The Centers for Medicare and Medicaid Services (CMS) plans to significantly reduce reimbursement for dual-energy X-ray absorptiometry (DXA),—used to measure bone density, diagnose osteoporosis and help prevent fractures—performed as a hospital outpatient service in the 2017 Hospital Outpatient Prospective Payment System (HOPPS). If finalized, by 2023 it will cut payment for the DXA testing by 37%.
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Where the ACR Stands & Why
The reduction follows a 75% decline in reimbursement for DXA performed in physicians’ offices since 2006. The ACR has worked with a coalition of state rheumatology societies, professional organizations and advocacy groups to author a letter to the CMS expressing opposition to these new cuts. The letter’s long list of authors includes the Black Women’s Health Imperative, the Philadelphia Rheumatism Society and the United States Bone and Joint Imperative.
Although randomized controlled trials have not shown that DXA testing prevents fractures, indirect and observational evidence shows that it “saves lives and money,” says ACR member and incoming chair of the Government Affairs Committee, Angus Worthing, MD, FACP, FACR.1
For example, between 2009 and 2014, when office-based reimbursement was sharply declining, 2.3 million fewer DXA tests were performed.2 Between 2008 and 2015, Dr. Worthing says, osteoporosis diagnoses dropped by 17%, with a concomitant increase in surprise hip fractures (no prior osteoporosis diagnosis) of 14%.
“An elderly woman who goes to the hospital for a bone density test now faces the risk that the hospital may not offer it,” Dr. Worthing says. “It appears that lower reimbursement in a fee-for-service system correlates with less utilization.”
Consequences of the Cuts
Medicare’s reimbursement cuts for office-based DXA testing were projected to save $2.8 billion over five years.3 However, recent estimates show that these cuts led to more than 5,000 deaths and an additional $1 billion in Medicare hip fracture-related expenditures between 2009 and 2014.2
“One-quarter of [elderly] people die within the first year of a hip fracture,” says Dr. Worthing. “And Medicare ends up spending a lot of money on these patients because they are often hospitalized and may require an operation.”
A 2007 study in the Journal of Bone and Mineral Research found that osteoporosis leads to 2 million fractures in the U.S. each year, a number expected to hit 3 million by 2025, at a cost of $34 billion annually.4
“There is cause for concern regarding whether and how Medicare beneficiaries will maintain access to a proven and noninvasive preventive service from their providers if the proposed [HOPPS] cuts are implemented,” the coalition letter says.
Support for Bipartisan Bill HR2461
The ACR also supports the bipartisan bill H.R.2461, which establishes a floor for DXA testing reimbursement. The ACR has conducted visits to Capitol Hill to lobby for adequate reimbursement rates for DXA testing, and it also encourages members to visit the Legislative Action Center for information on how to contact their state representatives.
The U.S. Preventive Services Task Force gives DXA testing a “B” rating as an effective screening tool and “it’s recognized by CMS as a fundamental test for elderly women during the ‘Welcome to Medicare’ preventive visit,” Dr. Worthing says.
- Kling JM, Clarke BL, Sandhu NP. Osteoporosis prevention, screening and treatment: A review. J Womens Health (Larchmt). 2014 Jul;23(7): 562–572. doi: 10.1089/jwh.2013.4611.
- Direct Research LLC. Medicare PSPS Master Files and Medicare 5 Percent Sample LDS SAF, analysis by Peter M. Steven, PhD.
- McAdam-Marx C, Unni S, Ye X, et al. Effect of Medicare reimbursement reduction for imaging services on osteoporosis screening rates. J Am Geriatr Soc. 2012 Mar; 60(3):511–516.
- Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res. 2007 Mar;22(3):466–475.
Kelly April Tyrrell writes about health, science and health policy. She lives in Madison, Wis.