Broken hips are among the most serious injuries incurred by older adults, and many fractures are preventable. According to the Centers for Disease Control and Prevention (CDC), approximately 300,000 people over the age of 65 are hospitalized each year for hip fractures, with women (who have lower bone density than men) experiencing three-quarters of all hip fractures.
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The Issue at Hand
Although dual-energy X-ray absorptiometry (DXA) is considered the gold standard in measuring bone density, diagnosing osteoporosis and helping prevent fractures, many physicians are finding it cost prohibitive to offer this service in their private practice.
“The [CMS] has cut DXA reimbursement in the private practice setting by more than 75% since 2007,” says Chris Phillips, MD, a rheumatologist in private practice in Paducah, Ky., and chair of the ACR’s Insurance Subcommittee. “The rate was $140 in 2007 and dropped to $42 in 2018.”
The ACR’s Response
Dr. Phillips and other members of the ACR have attended advocacy meetings in Washington, D.C., to support legislation for the Increasing Access to Osteoporosis Testing for Medicare Beneficiaries Act (H.R. 2693/S. 283). If passed, this would set the minimum for Medicare reimbursement at $98, ensuring bone density testing can be performed for more patients. The CMS has raised the reimbursement rate for DXA testing in the hospital setting, but the ACR would like to see rates raised in the private practice setting as well.
“It’s currently not cost effective for many physicians to replace older DXA machines when they break,” Dr. Phillips says. “We once had 22,000 DXA providers; today, there are less than 16,000. This can make testing difficult for patients who live in a rural area and don’t have easy access to a hospital.”
Why It’s Important
Dr. Phillips notes that raising reimbursement rates makes sense, because fractures in older adults often result in poor medical outcomes. A recent study found that one in three adults age 50 and older dies within 12 months of suffering a hip fracture.
“We’ve seen a 50% decline in DXA testing over the past decade,” says Ken Saag, MD, MSc, a rheumatologist in Birmingham, Ala., current ACR secretary and past president of the National Osteoporosis Foundation. As DXA testing has declined, doctors have seen an increase in the number of hip fractures reported among older adults. “Hip fracture rates had been on the decline, but in 2013, hip fracture rates leveled off and in some age groups, were even higher,” says Dr. Saag.
In 1986, I was the first practicing physician to purchase a dual-energy bone densitometer in the world. My fellow members of the ACR Council on Rheumatologic Care soon followed, and by the turn of the century, rheumatologists were providing 3 of 4 DXA studies in the US. We not only provided this service to our rheumatic disease patients, but to those referred by our colleagues. Many rheumatologists broadened their scope of practice to manage metabolic bone disorders with the drugs that emerged over the same decades. We came to understand that the report generated by the DXA machines was a non-starter for primary physicians and other specialties who either didn’t understand the management of metabolic bone diseases or weren’t interested managing them. So we created a broader scope of service including clinical history and recommendations for management to meet these needs.
What went wrong? To begin, CMS persistently denied payment for DXA in the 1990’s, and when forced to do so by congressional mandate, they made a pact with the American College of Radiology—the other ACR— to cut the reimbursement to a level incompatible with our “clinical densitometry” service. In my own market and many others this was a shameless power play by the other ACR to hold on to this imaging technology, much as they tried to do with OB-GYN ultrasound, and without consideration for the negative impacts on patient care and fracture incidence that Dr. Saag has described. As importantly, a robust multi-specialty US osteoporosis initiative, advances in delivery of care approaches for the populations at risk, and publications about clinical densitometry in Arthritis Care&Research and other publications withered.
Rheumatology’s lobbying for increased reimbursement is critical. The $95 payment will work out IF practices adopt efficient approaches to providing clinical densitometry and consultative care. Perhaps it will be helpful in our lobbying to point out to Congress the negative impacts of CMS’ policies in causing the shameful performance of the US health system in managing osteoporosis and other metabolic bone disorders.