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Publication Briefs

Significant Cost Difference between VA and Community Care for Testing among Veterans with Obstructive Sleep Apnea

When VA cannot achieve predefined access standards, Veterans are eligible for referral to non-VA providers under a fee-for-service reimbursement model with direct relationships between VA and community providers. The Choice program used third-party administrators to contract with providers and coordinate care; referrals from this program now exceed $5 billion annually. Almost half of Veterans are at high risk for obstructive sleep apnea (OSA), and community sleep programs represent an opportunity for improved access. Traditionally, laboratory-based sleep testing was necessary to diagnose OSA, but portable home sleep apnea tests provide an efficient patient-centered option, have equivalent accuracy among appropriate patients, and cost much less than lab-based testing ($170 vs. $663 per test). Using VA administrative data for Veterans' sleep studies conducted from October 2014 to July 2016 – a period of transition from Fee-Basis to Choice for community care – investigators compared sleep study use among Veterans tested by VA, Fee-Basis, and Choice providers. Investigators also examined patient demographics, diagnoses, and medications. Regardless of where testing occurred, patients had similar characteristics across age, demographics, and comorbidities.


  • Veterans referred for community care were much less likely to receive home sleep apnea testing than Veterans cared for in the VA healthcare system, and were more likely to receive in-lab testing, leading to greater costs to the system.
  • VA providers performed 38% of studies as home tests, compared to 19% in Fee-Basis, and 4% in Choice. Due to lower rates of home-testing, every 100 Veterans referred to Fee-Basis represented $8,831 greater costs relative to VA, and every 100 Veterans referred to Choice represented $15,814 greater costs.


  • Although home tests were performed among only a minority of patients, there was a marked difference in the use of home tests between VA and community care. Thus, these study results have important implications for VA as it expands the use of community care under the MISSION Act with regard to promoting efficient and patient-centered care for Veterans.


  • The cost model used in this study likely underestimated the cost difference between community care and VA.
  • Investigators did not measure or compare patient outcomes (i.e., treatment adherence).

Drs. Donovan, Feemster, Zeliadt, and Au (co-Director) are part of HSR&D's Center of Innovation for Veteran-Centered & Value-Driven Care, Seattle, WA. All authors except Dr. Kirsh are part of the VA Puget Sound Health Care System. This study was funded by VA's Office of Rural Health and the Office of Veterans Access to Care.

PubMed Logo Donovan L, Coggeshall S, Spece L, Griffith M, Palen B, Parsons E, Todd-Stenberg J, Glorioso T, Carey E, Feemster L, Zeliadt S, Kirsh S, and Au D. Use of In-Laboratory Sleep Studies in the VA and Community Care. American Journal of Respiratory and Critical Care Medicine. June 17, 2019; Epub ahead of print.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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