Healthcare Utilization and Costs in Persons With Insomnia in a Managed Care Population

Published Online: May 20, 2014
Louise H. Anderson, PhD; Robin R. Whitebird, PhD, MSW; Jennifer Schultz, PhD; Charlene E. McEvoy, MD, MPH; Mary Jo Kreitzer, PhD, RN; and Cynthia R. Gross, PhD

To better understand the direct costs of insomnia. Our study aimed to compare healthcare costs and utilization of patients diagnosed with insomnia who received care in a managed care organization with a set of matched controls.


Our observational, retrospective cohort study compared 7647 adults with an insomnia diagnosis with an equally sized matched cohort of health plan members without an insomnia diagnosis between 2003 and 2006. We also compared a subset of patients diagnosed with and treated for insomnia with those diagnosed with insomnia but not treated.


A large Midwestern health plan with more than 600,000 members.


Multivariate analysis was used to estimate the association between insomnia diagnosis and costs, controlling for covariates, in the baseline and follow-up periods. Although we cannot conclude a causal relationship between insomnia and healthcare costs, our analysis found that insomnia diagnosis was associated with 26% higher costs in the baseline and 46% in the 12 months after diagnosis. When comorbidities were recognized, the insomnia cohort had 80% higher costs, on average, than the matched control cohort.


These outcomes suggest the need to look beyond the direct cost of insomnia to how its interaction with comorbid conditions drives healthcare cost and utilization.

Am J Manag Care. 2014;20(5):e157-e165
Chronic insomnia, difficulty falling or staying asleep or experiencing poor-quality sleep, is a growing health problem with significant consequences for both individuals and the healthcare system.1,2 Chronic insomnia is associated with a host of physical, psychosocial, and emotional problems, including premature mortality, depression, anxiety, and poor quality of life.3-7 Chronic insomnia can also exacerbate comorbidities.8,9 In addition to the personal toll of chronic insomnia on the individual, major economic consequences for the healthcare system include increased direct medical costs and healthcare utilization.6,10,11 Research examining the economic consequences associated with chronic insomnia has highlighted the burgeoning indirect societal costs of insomnia, such as workplace absenteeism, lost productivity, and increased workplace errors and accidents.12-16 Less attention has been focused on direct healthcare costs and increased utilization associated with chronic insomnia.

Direct costs to the healthcare system associated with chronic insomnia are difficult to assess due to complexities and gaps in available data.17 Estimates of the aggregate costs of insomnia vary widely depending on the costs considered. 15,18,19 In earlier work, Simon and Von Korff20 interviewed patients in primary care clinics to measure insomnia prevalence, associated functional impairment, lost productivity, and comorbidities. They found that 10% of patients reported insomnia, which was associated with functional impairment, disability, and increased use of health services. A more recent study estimated the direct and indirect costs of untreated insomnia and found that direct and indirect costs for adults younger than 65 years with insomnia were $1253 greater than for subjects without insomnia for the 6-month study period.10

The most common treatment for insomnia is pharmacotherapy, with 2.5% of Americans taking prescription drugs to treat insomnia each year, and about 1 in 4 of them continuing treatment for 4 months or longer.21-24 Commonly prescribed US Food and Drug Administration (FDA)–approved hypnotics include benzodiazepines such as temazepam and triazolam, and drugs that act as agonists to benzodiazepine receptors such as zolpidem.25 These agents are efficacious in the short-term management of insomnia, but adverse effects include residual daytime sedation, cognitive impairment, motor incoordination, dependence, and rebound insomnia.26 A variety of cognitive and behavioral therapy (CBT) programs are as efficacious as approved sleep medications in the short term, side effects are nil, and benefits are more durable.27,28 There is, however, limited access to these programs due to a shortage of trained professionals.26,29-31 A 2002 national survey estimated that 2.2% of Americans use complementary or alternative therapies for insomnia.32,33 However, herbals, dietary supplements, over the counter medications such as diphenhydramine, and alcoholic beverages are not recommended for insomnia treatment due to lack of efficacy data, potential for adverse effects, lack of standardization, or a combination of these concerns.26

The purpose of this study was to estimate the healthcare costs associated with insomnia diagnosis by comparing costs and utilization of patients who have been diagnosed with insomnia to a set of matched controls. We compared costs in the baseline period before an insomnia diagnosis, in the 12-month follow-up period postdiagnosis, and the change in cost from baseline to follow-up. We also compared a subset of patients who received a diagnosis of insomnia and associated treatment with patients who received a diagnosis of insomnia but no treatment. This research will contribute to the scarce literature currently available on the direct costs and health services used by patients with chronic insomnia.


Study Population

We conducted a retrospective observational study using data from a large Midwestern health plan with more than 600,000 members. A study cohort of 7647 adults with an insomnia diagnosis during 2003 to 2006 was identified and compared with an equally sized matched cohort of health plan members without an insomnia diagnosis. All health plan members were eligible for the study if they met the following criteria: (1) at least 18 months of continuous enrollment from January 1, 2003, to December 31, 2006; (2) aged 18 years or older; (3) continuous pharmacy coverage; and (4) Medicaid or commercial insurance coverage.

Members were considered to have insomnia if they had a qualifying insomnia diagnosis code from January 1, 2004, to December 31, 2005, preceded by a 6-month period free of an insomnia diagnosis (baseline period) and if they remained in the plan for at least 12 months after the diagnosis (follow-up period). Qualifying insomnia cohort International Classification of Diseases, Ninth Revision codes were: 307.41 (transient disorder of initiating or maintaining sleep), 307.42 (persistent disorder of initiating or maintaining sleep), and 780.52 (insomnia unspecified). This research was reviewed and approved by the local Institutional Review Board.

Propensity Score Matching

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Issue: May 2014
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