Published November 1, 2019, in the American Journal of Managed Care by Robert Gagel, MD
Robert Gagel, MD, is chair of the Board at the National Osteoporosis Foundation. He is a professor of medicine at MD Anderson Cancer Center and an adjunct professor in the Departments of Medicine and Cell Biology at Baylor College of Medicine, both in Houston, Texas.
The importance of Medicare and the financial challenges it faces are at the forefront of our national discussions, whether during the 2020 Democratic presidential debates, or in Congressional conversations over price transparency and lowering the cost of prescription medications for patients. But these debates often ignore a serious health issue that threatens millions of Americans and the financial stability of Medicare.
Osteoporosis, or weakening of the bones leading to fractures, is a public health crisis that many people experience, yet few people know about. A new study by independent actuarial firm Milliman commissioned by the National Osteoporosis Foundation (NOF) found that an estimated 2 million Americans covered by Medicare, mostly women, suffered over 2.3 million osteoporotic fractures in 2015. In fact, osteoporosis-related bone fractures are responsible for more hospitalizations than heart attacks, strokes, and breast cancer combined. Spine and hip fractures are often defining moments in an older person’s life—leading to loss of independence, additional hospitalizations, and increased likelihood of death.
The cost and care implications of osteoporosis are expected to grow substantially as the baby boomers age. A study published this year found the total annual cost of providing care for osteoporotic fractures among Medicare beneficiaries, including direct medical costs as well as indirect societal costs related to productivity losses and informal caregiving, would rise from $57 billion in 2018 to over $95 billion in 2040 unless strategies are implemented to prevent fractures.
One of those impacted by osteoporosis is Claudia Kaufman, who suffered her first osteoporotic fracture in 2010. It wasn’t until her third fracture that she was diagnosed with osteoporosis. She recently learned that following her first fracture she had a screening that showed she had osteopenia — a precursor to osteoporosis. But she says her doctor never followed up to relay the results. Had this information been shared, Claudia could have started treatment and likely avoided the repeat fractures and a shoulder replacement she now needs.
We have the tools to fix this problem. Medicare pays for state-of-the-art bone density testing to identify those at risk of bone fractures, allowing for early and effective preventive steps and interventions. Medicare also pays for FDA-approved drug treatments for osteoporosis that can help reduce spine and hip fractures by up to 70 percent and cut repeat fractures by about half.
In addition, new models of coordinated, post-fracture care from health organizations such as Kaiser Permanente and Geisinger have proven to reduce rates of fractures. The NOF Milliman report concludes that reducing just 20% of repeat fractures could reduce Medicare spending by over $1.2 billion in 2 to 3 years.
Yet, all too often the tools we have go unused. The NOF Milliman study found just 9% of women covered through Medicare fee-for-service who suffered an osteoporotic fracture had a bone mineral density test within 6 months following their fracture. Other studies have shown that around 80% of those who have suffered a fracture have not received effective drug therapies to help prevent additional fractures. This is unacceptable.
It’s time to better utilize the tools we have to stem the osteoporosis crisis. The Senate Special Committee on Aging is taking this issue seriously and holding hearings and proposing reforms. Meanwhile, Medicare and other payers must incentivize and promote evidence-based care management and coordination—such as fracture liaison services—for those who have suffered a bone fracture and are at risk for another. Medicare payments for chronic care management should explicitly cover this needed and cost-effective care.
Cuts to Medicare payment rates for osteoporosis screening should be reversed – it is an example of false economy and has demonstrably reduced the availability of bone density testing. This would better encourage appropriate use of this proven way to reduce fracture rates.
Medicare and other payers should establish, adopt and incentivize appropriate quality measures for both optimal screening and treatment of osteoporosis and bone fractures. Medicare Advantage Star rating measures related to post-fracture care should be improved by creating separate measures for high rates of post-fracture screening and appropriate drug therapy treatment and adherence. Medicare Fee For Service should adopt and incentive similar measures.
While larger debates about health care coverage play out on the political stage, let’s ensure that we’re doing everything we can to end this public health crisis. For people like Claudia Kaufman, who have personally experienced the toll of osteoporosis, the system has already failed. But if we implement what we know works, we can help older Americans like Claudia and avoid the same suffering for others.