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ResMed CPAP-2012
ResMed CPAP-2012
Research Question:
Are increased competition, lower reimbursements and the CMS competitive bidding
program leading to less market share for CPAP industry leader ResMed?
Silo Summaries
Summary of Findings
ResMed holds 70% share of the sleep apnea mask market and
splits the CPAP machine market with Respironics, each with 40%
to 45% share. Fisher & Paykel Healthcare Corp. Ltd. (FPH) and
DeVilbiss Healthcare LLC are quality CPAP manufacturers but
only hold a very small percentage of the CPAP market.
ResMed
Share at
Risk
CMS Cuts
to Continue
5) INDUSTRY SPECIALISTS
ResMed Inc.
Background
Despite its leading position in the CPAP market, U.S.-based ResMed faces several challenges including increased competitive
bidding, reimbursement cuts and greater competition from low-cost vendors. ResMed management contends that competitive
bidding accounts for only 9% of its worldwide business, but bids represent 22% to 25% of the companys U.S. revenue.
ResMed is responding by increasing its product selection, improving efficiencies and testing partnerships with customers to
improve its bidding success.
CURRENT RESEARCH
To assess whether ResMed is losing market share because of challenging marketing conditions, we employed our pattern
mining approach and established sources in six independent silos:
1) Sleep therapy clinic professionals (9)
2) Corporate home health providers (6)
3) Physicians and dentists (8)
4) Sleep apnea equipment sales professionals (5)
5) Industry specialists (8)
6) Secondary sources (3)
We interviewed 36 primary sources and included three of the most relevant secondary sources focused on sleep disorder
diagnosis and treatment.
Next Steps
Blueshift will continue to monitor the bidding environment for sleep apnea equipment providers in the United States,
including ResMed and Philips Respironics. We will check on the trend toward in-home testing and determine if ResMed can
challenge Respironics apparent lead in this segment. We also will research ResMeds business outside the United States and
its growth and expansion in new markets and performance in more mature markets. Next, we will follow the growing market
of oral sleep-apnea devices and the dental communitys involvement. Finally, we will research ResMeds planned expansion
plans, including its own oral treatment device and treatment of other breathing disorders.
Silos
1) SLEEP THERAPY CLINIC PROFESSIONALS
Only one of nine sources said Philips Respironics was offering lower prices in bids and taking share from ResMed. Both
companies are the dominant providers of CPAP equipment. ResMed holds 70% share of the mask market but splits the CPAP
machine market with Respironics. Fisher & Paykel is a competitor but not an overwhelming concern. Sources agreed the
landscape for diagnosing and treating sleep disorders is changing and expanding. CMS and insurance company
reimbursement cuts are expected to continue, but will have a minimal effect on the CPAP market. Home sleep studies are an
emerging trend and are encouraged by the CMS and insurance companies. Respironics has an advantage in serving the inhome testing market. Sleep clinics are experiencing increased demand but are feeling the fiscal pinch of lower
reimbursements and the shift toward home testing.
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ResMed Inc.
Were in the second wave of CMS bidding, and were expecting 30%
reductions. It means no competition, and its a bad thing for patients.
The home sleep studies and
Theres limited equipment choice and mask availability; what they get
units are increasing. Philips
is already decided.
Respironics has a huge market
Our volume is declining due to competition.
there. Theyre doing a spring
Philips Respironics can offer cheaper pricing so theyre getting the
bid. Respironics is getting a little more market share because Philips
cleaning of the other guys.
is behind them financially.
Sleep Clinic Manager
ResMed has the best products. ResMed has an incredible marketing
Over 10 Years of Experience
department, and they can keep prices low. Fisher & Paykel [just
doesnt] have the market share.
We prefer the small CMEs [common medical equipment vendors] because they do more for patients than the
big companies, but patients have to go to them because of insurance.
The home sleep studies and units are increasing. Philips Respironics has a huge market there. Theyre doing a
spring cleaning of the other guys.
Manager of a midsize sleep center and also a sleep apnea patient, Arizona
ResMed equipment is superior, and its nasal pillows are popular. The company will not lose share, but the expected
decrease in CMS reimbursements will force DMEs and patients to use less expensive CPAP models, which manufacturers
are developing. Insurance companies will follow quickly and reduce their own reimbursements. Insurers are pushing inhome studies, which one-fourth the cost of a lab sleep study. The source said UnitedHealth Group Inc. (UNH) soon will no
longer pay for lab sleep studies in Arizona unless patients have comorbidities. He expects patient compliance to
deteriorate. Pediatric cases are driving up his centers patient volume.
