seriously. Insomnia is a sleep disorder that can have a meaningful impact on daytime functioning, quality of life, and overall health. It should not be dismissed as simply having a few bad nights of sleep.

At the same time, we need to be careful about what this particular study tells us. The researchers identified an association between insomnia and stroke and hospitalization, but that does not establish that insomnia causes stroke. Often, individuals with medical problems do not sleep well and are diagnosed with insomnia.

The findings add to the growing body of research examining the relationship between sleep and health while underscoring the importance of appropriate evaluation and treatment of chronic insomnia.

MHE: Health plans have historically treated conditions like hypertension and diabetes as priority areas for care management. Where does sleep health — and insomnia specifically — rank in that hierarchy, and should it rank higher?

Abbasi-Feinberg: Healthy sleep is essential to health and well-being, and sleep health should be considered as part of comprehensive patient care. Sleep disorders also frequently coexist with other medical conditions, so overlooking sleep can mean overlooking an important part of a patient's health.

For chronic insomnia specifically, we already have effective, evidence-based treatment. The AASM strongly recommends cognitive behavioral therapy for insomnia, or CBT-I, as a treatment for chronic insomnia in adults. Ensuring that patients can access recommended treatments such as CBT-I is an important step health plans can take.

MHE: Stroke-prevention and cardiometabolic care-management programs typically screen for things like blood pressure and A1c. Should insomnia screening be built into those same programs, and if so, whose job is that — primary care, cardiology, or sleep medicine?

Abbasi-Feinberg: Sleep should be part of the conversation about a patient's overall health, particularly when patients report persistent difficulty sleeping or other symptoms of a sleep disorder. Primary care physicians and other clinicians can play an important role in identifying sleep concerns and referring patients for further evaluation when appropriate.

It is also important to distinguish screening from diagnosis. Identifying symptoms can help determine who needs additional evaluation, but diagnosing a sleep disorder requires an appropriate clinical assessment. Sleep health should not belong exclusively to one specialty. Better coordination among primary care, cardiology, neurology, and sleep medicine can help patients get the appropriate care.

MHE: What are the biggest barriers patients face in getting from "I think something's wrong with my sleep" to an actual diagnosis — and which of those barriers are structural versus clinical?

Abbasi-Feinberg: Recognition is one of the first barriers. People may normalize chronic difficulty falling asleep, staying asleep, snoring, fatigue, or excessive daytime sleepiness without realizing that these symptoms may warrant medical attention.

There can also be structural barriers, including access to clinicians with expertise in sleep medicine and access to appropriate diagnostic testing and treatment. Improving sleep care requires both helping patients recognize when they should seek care and ensuring that there is a clear pathway to an appropriate evaluation, diagnosis, and evidence-based treatment.

MHE: CPAP remains the gold-standard treatment for obstructive sleep apnea, but adherence is notoriously difficult. How should payers be thinking about covering alternative therapies when the "proven" treatment so often fails in practice?

Abbasi-Feinberg: Positive airway pressure therapy is an effective and reliable treatment for obstructive sleep apnea, but treatment should also be individualized to the patient. Many patients do incredibly well on CPAP. Compliance rates are variable, but we all take care of lots of patients that absolutely love their CPAP. Some patients have difficulty tolerating PAP therapy despite appropriate support, and evidence-based alternatives are available for certain patients.

For example, AASM clinical guidance supports considering oral appliance therapy for adults with OSA who are intolerant of CPAP therapy or prefer an alternative. There are also hypoglossal nerve stimulators that are effective in certain situations. Sometimes weight loss or positional therapy can be extremely helpful.

The appropriate treatment depends on factors including the patient's clinical circumstances, preferences, and response to therapy. Coverage policies should support evidence-based treatment options and allow clinicians and patients to determine the most appropriate approach.

MHE: Prior authorization is a constant friction point in sleep medicine. Where do you see it functioning as intended, and where is it mostly just adding delay without improving outcomes?

