Medicare payment cuts for osteoporosis testing reduced use despite tests' benefit in reducing fractures.

Bone imaging known as DXA ("dexa")-dual energy x-ray absorptiometry of the central skeleton--is considered the "gold standard" test for osteoporosis, which affects more than fifty million Americans. The tests are associated with improved clinical outcomes through preventing bone fractures. Cuts in Medicare Part B reimbursement for the provision of this preventive imaging in a physician's office began in 2007 and reached 56 percent below the 2006 level in January 2010. To encourage the use of DXA testing, the Affordable Care Act of 2010 provided partial relief from the cuts for two years (2010-11). Our study found that after a decade of growth, DXA testing in all Part B settings plateaued in 2007-09, resulting in 800,000 fewer tests than expected for Medicare beneficiaries--tests that might have prevented approximately 12,000 fractures. Testing declined in 2010, when the start of reimbursement relief under the Affordable Care Act was delayed, and increased outpatient testing failed to offset reduced use in physician offices. Our findings strongly suggest that the payment cuts reduced beneficiary access and that the tests were underused by elderly female Medicare beneficiaries despite strong association with fracture prevention. We recommend that Congress extend the payment relief granted under the Affordable Care Act for at least another two years.

Interstate variation in the burden of fragility fractures.

Demographic differences may produce interstate variation in the burden of osteoporosis. We estimated the burden of fragility fractures by race/ethnicity, age, sex, and service site across five diverse and populous states. State inpatient databases for 2000 were used to describe hospital fracture admissions, and a Markov decision model was used to estimate annual fracture incidence and cost for populations >or=50 yr of age for 2005-2025 in Arizona (AZ), California (CA), Florida (FL), Massachusetts (MA), and New York (NY). In 2000, mean hospital charges for incident fractures varied 1.7-fold across states. For hip fracture, mean charges ranged from $16,700 (MA) to $29,500 (CA), length of stay from 5.3 (AZ) to 8.9 days (NY), and discharge rate to long-term care from 43% (NY) to 71% (CA). In 2005, projected fracture incidence rates ranged from 199 (CA) to 266 (MA) per 10,000. Total cost ranged from $270 million (AZ) to $1,434 million (CA). Men accounted for 26-30% of costs. Across states, hip fractures constituted on average 77% of costs; "other" fractures (e.g., leg, arm), 10%; pelvic, 6%; vertebral, 5%; and wrist, 2%. By 2025, Hispanics are projected to represent 20% of fractures in AZ and CA and Asian/Other populations to represent 27% of fractures in NY. In conclusion, state initiatives to prevent fractures should include nonwhite populations and men, as well as white women, and should address fractures at all skeletal sites. Interstate variation in service utilization merits further evaluation to determine efficient and effective disease management strategies.

Fracture Reduction Affects Medicare Economics (FRAME): impact of increased osteoporosis diagnosis and treatment.

Osteoporosis is a common, debilitating disease affecting US Medicare beneficiaries, yet diagnosis and treatment lag behind medical advances. We estimated the cost of fractures to the Medicare program and the impact of increasing osteoporosis diagnosis and treatment. A Markov model was used to predict fracture incidence and costs in postmenopausal women aged 65 years and older, over 3 years (2001-2003). Only 1.80 million women were estimated to receive a Medicare-reimbursed bone mineral density (BMD) test in 2001. We evaluated the budget impact of testing an additional 1 million women from Medicare and patient perspectives. These women were stratified into high-risk (osteoporotic with prevalent vertebral fracture) and moderate-risk (without prevalent vertebral fracture) groups. During 2001-2003, an estimated 2.39 million fractures occurred among the 5.11 million women aged 65+ with osteoporosis, at a cost to Medicare of 12.96 billion dollars. We projected that BMD testing of an additional 1 million women in 2001 would result in treatment of 440,000 new patients with a bone-specific medication, preventing over 35,000 fractures over the 3 years. The decrease in fractures would produce a net discounted savings to the Medicare budget of 77.86 million dollars. Medicare's hospital inpatient cost would decrease by 115.41 million dollars and long-term care cost by 43.51 million dollars, more than offsetting incremental outpatient cost of 81.07 million dollars. Patients would benefit from fracture avoidance, but their out-of-pocket medical costs would increase by 63.49 million dollars during 2001-2003, or 1,771 dollars per fracture avoided. Sensitivity analyses showed that savings to the Medicare program varied in proportion to the unit cost of fractures, fracture risk of the populations tested, treatment rate, and adherence to therapy. Increased osteoporosis diagnosis may produce savings for the Medicare program if interventions are targeted to women at elevated risk for fracture and may be budget neutral if all older women are screened.

Methodology for estimating current and future burden of osteoporosis in state populations: application to Florida in 2000 through 2025.

OBJECTIVES: The aging population is expected to increase the burden of osteoporosis on the US health-care system. We developed a methodology for estimating current and future costs of osteoporosis in state populations and applied it to Florida. METHODS: We used Florida hospital, population and mortality data, along with national data on outpatient and long-term care, to estimate the cost of osteoporotic fractures in the year 2000. For men and for "other" fractures in women, costs were based on the incidence of hospital admissions for fractures. For hip, spine, and wrist fractures in women, we integrated hospital and nonhospital fracture incidence in a Markov model of osteoporosis. Consecutive cohorts were run by race for each age, 50 to 99 years, to estimate the number and cost of incident fractures. Ongoing costs of prevalent fractures in women were estimated using postfracture health states for each individual age cohort. Total costs and fractures for the years 2001 through 2025 were projected by multiplying the base-year cost and fracture distribution by age-, sex-, and race-specific population growth rates. RESULTS: In Florida, 86,428 osteoporotic fractures were estimated to occur in the year 2000 at a cost of 1,238,445,114 dollars. By 2025, the estimated number of incident fractures would increase to 151,622, at a cost of 2,135,130,564 dollars. CONCLUSIONS: This disease-modeling approach generates detailed information on the current and future cost burden of osteoporosis for an individual state population. Predictions based on this methodology may enable health-policy decisions that are tailored to local needs.