DME companies provide compliance tracking and work with the patient. If reimbursement is cut 30%, it will be
very difficult to provide that. Compliance training programs helps the patient and helps identify if theyre not
compliant. Thats the goal of our DME and our sleep centers.
If reimbursement decreases, [vendors] will get more innovative with the tracking. Now DME companies have
teams to call patients and even get them in to see their physicians. There will be more wireless or web-based
programs.
If CMS cuts reimbursement 30%, insurers will renegotiate for less. Theres not a lot to reimburse higher when
their formulas are based on CMS rates.
Ive worked in sleep apnea for eight years now, and its definitely changing. UnitedHealth on Nov. 1 in our state
will no longer cover a lab sleep study unless the patient has comorbidities. A home sleep test is very limited, and
is only for obstructive sleep apnea. Its a dumbing down of sleep medicine, but it is finally decreasing the costs.
I dont think ResMed will lose market share, but the patient has to suffer with cheaper-built and noisier
machines. Both ResMed and Respironics are coming out with economy machines, with no bells and whistles, to
meet that demand.
ResMed and Respironics have great products, and both companies are coming out with new designs for better
tolerance. I think having two strong competitors is great for the patient. As far as machines, the ResMed is quiet
and a nice package. Their masks far exceed others we use here. ResMeds R&D is the best, and their reps are
professionalnot to say Respironics arent.
The new nasal pillow design Swift FX by ResMed is gaining. We use a lot of ResMeds Mirage [FX]. Theyre
really, really popular, and the techs find it easy to fit.
Our organization has its own CME company that we work with, but they dont dictate what we use. We see more
patient tolerance and effectiveness with ResMed equipment in our lab.
I havent heard about tighter mask regulations, but it sounds terrible. Theyre a wear item, and its good to have
auto shipments, which reduces the chance of infection. People come in to our sleep center with awful masks.
Dentists set up a CPAP or oral device, but who follows up then? Each dentist decides what oral device to use. I
attended one talk, and there were 70 to 80 dental devices on the market. ResMed just purchased their own
device. One dentist specialist gave a talk and whittled that down to two models.
DME is a big service industry, and not all are good. Its not just putting CPAPs on the patient. If patients arent
seeing a sleep specialist, their primary care doc doesnt always know what is best. They rely on the DME who too
often says, Heres the machine, and good luck.
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ResMed Inc.
This is our best year; were up about 7% year to year. Were seeing our pediatrics volume double the last few
years.
Sleep practice manager for a medical center in the central United States
This source has not heard about the CMS-directed reimbursement cuts, but said health insurance companies likely will
mirror the decrease. ResMed, Respironics and Fisher & Paykel products are
prescribed and used equally, although some patients prefer Respironics.
Starting in November, home testing will be the norm, but patients with more
Starting in November, testing
difficult cases still will be tested in the lab.
will be done in-home. It was
I havent heard of any new CMS cuts. I would imagine that other
driven by insurance companies
[insurance] companies would follow.
We prescribe both ResMed and Respironics. We also prescribe Fisher
because it is hundreds of
& Paykel. One is not really used much more than the other. We give our
dollars cheaper. Severe apnea
patients choices.
cases will still be tested in the
Our patients might prefer Respironics just a bit more because it is
hospital.
easier to use.
Starting in November, testing will be done in-home. It was driven by
Sleep Practice Manager
insurance companies because it is hundreds of dollars cheaper.
U.S. Medical Center
Severe apnea cases will still be tested in the hospital.
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ResMed Inc.
ResMed and Respironics place approximately equivalent numbers of blowers, effectively dominating the entire
market between them. ResMed is definitely the mask leader with 70% of the market. Respironics controls 25%
of the mask market, with various other manufacturers making up the remaining 5%.
ResMed has the best mask. It is easier to fit, more comfortable, and has fewer parts.
CPAP is 100% effective but not always individually viable. Newer technologies will fill a niche for [non-CPAP
compliant] OSA patients. Oral appliances are not for everyone. Surgery is painful, expensive and provides only
short-term results. Other technologies like microwaving the palate to tighten it have not demonstrated longterm success.