Abbasi-Feinberg: Payer policies should be aligned with evidence-based clinical guidelines and support patient safety and high-quality care. Prior authorization can be useful when it ensures that testing or treatment is clinically appropriate, but it becomes problematic when administrative requirements create unnecessary barriers or delays for care that meets established clinical criteria.

The AASM has specifically evaluated payer policies for diagnostic testing for obstructive sleep apnea based on how closely those policies align with evidence-based clinical practice guidelines. That alignment is important. When clinical indications for testing or treatment are established, the process should help patients receive appropriate care efficiently.

MHE: The researchers behind the stroke study were careful to call the link correlation, not causation. How should a payer or health system interpret a finding like that — is it strong enough evidence to justify changing coverage or screening policy, or is it more of an early warning sign?

Abbasi-Feinberg: I would consider this an important signal that warrants continued research rather than evidence that, by itself, should drive a change in coverage policy. An association does not establish that insomnia causes stroke, nor does it establish that treating insomnia will reduce stroke risk.

What we already know is that chronic insomnia is a sleep disorder for which evidence-based treatments are available. Health systems and payers do not need to wait for evidence of a causal relationship with stroke to make sure that patients with chronic insomnia can receive an appropriate evaluation and have access to recommended treatment.

MHE: How is telehealth and home sleep testing changing access to sleep medicine, particularly in rural or underserved areas — and have payer policies kept pace with that shift?

Abbasi-Feinberg: Telehealth and home sleep apnea testing can help expand access to sleep care when they are used appropriately. AASM guidance recognizes home sleep apnea testing as an alternative to polysomnography for diagnosing obstructive sleep apnea in uncomplicated adults who have signs and symptoms indicating an increased risk of moderate to severe OSA.

However, home sleep apnea testing is not appropriate for every patient and should not be used for general screening of asymptomatic populations. The decision to use a home sleep apnea test should be based on a patient's medical history and clinical evaluation, and the test should be ordered and appropriately interpreted as part of medical care. Maintaining those clinical safeguards while supporting appropriate telehealth and home testing can help expand access without compromising quality.

MHE: What would a genuinely value-based payment model for sleep medicine look like, and what's stopping the field from getting there?

Abbasi-Feinberg: A value-based approach to sleep medicine would focus on whether patients receive appropriate, evidence-based care and achieve meaningful outcomes rather than simply counting individual visits, tests, or procedures. That means supporting appropriate diagnosis, effective treatment, follow-up, and long-term management of chronic sleep disorders.

Sleep medicine also intersects with many other areas of health care, which can make measuring its value more complicated. Better integration of sleep care with primary care and other specialties, along with appropriate measures of quality and outcomes, can help us move toward models that reward high-quality, coordinated care.

MHE: Sleep medicine sits at the intersection of a lot of specialties — cardiology, neurology, psychiatry, primary care. How well coordinated is care for patients with sleep disorders today, and what's the cost of poor coordination?

Abbasi-Feinberg: There is significant opportunity to improve coordination. Sleep disorders can coexist with cardiovascular, neurologic, metabolic, and mental health conditions, so sleep cannot always be considered in isolation.

Better communication among sleep medicine physicians, primary care physicians, and other specialists can help patients receive appropriate evaluation and treatment while reducing gaps in care. The goal should be to treat the whole patient and recognize sleep as one component of overall health.

MHE: If you had the attention of health plan medical directors for five minutes, what's the one thing about sleep medicine you'd want them to understand that you don't think they currently do?

Abbasi-Feinberg: Sleep is essential to health, and sleep disorders deserve the same attention as other chronic medical conditions. These disorders can affect daytime functioning, quality of life and overall health, and evidence-based diagnostic and treatment options are available.

I would encourage health plans to make sure their policies align with evidence-based sleep medicine guidelines and provide patients with access to appropriate evaluation and treatment. Supporting high-quality sleep care is part of supporting the health of the whole patient.