Screening and Diagnosing Osteoporosis

Peter L. Salgo, MD: How do we make these diagnoses? What is the prevalence of screening in the diagnosis of osteoporosis in this country?

Thomas P. Olenginski, MD, FACP, CCD: The prevalence of screening is…we’re concerned about screening today as opposed to 10 years ago. But again, we touched on this prevalence of osteoporosis. Claire mentioned 10 million patients with T-score osteoporosis, and 44 million with low bone mass.

Of those, that’s 50% of the population over the age of 50. One in 2 women will fracture by the time she’s 70 or 75. Probably 1 in 4 or 1 in 5 men will fracture. Not to pick on men, but I’ll speak for them. In our hospital, we have a fracture liaison service. We call it HiROC [high-risk osteoporosis clinic]. We programatically see every patient in the hospital over the age of 50 with a broken bone.

Probably 25% to 30% of the population are men. Men get this condition and they probably suffer from it more. They don’t do as well as women. This condition is staggeringly affecting us. As Dr Singer said, we’re trying to just get it on plane with the other conditions that everyone kind of believes they should take seriously.

Peter L. Salgo, MD: So let’s run down those things we can do to diagnose osteoporosis. What kind of testing is there?

Andrea J. Singer, MD, FACP, CCD: The gold standard test is a central DEXA [dual energy x-ray absorptiometry] scan of bone density that looks at the spine and the hips, and sometimes the distal radius. That really gives us an idea of, as we mentioned earlier, that bone density score. There’s a better correlation between bone density and risk for fracture than there is between other common things that we do, like blood pressure and stroke risk, and cholesterol and heart disease risk. So it’s an easy noninvasive low radiation tool. Unfortunately, the availability over the past number of years has changed because of decreases in reimbursement. There are many DEXA centers in the United States that have closed because they can’t pay....

Peter L. Salgo, MD: Stop. I did not know this, and I want to get my mind around this. Here’s a disease that’s increasing in prevalence because the American population is aging. It is dangerous. It is life-changing for the worse. We should be increasing our ability to scan, and you’re telling me that we’re decreasing this?

Andrea J. Singer, MD, FACP, CCD: Yes. You just laid out one of the major problems. It’s not the only issue, in terms of looking at fracture rates going up, and I can mention that in a moment. But the cuts from a CMS [Centers for Medicare & Medicaid Services] perspective, and Medicare reimbursement, have decreased by a significant number. So where reimbursement used to be somewhere around $130, $140 for a central bone density test, now the average is about $48, depending on where we are locally.

Peter L. Salgo, MD: This goes back to my other question, right? Is it cheaper to just let them fracture? The federal government seems to be saying, “Yes.”

Andrea J. Singer, MD, FACP, CCD: No, but it’s often shortsighted, in terms of the way people look at the budgeting process.

Peter L. Salgo, MD: I know what you’re saying. They’ve got to make their fourth quarter.

Thomas P. Olenginski, MD, FACP, CCD: It’s not though, because they’re going to end up in the hospital. They’re going to have surgery. They’re going to have rehabilitation. They’re going to have extended post-rehab stays. They’re not going to get home.

I’m going to talk about men. Men get the condition. We talked about height loss. There used to be Medicare reimbursement for patients who had a documented height loss of 1.5 inches. We had a project at our institution where we screened with that code. You can’t screen a man. There’s no male DEXA screen code. There is not a code.

So at that time we screened about 450 patients because of height loss. They knew they were going to get this. They knew their insurance was going to cover it. About 40% of the men screened were found to be at risk for fracture, and we tried to get them on therapy.

Then in 2015, I don’t know how you retire a code, but the height loss code was retired. That project went to 4, and it just points out that we are, in a way, dependent on reasonable reimbursement legislation when you want to do a test. You don’t want to order a test and have a patient say, “You had to sign a waiver because there may not be a payment.” That was what we had to do for these men. And they just said, “This is enough.”

Peter L. Salgo, MD: That’s crazy.

Thomas P. Olenginski, MD, FACP, CCD: It’s crazy because, again, men fracture and we just want to screen the patients who are most at risk to fall under care.

Peter L. Salgo, MD: Let’s take a look at who gets screened. Who should get screened? Who’s getting screened? Vertebral imaging—is that getting done?

Claire Gill: It is not.

Peter L. Salgo, MD: Thank you, we’ll keep moving. I just want to get a list of craziness here.

Claire Gill: There’s more than a list of craziness. There’s a lot of things that are going on, and I think it’s not common sense, right? What should be common sense is that I could easily prevent this horrible debilitating disease by doing this simple noninvasive test. It doesn’t get done. I think we have to look at what we’re trying to get the patients to focus on. If they are fractured over the age of 50, they need to consider with their doctor whether they have an underlying disease.

Peter L. Salgo, MD: We’re not going to do vertebral imaging. We’re not going to do your scans. We’re going to wait until somebody fractures, and then we’re going to scan them. Do they do that?

Claire Gill: Oh, no.

Peter L. Salgo, MD: No?

Claire Gill: They don’t even scan them then. Eighty percent of patients who fracture never get a DEXA scan or treatment. So we’re missing a whole lot of people. When you get the “Welcome to Medicare” packet, DEXA is included in that. Yet we’re not reimbursing doctors to be able to provide that DEXA scan.

Peter L. Salgo, MD: What other laboratory test can you get? Suppose I say, “The scan’s expensive, give me a blood test?”

Andrea J. Singer, MD, FACP, CCD: Well, I’m not sure the scan is any more expensive than the blood test. As a matter of fact, given what CMS is reimbursing, Medicare is reimbursing, the blood test may be cheaper. Let me just step back for a second and liken this to something that people can understand. Claire talked about the care gap. I think there’s roughly a 70% to 80% care gap. In 2019, it would be, I would say, considered malpractice if you had a patient who had a heart attack, an MI [myocardial infarction], and was discharged from the hospital and not treated with a beta blocker and a baby aspirin and a statin and maybe an ACE [angiotensin-converting enzyme] inhibitor as well. Yet most patients are sent out of the hospital, or the emergency department, or a physician’s office following a fracture and, in the 6 months following a fracture, do not get a diagnostic test, a bone density, or treatment, or both.