ResMed Inc.
We use ResMed masks but not ResMed equipment. We use Philips Respironics. Its a physician decision.
ResMeds masks are better than any other companys. They have amazing masks for patients. We dont work
with them on other devices like CPAP machines.
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ResMed Inc.
There is an expectation that the DOT [Department of Transportation] will mandate OSA screening in the next
three to four years. OSA is considered an epidemic among truckers.
New OSA innovations are likely to address only a small percentage of the market. There are concerns about
clinical efficacy, reimbursement and total cost to the patient. CPAP is the most effective and reliable solution for
sleep apnea patients. Compliance and monitoring are also critical to a CPAP treatment program. These
alternatives do not offer clear approaches to ensuring compliance.
Two of these six sources think ResMed will lose share to Philips Respironics. Both ResMed and Respironics are considered
the sleep therapy equipment market leaders and are expected to do well despite the continuation of CMS cuts and the new
medical device tax. The diagnosis and treatment of sleep apnea are growing. Cost-containment efforts include home testing,
competitive bidding in additional markets, and cheaper CPAP devices from China.
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ResMed Inc.
ResMed Inc.
As far as CPAPs, whats increasing are sophisticated CPAPs that tell us more data about the patients sleep.
[Ventus Medical Inc.s] Provent is something to look at and is a small piece of the puzzle. When it works, it
works very well.
Vice president of finance for a home service company in the Pacific Northwest
This source expects 30% CMS reimbursement cuts. To survive, the sources company will ask ResMed and Respironics
for price cuts and will focus on serving rural areas for more clients. ResMed and Respironics each control nearly one-half
of the sources service area. Patients rarely question the ordered brand. The sleep apnea market is on the increase. Inhome testing is just starting to take off, and 20% of patients will have in-home testing by next year. The sources company
has a 92% compliance rate because it works carefully with each patient.
Round-two bidding is starting, when the new rates will come out. We
bid to win. I know we will be offered a contract and a 30% cut. To
Most patients are being tested
survive, we are expanding business to focus on rural areas, a whole
in the lab, but we are just
new shift. DMEs make less than 3%, and there is little to cut from.
starting to see a shift to in We will need to go back to ResMed and Respironics and say that we
need to pay less. We will be more aggressive in our quarterly buys with
home testing. Last year 99%
them. Our sales reps will work with us. Our success is their success.
were lab tested, and 1% was
You cant shove the extra prices onto Medicare patients. Thats part of
done at home. Today we see
the ADMs. Its always been a rule that you cant upscale Medicare
90% lab testing and 10% in
patients.
home. In one year, it will be
We are strong and not overleveraged. We think we will be fine [after
the Medicare cuts].
80% in lab, 20% in home. After
I hope other insurance companies wont follow CMS cuts. We had to
that, in-home testing will really
drop UnitedHealth last year because of their cuts. We accept Aetna
take off.
[Inc./AET], but they only give a basic mask. The patient has to pay for
the upgrade.
VP of Finance, Home Service Company
Pacific Northwest
I havent heard about mask restrictions.
Both ResMed and Respironics are great machines. Fisher & Paykel is
good as well. DeVilbiss Healthcare is smaller. DeVilbiss may carry 3% of the market.
The sleep apnea market is absolutely increasing.
Most of our physicians write the requested brand in the prescription. What brand is sold where really depends
on the quality of the sales rep. The sales reps are hard-working and very good.
The patients just go along with what is ordered. We rarely have a patient specify a certain brand.
We co-market with the sales reps, so it works both ways. People know to order from us.
Most patients are being tested in the lab, but we are just starting to see a shift to in-home testing. Last year
99% were lab tested, and 1% was done at home. Today we see 90% lab testing and 10% in home. In one year, it
will be 80% in lab, 20% in home. After that, in-home testing will really take off.
Respiratory therapist and educator for a home health service in the Midwest
This source has not noticed any Medicare or insurance cuts, and said mask regulations are the same. The service equally
stocks ResMed, Respironics and Fisher & Paykel. Doctors prescribe only settings, not brands. Cases have increased
slightly because growing public and physician awareness.
Fees are the same. They are determined by the different insurance companies. We are not affected by
Medicare cuts in our area. There will be tighter regulations, but I havent seen anything yet. The cuts may not
affect patients, but they will affect the suppliers ability to supply.
