Doctors have an effective way to scan bones for osteoporosis and the risk of fractures, but Medicare is paying less and less for those scans when they are done in doctors' offices.
Lower reimbursement appears to have resulted in fewer doctors providing the service, meaning some patients who could take medicine to prevent bone loss might go undiagnosed. The Medicare system will save money for the short term, some experts say, and rack up greater costs in the treatment of hip, back and wrist fractures over the long term.
The problem is of growing concern, they add, with the population aging. And it affects elderly rural residents more profoundly because they may have to travel farther for their scans if a doctor stops providing the service in their town.
The declining use of bone-density scans, commonly called DXA, demonstrates the influence federal Medicare administrators' decisions have on doctors and patients. Taxpayer-funded Medicare and others in health care are aiming to curb cost increases, and proponents of the bone-density scans say they have been ensnared in national concern about overuse of imaging in general.
But reducing reimbursement makes no sense when it comes to a disease that already is widely ignored and diagnosed and treated far too rarely, says an osteoporosis researcher in Omaha who leads the National Osteoporosis Foundation.
“It's scandalous in the United States,” said Dr. Robert Recker, director of the Creighton University Osteoporosis Research Center.
The International Society for Clinical Densitometry reported that the number of women on Medicare who received scans dropped from 2.24 million in 2010 to 2.10 million two years later.
The society said the scanning system is underutilized, not overutilized. Dr. John Schousboe, the society's president, said a study found that 41 percent of women 65 and older didn't have a scan between 2002 and 2010.
Dr. Jeffrey Curtis, a University of Alabama at Birmingham associate professor, wrote in a 2012 report about DXA and Medicare reimbursement that a net 482 physician practices discontinued doing DXA scans in 2009 (1,876 discontinued the service and 1,394 initiated it).
Curtis said it's more convenient to have the scan done in a patient's doctor's office and more expensive to have it done in the hospital. If a patient has to travel a fair distance to get it in a hospital, he said, “you may be less likely to do it.”
A national initiative called Choosing Wisely aims to reduce unnecessary tests and procedures, including the more expensive MRIs and CT scans. It says DXA scans generally aren't necessary for young people and “can be a waste of money” when used inappropriately. The initiative also says the test is worthwhile for older people and those at risk of having weak bones.
Early menopause for Kathleen Lee compelled her doctor to order a scan for her two years ago. Lee, now 47, recently received a follow-up scan, which lasted about 10 minutes.
DXA — which stands for dual energy X-ray absorptiometry — is a form of low-dose X-ray technology that measures bone density. The device first produced in the 1980s includes a platform upon which the patient lies while a mechanical arm passes over the body.
Lee is at moderate risk of osteoporosis and fracture, with little change in her scan from 2011. “So just continue to take calcium,” Lee reminded herself as she discussed the scan with X-ray tech Jennifer Larsen.
“And vitamin D,” Larsen said.
“I feel good,” Lee said. “Everything's about the same.”
Lee later said her insurance company, UnitedHealthcare, covered the cost. The scans generally cost a patient or her insurer about $250, although that varies considerably.
Medicare on average pays doctors' offices with DXA scanners $51 per scan this year. That's down from $139 in 2006, with rates generally declining since then.
The cuts resulted from the Deficit Reduction Act of 2005, which trimmed federal payment for imaging in doctors' offices; a downgrade by the Centers for Medicare & Medicaid Services of physician time attributed to DXA; and a new Centers for Medicare & Medicaid Services calculation of non-physician expenses related to DXA scans and other procedures.
Those scans increased to $98 for two years under the Affordable Care Act, but they slumped again over the past couple of years.
The Centers for Medicare & Medicaid Services annually tweaks the amounts it reimburses for various procedures. Organizations such as the National Osteoporosis Foundation and the International Society for Clinical Densitometry continue to argue for higher reimbursement for doctors' offices that provide DXA scans.
For hospitals with DXA scanners — and most large hospitals and many hospital outpatient clinics have them — Medicare has compensated about $80 per scan consistently over the same period, the society said.
Many physicians say the devastating nature of osteoporosis isn't appreciated by the public and by some medical providers. Osteoporosis causes bones to become brittle, thin and porous. It generally hits older women harder than men, but men can suffer from it, too.
