By E. Michael Lewiecki, MD, New Mexico Clinical Research & Osteoporosis Center and Andrea Singer, MD, Chief Medical Officer, National Osteoporosis Foundation and Director of Bone Densitometry, MedStar Georgetown University Hospital
Susan is an active 76-year-old woman who enjoys cooking large meals for her friends in her senior community. She has six grandchildren and while playing with the youngest grandchild, she fell and fractured her hip. Her bone break resulted in hospitalization and surgery, followed by a stay at a rehabilitation facility to build strength and practice daily activities in a safe environment. She practiced everyday skills like how to get in and out of the shower and wash dishes. She is back in her apartment now, but she has difficulty performing some of the activities that have given her great joy in the past.
Does this story sound familiar to you? Do you have a mother, grandmother, sister or aunt who has experienced a life-changing fracture?
Every three seconds, someone in the world breaks a bone because of osteoporosis,1 and in the U.S., one in two women over the age of 50 will have an osteoporosis-related bone break in her lifetime.2 Osteoporosis is a major public health crisis, and many experts agree that this crisis is caused by the declining rate of testing, diagnosis and treatment of high-risk patients.3 Today, fewer than 20 percent of women receive treatment for osteoporosis even after breaking a bone.4 Repeated fractures, especially of the hip, lead to hospitalizations and long-term care needs. In 2018, the annual direct medical costs associated with osteoporotic fracture were estimated to be $48.8 billion, with this cost projected to increase.5
Focus on Diagnosis
Not too long ago, between the mid 1990s and early 2000s, the number of hip fractures in the United States were steadily declining.6 But that decline plateaued in 2012.3 Without policy changes to increase testing, diagnosis and treatment, the annual number of fractures due to osteoporosis is projected to increase from 1.9 million to 3.2 million, or in other words 68 percent from 2018 to 2040, at a total estimated cost to society of over $95 billion annually.5
The stalled progress in reducing hip fractures coincides with decreased availability of an essential diagnostic tool called dual-energy X-ray absorptiometry (DXA). Since 2008, the number of physicians in the United States offering this standard osteoporosis test has fallen by 26 percent.7 Osteoporosis diagnoses have fallen 21.5 percent since 2009, despite the aging of the population, and the National Osteoporosis Foundation estimates that 43,661 additional hip fractures have occurred as a result.7 We believe the decrease in DXA screening has been driven by reduced Medicare reimbursement to levels that are below the cost of providing for the procedure at many facilities. Since 2006, Medicare reimbursement for DXA in the physician office setting has shrunk by 70 percent.7
Congressional action is urgently needed to reverse this trend. This year a bipartisan bill has been introduced in the Senate by Republican Susan Collins of Maine and Democrat Ben Cardin of Maryland that would restore DXA reimbursement. Similar legislation has been introduced in the U.S. House of Representatives by Democrats John Larson of Connecticut, Linda Sanchez of California and Republicans Susan Brooks and Jackie Walorski both of Indiana. Under this proposal, a floor on Medicare reimbursement for DXA would be set at $98, helping to ensure patient access to this important test. The national average for Medicare reimbursement of DXA scans of axial skeleton sites, which include the hips, pelvis and spine, done in a physician office are currently around $40 per scan.8 Such measures are an important step to restoring the downward trend in hip fractures and their associated health effects.
The Benefits of Awareness
Osteoporosis is often called a “silent disease” because weakened bones cannot be felt.2 Most women aren’t even aware they have osteoporosis until they break a bone.2 Fractures are widely considered an inevitable consequence of old age, but many don’t realize that if you fall or trip at standing height and break a bone, it’s likely not due to clumsiness, but due to osteoporosis. With proper testing, the risk of breaking bones can be assessed, even before the first fracture. For high risk patients, treatment to reduce fracture risk should be considered. Patients should also be evaluated for balance and muscle strength so that interventions to reduce the risk of falls can be started, when needed.
DXA, or a bone density test, are recommended by the U.S. Preventive Services Task Force for all women over 65 years, and for many women under 65 who have certain risk factors.9 The American College of Physicians recommends DXA for men at increased risk of osteoporosis .
In our study recently published in the Journal of Bone and Mineral Research Plus, we found that increasing DXA screening could have substantial benefits that include preventing 3.8 million fractures. Our research suggests that together, boosting screening to 31.3 percent and doubling treatment rates in women 65 years and older has the potential to reduce the total direct medical costs of osteoporosis by just shy of $55 billion through 2040.5 Improving postmenopausal osteoporosis management can reduce fractures and result in substantial cost‐savings, a rare and fortunate outcome in the current healthcare landscape.
We can help prevent the serious consequences of this disease. If you have a loved one who is at high risk for fracture, talk to her about osteoporosis and the importance of asking her doctor for a bone density test.
Additionally, ask your elected representatives to support the Increasing Access for Medicare Beneficiaries Act of 2019 legislation, which would increase Medicare reimbursement for this important diagnostic test. With policy changes and increased awareness of the benefits from testing, diagnosis and treatment, we can substantially limit the impact of osteoporosis for America’s older people and society in coming decades.
1IOF. Facts and Statistics. Available at: https://www.iofbonehealth.org/facts-statistics. Accessed April 29, 2019.
2NOF. Osteoporosis Fast Facts. Available at: https://cdn.nof.org/wpcontent/uploads/2015/12/Osteoporosis-Fast-Facts.pdf. Accessed April 29, 2019.
3Lewiecki EM, Wright NC, Curtis JR, Siris E, Gagel RF, Saag KG, et al. Hip fracture trends in the United States, 2002 to 2015. Osteoporos Int. 2018 Mar;29(3):717–22.
4Boytsov, N. N., Crawford, A. G., Hazel-Fernandez, L. A., McAna, J. F., Nair, R., Saundankar, V., … Yang, F. E. (2017). Patient and Provider Characteristics Associated With Optimal Post-Fracture Osteoporosis Management. American Journal of Medical Quality, 32(6), 644–654.
5Lewiecki EM, Ortendahl JD, Orgle-Vanderpuye J, Grauer A, Arellano J, et al. Healthcare Policy Changes in Osteoporosis Can Improve Outcomes and Reduce Costs.JBMR. 2019 Mar 15.
6Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and Mortality of Hip Fractures in the United States. JAMA. 2009 Oct 14;302(14):1573–9
7Peter M. Stevens, PhD. Direct Research LLC, Medicare PSPS Master Files and Medicare 5% LDS SAF. Cost model and projections. https://cdn.nof.org/wpcontent/uploads/DXA-Testing-State-slides-6-19-18.pdf. Accessed April 25, 2019.
8P2017 Bone Density & Supplementary DXA Exam Reimbursement Guide. GE Healthcare. https://www.gehealthcare.com/-/media/1c85e676e8c148fb9e65425d9916fc37.pdf?la=en&hash=2A1F29DADA32816C6DC0D82F1E0BEEE7323D9CCA. Accessed May 16, 2019.
9U.S. Preventive Services Task Force. Published Final Recommendations: Osteoporosis Screening. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/osteoporosis-screening1 Published June 2018. Accessed April 25, 2019.