Mask cuts may affect the patients, but we havent been hit yet.
We sell the three top brands, ResMed, Respironics and Fisher & Paykel.
The doctors do not recommend a brand; they just write a prescription for the settings. The patients come in,
and we show them the different styles. We talk about fit, what feels good. They pick out a brand depending on
what is most comfortable to them. All the pumps are just about the same, so it is really the mask they are
deciding on. The masks are interchangeable with the tubing, but they get a free mask to start out with, and we
generally match the masks to pumps. Of course, it also depends on their insurance.
There is an increase in patients ordering apnea devices, but it is not significant. I think there is more awareness
of the problem, and more doctors are prescribing the tests.
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ResMed Inc.
Our patients are often the elderly although CPAP patients are getting younger and younger.
These eight sources, comprising six physicians and two dentists, said the sleep apnea diagnostic and treatment population is
growing. ResMed and Respironics are the clear leaders in CPAP device manufacturing. Pricing pressure stemming from
competitive bidding and reimbursement cuts from CMS and insurance companies is leading to increased in-home testing and
the use of lower-grade equipment. The use of oral devices is on the rise, particularly when a CPAP patient has compliance
challenges. Dentists are realizing the financial opportunities and flocking to conferences and seminars to learn about sleep
apnea treatments.
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ResMed Inc.
Respironics are the leaders, but Provent is an exciting innovation. Additional reimbursement reductions are a concern as
current reimbursement often does not even cover costs. As a result, this center does not accept Medicaid.
Competitive bids are horrible. Customer support [by the large DMEs] is abysmal already, and then you lose
staff, which directly affects patient success. The equipment is poor, and theres no teaching. CMS is shooting
themselves in the foot.
The biggest issue is the DME companies. They will say the folks are compliant because they deliver the
machine, but then they take the machine away.
Were scared about the CMS competitive bidding because we already dont cover our costs. We have to exclude
[Medicaid] because it doesnt pay the cost of the sleep study.
The high-end equipment is important. Those bells and whistles churn out important data. Those data cards
dont just measure compliance; they tell me if the patient is still having events.
With the DME we use, patients can give some input on equipment. They certainly dont have that with Apria.
Apria underbid and has all the HMO business in the area. Theyre horrible.
ResMed and Respironics are the gold standard. I dont think Fisher & Paykel is very good.
Provent is exciting. A lot of things are still experimental such as oral appliances and [nerve] stimulators.
Procedures are growing. Primary physicians are more aware that patients insomnia cases may be sleep
apnea.
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ResMed Inc.
I think volume [of our in-patient sleep studies] has been fairly flat. We dont offer the at-home, but were in the
process to have the equipment for that.
I think all the manufacturers are represented in the automated equipment.
My scrips are open-ended. Im not all that familiar with the individual manufacturers equipment differences.
I dont think patients really understand the differences, so they go with the recommended equipment.
Assistant professor of sleep medicine for a large East Coast medical center
This source had not heard of any CMS reimbursement or mask replacement changes, but said health insurance
companies would follow CMS lead. CPAP manufacturers offer similar quality. Physicians do not order a specific brand,
and patients have their own preferences. The field is definitely growing. In-home testing is not as complete as lab testing.
Oral appliances are becoming more popular but are not as effective as CPAP.
I havent heard of any new Medicare fee changes, but if Medicare changes, the other insurance companies will
follow in time. The same goes for mask replacements.
There are a number of companies manufacturing CPAP, and they are equally as good.
The physicians here just order a CPAP, and the patients try out the different types in clinic. They pick out the
brand they prefer.
More people are asking about sleep apnea because there is more talk about it. The field is increasing.
In-home testing is not as good as lab testing. Lab testing is more complete.
The fees for this program have remained the same. Some insurance companies are better than others, but that
is always the case.
More people are using oral appliances, and a lot of companies are making them. [But] I dont think they are as
effective as CPAP.
ResMed Inc.
get the diagnosis, there is a possibility we can get coverage on medical for patients as opposed to dental.
I dont take Medicaid or Medicare at the moment.
Dentists probably dont want to use a CPAP because you could ruin your referral source from the sleep center
that does use CPAP.
I dont know a lot about the companies that make CPAP devices. The best device really depends on the cost
factor and what works best for the patient.