Two million fractures a year in this country are attributable to osteoporosis, the vast majority occurring in Medicare patients, Recker said. He called it a “silent disease” because many people don't know they have it until they fall and break a bone.
Some patients shrug off fractures as the natural byproduct of aging or the result of a fall that would have injured anyone. Recker said there may be an element of age discrimination and sexism in society's attitude toward osteoporosis.
He said hip fractures can lead to permanent stays in nursing homes and can kill people because pneumonia, blood clots and other complications may follow.
Most patients with osteoporosis aren't diagnosed or treated for the disease even after suffering a fracture, Recker said. Effective medications became available to halt bone loss in the mid-1990s, he said.
The trend toward fewer scanning locations is expected to hit rural residents especially hard.
Norma Steinkruger, who lives on a farm near the south-central Nebraska town of Franklin, used to get her DXA scan through a mobile service that parked in the Franklin hospital's parking lot. But that service, out of Topeka, Kan., stopped coming to Nebraska six months ago because the low Medicare reimbursement rate made it unprofitable.
Now Steinkruger, 81, will have to drive to Kearney or Hastings — 50 and 60 miles away, respectively — for her bone-density scan every other year. She was diagnosed with osteoporosis about 20 years ago.
“Well, I can still drive,” said Steinkruger, who still takes care of three calves and mows her lawn with a riding mower. But “it's not handy, because I don't like driving in the towns, in the bigger towns, and it kills a day when you go.”
Cori Wegner of the Topeka, Kan., mobile DXA service said maintaining machines and paying gas prices and staff require more Medicare reimbursement than her company, Osteoporosis Services, currently receives.
It became a situation, Wegner said, where her service couldn't afford to visit Nebraska anymore.
Treatment related to osteoporosis and fractures costs American health care an estimated $22 billion in 2008, most absorbed by Medicare, a study found. The National Osteoporosis Foundation reported that osteoporosis was Medicare's 10th-highest-cost disease in 2010 in an analysis of Medicare's most expensive beneficiaries.
The disease will only increase as baby boomers age. The number of Americans 65 and older is expected to increase to 56 million in 2020, up 39 percent from 40.3 million in 2010, said David Drozd of the University of Nebraska at Omaha Center for Public Affairs Research.
The U.S. Preventive Services Task Force generally recommends that women 65 years of age or older be screened for osteoporosis. Younger women should be screened if they have risk factors.
Risk factors include having had a fracture from minimal trauma, smoking, having a parent or sibling who has osteoporosis, use of certain medications and early menopause.
Recker said insurance may cover DXA scans for men over 70 and younger men with some risk factors.
The DXA scan is the best way to diagnose osteoporosis. It's noninvasive, and the amount of radiation emitted is small, said Joan Lappe, a professor of both nursing and medicine at Creighton. “It's inexpensive, it's safe, it's easy. Then, if you find you're at risk, there's something you can do about it.”
DXA is one of the screening scans that will come with no commercial insurance copay for the patient as of next year as long as it's used appropriately, said Dr. David Filipi, a Blue Cross Blue Shield of Nebraska vice president. He said his company's insurance packages typically cover the scans every other year for osteoporosis patients.
“We've seen physicians become anxious and order them every year,” Filipi said.
Medicare covers the scan with no copay when it's used appropriately for women. It also covers men in certain cases, such as when a patient is on a long-term steroid like prednisone.
The DXA device costs from $40,000 to $80,000. Dr. Mark W. Woodruff, a family medicine physician in Omaha, said he and his clinic partner bought their scanner in 2005 for $68,000. Woodruff said the beam generator or tube must be replaced or reconditioned every 10 years or so at a cost of $10,300 to $13,750.
Declining reimbursement is a disincentive for owning a device, he said. “We certainly wouldn't be buying one now, based on the current rates.”
Dr. Joe Shehan, an internal medicine doctor in Omaha, said his group has a machine that it acquired about 13 years ago.
Scheduling patients to have a scan elsewhere, asking them to drive to a different clinic, then having to wait for the results could discourage some patients from following up, he said. If they are done at his clinic, he said, he can prescribe medication immediately to a patient found to have osteoporosis.
Shehan said the Affordable Care Act has focused on preventive care and keeping people out of the hospital. Lower reimbursement for DXA scans in doctors' offices, Shehan said, runs contrary to that goal.