About 54 million Americans are estimated to be suffering from, or are at a high risk for, osteoporosis—a disease characterized by weak bones that are susceptible to fractures. In addition to a healthy diet, preventive screening is recommended to reduce the risk of osteoporosis-related fractures. The U.S. Preventive Services Task Force recommends screening for osteoporosis with bone measurement testing in women over 65 years and in postmenopausal women under 65 who are at an increased risk of osteoporosis.
The National Osteoporosis Foundation (NOF) recommends that post-menopausal women and men over age 50 should receive a bone density test with dual-energy x-ray absorptiometry (DXA/DEXA) on the hip and spine. But for more than a decade, DXA screening has seen a steady decline.
Since a majority of the population affected by this syndrome have Medicare coverage, Medicare reimbursement rates should adequately cover the tests used to measure bone mass and predict fracture risk. However, these rates are inadequate: Medicare reimbursement for osteoporosis screening in physician offices has decreased by 70% over a decade: from $140 in 2007 to $42 in 2018. Consequently, DXA tests offered in private physicians’ offices have reduced by 26%, resulting in a 21.5% decline in the diagnosis of osteoporosis. Reimbursement for hospital outpatient DXA services, however, has remained unchanged.
The outcome is mind-boggling: reduced screening stemming from lower reimbursement has resulted in 43,661 additional hip fractures and led to 9,518 extra hip fracture–related deaths per year over the decade from 2008 to 2018. Medicare had to bear an additional cost of $1.8 billion to treat hip fractures alone, some of which could have been prevented with adequate screening.
In 2016, patient advocates and representatives from the International Society of Clinical Densitometry, NOF, the American Society of Bone and Mineral Research, and the American Association of Clinical Endocrinologists visited Washington, D.C., to lobby CMS for improving DXA payment. One of the participants, Sarah Morgan, MD, CCD, from the University of Alabama at Birmingham Osteoporosis Prevention and Treatment Clinic and UAB DXA facility, highlighted the importance of DXA in predicting an impending fracture. The lower Medicare reimbursement has resulted in “fewer DXA machines, patients are receiving fewer DXA scans, and we are seeing a significant increase in hip fractures,” Dr. Morgan said.
What Policy Changes Are Needed?
A simulated model has projected a 68% increase in annual fractures, from 1.9 million to 3.2 million, between 2018 and 2040, which would increase the related cost of care from $57 billion to an estimated $95 billion. A vision to put brakes on this rise in the number of annual fractures over the next two decades will require solid policy changes that will promote screening to actively identify and initiate treatment among those at risk for osteoporosis-related fractures.
Senator Susan Collins (R-Maine) introduced the Increasing Access to Osteoporosis Testing for Medicare Beneficiaries Act of 2019 (S.283) in the Senate in January 2019, which specifies that certain Medicare payment rules applicable to imaging services will apply to bone mass scanning using DXA. The bill, which was referred to the Committee on Finance, recommends a minimum payment amount under Medicare Part B for bone mass measurement. If passed, the minimum reimbursement for Medicare enrollees undergoing DXA in a private clinic will be set at $98, to help incentivize screening.
In her statement before the U.S. Senate Special Committee on Aging in October 2019, Elizabeth Thompson, CEO of NOF, recommended a few other policy changes going forward:
- Payers should promote evidence-based care management and coordination, such as fracture liaison services for those who have had a bone fracture and are at an increased risk for another. Medicare, for example, does not pay for the care coordination strategy called the Fracture Liaison Service, which has been shown to have a positive impact on screening and therapies to improve outcomes and reduce costs. NOF recommended the development of a Medicare demonstration pilot or a bundled payment model to incentivize improved coordination of care.
- Payers should develop and implement quality measures for optimal screening and treatment of osteoporosis and bone fractures
- Launch a national education and action campaign to raise awareness and promote action to reduce the rate of falls and fractures
Advocating for and drawing attention to these changes could create a dent in the predicted number of osteoporosis-related fractures in the coming decades.
Patients Rising acknowledges the important contributions of Surabhi Dangi-Garimella Ph.D. in this article. Improving patient access is our mission and we’re happy to utilize a variety of experts to carry that out.