These five sources, representing three CPAP companies and two oral device companies, consider CPAP to be the gold
standard for treatment and ResMed and Respironics to be the industry leaders. Competitive bidding and reduced
reimbursement will not affect the two companies market share. Emerging trends include the increase in home testing, the
use of oral devices, and growth in sleep apnea treatment for perioperative patients. One source expects equipment
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ResMed Inc.
manufacturers to begin buying DMEs or selling directly to consumers in an effort to remain competitive. Another said Provent
has bypassed the distribution channel and already is marketing directly to patients.
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ResMed Inc.
ResMed Inc.
Provent placements are on the increase. The device was originally targeted for CPAP-noncompliant patients.
Provent is FDA-cleared for all variants of OSA, however, so the focus is expanding beyond CPAP failures alone.
The advantages of Provent include greater comfort and no need for electricity or water. The technology is based
on the patients own breathing patterns. It typically takes three to seven nights to acclimate, but the company
has introduced a ramping process and more patient-centric education, which is reducing the acclimation time.
Provent costs are typically paid out of pocket although it has been reimbursed by insurers on a case-by-case
basis.
The Provent system may be successful in as much as 75% of apnea cases, particularly mild to moderate OSA
patients.
New technologies like hypoglossal nerve stimulation are still under development. The technology holds some
promise, but the effectiveness is unknown at this point.
Apnicure [Inc.] is another technology just approved in 2012. It involves a vacuum to stabilize the tongue and
increase the size of the airway. It also holds some promise but is not currently reimbursed.
ResMed Inc.
35% to 45% on machines and disposables. It is affecting revenues. 3) There is a movement to not replace parts
unless nonfunctional and broken. They wont automatically pay for disposables.
The oral appliance market is very small, 2% to 3%. It will grow slowly in the next few years to 5% to 8% and
eventually more because at least one-half of the people do not comply with CPAP. Its a matter of patient access.
Dentists are not vigilant in getting into medical insurance. We need to have this insurance ratio go up; then
patients would not have to pay out of pocket for oral devices.
There is 85% to 90% compliance for oral devices. This is a more stable area than CPAP.
A lot of dentists are opting out of Medicare because the reimbursement is not enough.
TAP has 75% of the oral market, and SomnoMed has most of the rest. Now with the Medicare approval of
Herbst, that essentially kicks everyone out.
The FDA and Medicare just came out supporting Herbst. Dentists who are prescribing other oral appliances,
even the most popular ones, could have problems without an FDA approval.
The CMS and FDA policy change and appliance approval are a mess right now. They approved only two of three
Herbst appliances because two labs got early approval during competitive bidding. However, these labs have no
traceable FDA 510(k) registration. This was a classic disconnection; there arent any kickbacks. There are
thousands of dental labs, and the FDA got flooded with requests, it got so out of hand. They need to reclassify
the policy. We are in the process of reapplying for the 510(k); we are refilling out everything.
5) INDUSTRY SPECIALISTS
These eight sources reported growth in the sleep apnea market and pricing pressure from reduced reimbursements and
increased competitive bidding. ResMed and Respironics are the clear market leaders. Fisher & Paykel and DeVilbiss hold
niche positions with quality products. In-home sleep studies are on the rise because of third-party payers cost-containment
measures. One source said small DMEs will be forced out of business because reduced reimbursements will result in tight
margins. The use of oral treatment devices is on the rise. A source representing a oral appliance lab said the devices
comprise 5% of the market today but that usage will grow 10 to 15 times in the next 10 years. Other new treatments will
serve only a small number of patients.
Executive at an OSA patient education organization that provides CPAP supplies and instruction
ResMed and Respironics compete head to head in the CPAP market. Respironics has an advantage in data management,
while ResMed dominates the mask market. Continued price pressure from payers is driving in-home sleep studies and
default therapy. CPAP is the established therapeutic standard. New technologies are promising but unproven.
Downward price pressure from payers is consistent across the board. The allowed number of masks and other
disposable components is going down.
Payers drive the clinical patterns for care. Aetna, United, Harvard Pilgrim [Healthcare Inc.] and others are
making in-lab sleep studies difficult. Within two years, every payer will bias payment toward home sleep studies
unless significant comorbidities exist.
Physicians claim the diagnostic value is much higher for in-lab sleep studies. They want to be able to rule out
other problems. But the truth is that OSA can be presumptively diagnosed on presentation, in about 20 seconds.
