Medicare Reductions Have Not Led to Significant BMD Screening Decline

February 17, 2012

February 17, 2012 — Medicare-eligible women have continued to get screened for osteoporosis, despite a reduction in reimbursement. The proportion of women diagnosed with osteoporosis after fracture (from 5.4% in 2005 to 8.3% in 2008), as opposed to by bone mineral density (BMD) screening (from 76.6% in 2005 to 65.0% in 2008), has increased, however, with the reduction in screening reimbursement.

The reasons for this increase in diagnosis postfracture are not entirely clear, according to new findings by Carrie McAdam-Marx, PhD, from the Pharmacotherapy Outcomes Research Center, University of Utah, Salt Lake City, and colleagues, published online February 13 in the Journal of the American Geriatrics Society. The authors suggest that it may be a result of women not being diagnosed until a fracture occurs. However, an alternative explanation would be that women screened earlier (eg, in 2005) who did not have osteoporosis at the time were not candidates for repeat screening (eg, in 2008), but went on to have a fracture.

Sharon A. Brangman, MD, past-president of the American Geriatrics Society, spoke with Medscape Medical News about the study, and offered her explanation of the data: "I think most doctors are basing their care on what's best for the patient." She explained that the concept of coping with reimbursement restrictions is not new for gerontologists because Medicare typically does not reimburse for the complexities of care for older adults.

The study was based on a large administrative claims database (MarketScan). Of the 5.6 million women in the database, the study focused on women aged 65 years and older with continuous employer-sponsored supplemental Medicare plan enrolment who had no claims history of osteoporosis diagnosis or treatment in 2004. It included a fixed cohort of 405,093 women (average age, 74.1 ± 6.7 years) for a 5-year period.

During the January 1, 2005, to December 31, 2008, study period, 37.9% of patients received 1 or more BMD test. Over the course of the study, 12.9% received the test in 2005, 11.4% in 2006, 11.8% in 2007, and 11.6% in 2008. BMD testing rates were highest in the youngest women. These rates are consistent with testing guidelines, although previous studies demonstrated a screening rate of 13% in 2005 and a trend toward increased screening in 2006 and 2007.

A total of 18.3% (n = 74,179) women received a new diagnosis of osteoporosis during the study.

The authors acknowledge that 5 years is a short period of time for assessing overall BMD screening and osteoporosis diagnosis. They also note that the claims database lacked data on osteoporosis and fracture risk factors, including BMD test results, alcohol use and abuse, and smoking.

The Medicare reimbursement reduction stemmed from the 2005 US Deficit Reduction Act (DRA), which was not specific to BMD testing. The DRA was estimated to reduce radiologists' income by an average of 1%. A previous study found that BMD screening in women aged 65 years and older who had employer-sponsored retiree health benefits did not significantly decline after DRA 2005 reimbursement reductions.

The more specific, 2007 reduction in Medicare reimbursement for office-based imaging services was projected to save $2.8 billion dollars over the course of 5 years. This study was performed in reaction to concern that BMD screening rates would decline after the 2007 Medicare reimbursement reduction for office-based imaging services. The authors found, however, that screening did not decrease at a rate relative to reimbursement reductions.

Dr. Brangman explained that there is always a concern about conflict of interest when a physician owns the screening equipment and is making a referral for the screening test. This study suggests that physicians continue to follow national guidelines with regard to screening. From a Medicare perspective, this is perfect because it decreases Medicare costs. It is also good from the patient perspective because patient care is not compromised.

The study was supported in part from an educational research grant by Novartis. Dr. McAdam-Marx and 3 coauthors have disclosed receiving salaries paid in full or in part by the Pharmacotherapy Outcomes Research Center, which received a research grant from Novartis to conduct this study. Dr. Brangman reports no conflict of interest.

J Am Geriatr Soc. Published online February 13, 2012. Abstract

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