The payer is driving cheaper approaches to diagnosis. There is a trend now from presumptive diagnosis to
default CPAP therapy. The additional sleep studies are done only if CPAP does not resolve the problem.
The direct-to-CPAP approach makes sense to me. CPAP is a no-harm therapy and an effective approach to cost
containment. Payers are partnering with utilization management
companies like CareCore National [LLC] and CareCentrix [Inc.] to drive
behavior toward the lowest cost options.
The Respironics system has
CPAP systems have two basic parts: a blower and a mask. The
better data capabilities, which
software algorithms may vary somewhat, but the basic CPAP brands
are functionally equivalent. DME companies will buy whichever is
makes it more useful for home
cheaper.
sleep studies.
CPAP therapy brand selection is made either by the physician or the
Executive
DME. Some physicians are closely involved with the process, but in
OSA Patient Education Organization
general they leave it up to the DME. The patient load is simply too high
for a lot of personalization by the provider. Some MDs will make mask
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ResMed Inc.
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ResMed Inc.
I am not aware of a patient CPAP device preference. They would rather not have any device at all. The CPAP
brand is typically recommended by the physician. Unfortunately, if the patient is uncomfortable with the original
device/mask, they will often just give up on CPAP altogether.
ResMed Inc.
ResMed Inc.
We are in the process of looking at competitors policies. From an economic standpoint, it would be less
expensive to have a flexible plan and a proper mask fitting, than to deal with and overturn complaints.
CMS currently has a six-month policy on masks and a three-month policy on tubing. Most masks are made well.
This is not a bad policy.
The vendors take care of at-home monitoring, to ensure compliance. They follow the patients carefully for the
first 12 months to ensure that they are doing OK. Some patients may get a warning if they are not using the
equipment appropriately. In rare cases, the patient is denied, and the equipment is taken away after a year. The
patients may or may not appeal that process.
[Testing for] sleep apnea addresses a lot of health issues. Under our plan, oral appliances for obstructive sleep
apnea are considered a medical necessity.
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ResMed Inc.
We need better pediatric devices, but there is not a lot of money in pediatrics. We have a lot of hoops to go
through to get products approved.
Forty percent of the kids are compliant, about the same as the adults. Its best to get the kids to wear the
masks. The kids are going through critical growing periods, metabolic function changes, and it could affect them
cognitively.
If adults wear the masks just four hours at night, or 50% of the time, they are compliant. But kids sleep more,
and four hours is not enough time for them to benefit.
Secondary Sources
The sleep apnea diagnostic and treatment market is expected to grow to $8.4 billion by 2018. ResMeds plans for future
growth are in new markets, including the treatment of non-sleep apnea breathing disorders. A poll of a sleep apnea patient
forums CPAP users revealed that ResMed and Respironics were the clear leaders in CPAP equipment.
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ResMed Inc.
and Therapeutic segments, large base of undiagnosed sufferers, knowledge regarding the inter-relationship
between Sleep Apnea and other conditions, and the usage of devices for Home Sleep Testing constitutes the
other factors expected to drive market growth in the future.
There are around 84 types of sleep disorders presently known, of which Obstructive Sleep Apnea (OSA) is the
most frequently occurring type, with about 100 million individuals across the world suffering from OSA. Of this,
about 83% of the cases are still undiagnosed. However, the awareness of the disease condition, and of the comorbid conditions, among patients and doctors is growing. Against this backdrop, given the large percentage of
undiagnosed sufferers, there exist vast prospects for sleep apnea diagnostic and therapeutic devices.
Increasing preference for home diagnostics is encouraging individuals to undergo sleep testing in the comfort of
their homes, increasing the rate of diagnosis.
Sleep apnea is seen in more than 18 million individuals in the US. The sleep therapy sector presents lucrative
growth opportunities given the increasing number of patients diagnosed with OSA in the US. Nevertheless,
growth is expected to mainly surge from the emerging markets, including the Middle East, Asia-Pacific, and Latin
America. The regions together are projected to surge ahead, exhibiting a CAGR of 18.9% over the analysis
period. With better equipped sleep labs and increasing knowledge among general physicians, the markets are
geared up for significant growth. Europe and Japan offer more significant growth opportunities compared to the
US, given the fact that penetration rates are much lower than in the United States.
Additional research by Linda Richards, Renee Euchner, Steve Evans and Pam Conboy
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