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A Medicare Contradiction! Osteoporosis and Chronic Disease Management

Stanley Feld M.D.,FACP,MACE

I have stressed the need for encouraging and developing systems of care for chronic diseases since the treatment of the complications of chronic disease consumes 90% of the healthcare dollar. Physicians are working very hard to teach other physicians systems of care for the prevention and treatment of osteoporosis.

We are in an era where medical care lives and dies by evidence based medicine. We are in the process of eliminating clinical judgment and the patient physician relationship, both of which are important to the therapeutic effect. I have point out the defects in reporting statistical significance for evidence based medicine studies. The two studies have been referenced. The Women’s Health Initiative and the recent rosiglitizone meta-analysis of the incidence of heart disease by Nissen.

The government has decreased the funding of clinical research. Therefore, most clinical research is driven by pharmaceutical interests. This has the potential to distort the integrity of evidence based medicine studies even further. Recently the FDA was criticized for not monitoring clinical studies more effectively.

The government has realized that 90% of the cost of medical care is due to the complications of chronic disease. In order to decrease the complications of chronic disease physicians have to recognize and treat all people with the chronic disease. Most studies show physicians can decrease the complication rate of osteoporosis by 50% if it is recognized and treated effectively.

NCQA is the National Committee for Quality Assurance. The organization tries to define quality medical care. In its 2007 report on osteoporosis, it found that osteoporosis was only evaluated in 21.7% of patients at risk using the NCQA accepted guidelines for the evaluation and treatment of osteoporosis.

The National Osteoporosis Association, the American Association of Clinical Endocrinologists and the International Society for Clinical Bone Densitometry have all published guidelines for the evaluation and treatment of osteoporosis which are more inclusive and I feel more accurate than the NCQA accepted guidelines.

Medicare, despite its recognition that preventing the complications of osteoporosis is important to lower the cost of care has acted to discourage physician from evaluating patients at risk.

The general physician performance for evaluation and treatment of osteoporosis was reported by NCQA to be only 21.7%. Physician performance in evaluating and treating osteoporosis should be increased to 100% in the patients at risk. Osteoporosis does not occur overnight. It takes at least thirty years to develop significant bone loss. During those 30 years the patient is losing bone mass. It would seem logical to detect significant decreases in bone mass early, before the patient suffered a fracture. Fracture that could be prevented is patients at risk are evaluated and treated appropriately.

Many healthcare insurance companies will not pay for bone density studies in women under sixty years old with risk factors for fracture because USPHTF said the evidence is not good enough. Unfortunately, they did not review and evaluate all the studies before reaching that conclusion. The private healthcare insurance companies figure a patient 65 years or older is the governments problem and not its problem anymore.

I should think osteoporotic fractures are the patients’ problem. I should think preventing osteoporotic fractures should be the patients’ goal. It should also be the government’s goal.

Medicare spends 21 billion dollars a year to treat the complications of osteoporosis. In an effort to reduce cost of diagnostic testing with CAT scans,MRI scans and Ultrasound scan the government has past the DRA (Deficit Reduction Act). In error DXA testing (bone mineral densitometry) was included on the list in the DRA. Medicare regulators elected to reduce the reimbursement to physicians for bone densitometry from $140 in 2006 to $82 in 2007 and as low as $34 by 2010. This reimbursement is far below the average cost of doing the DEXA scan. A recent study by the Lewin group showed that the average cost of doing a DEXA scan is $134. Many clinics had been forced to discontinue doing DEXA scans. The physicians taking care of osteoporosis can not afford to continue to do scans for less reimbursement that it cost.

There is no motivation on the part of family practitioners to do bone densitometry in his office with the extreme reimbursement cuts and the excessive overhead. It is logical not do anything that will result in a loss of income. There is less desire to subject the patient to the hassle of making an appointment in 3 weeks and going to the radiology department of a hospital for a bone density and then making a return office visit. The new ruling has created a disincentive for primary care physicians to learn systems of care for the prevention of the complications of osteoporosis. The result is just the opposite of Medicare’s goal.

If we did DXA on all women over 65 years old, 50% would have either vertebral fractures or bone densities low enough to treat by the guidelines of the major medical organizations involved in the treatment of osteoporosis. If all patients over 65 years old were evaluated and treated if necessary the Lewin group calculated that it would create a net saving to Medicare of $1.14 billion dollars a year. Women would also be healthier also.

There are no studies or guidelines for men. However, 1 in 5 men over 70 years old have significant reduction in bone density or a vertebral fracture. Where is the regulators common sense and empathy in their effort to reduce the deficit? They should be concentrating of fixing the broken healthcare system and saving the patients’ health as well as the governments money.

If you go to any Wal-Mart at 10 am on any week day you would see many retired people. Of those over 65 years old you could diagnose osteoporosis in at least 50% of the women and 35% of the men just by asking them their height at age 20 and then accurately measuring them. They all know how tall they where at age 20. If they lost one and one half inches in height they have had a painless vertebrae fracture. Only 35% of vertebral fractures are painful.

There are no large evidence based medicine studies in men. Therefore neither private insurance nor the Medicare pays for bone densitometry in men.

My question is again, who should buy your shoes, clothing, or food? The answer is obvious. We should. Who should buy our medical care? To me the answer is equally obvious. We should. The only way we are going to be able to do it is if the system is changed to a consumer driven model where we own our healthcare dollar. The Ideal Medical Savings Account provides the correct incentives for all the stakeholders.

P.S. If you are as bothered and concerned about this issue as I am please go to put in your zip code and send a letter to your congressperson urging him/her to co-sponsor Congresswoman Shelley Berkley’s bill “Fracture Prevention and Osteoporosis Testing Act of 2007”.

Thank you
Stanley Feld M.D.,FACP,MACE

  • Michael Samuels

    Note that both AARP and The American Cancer Society are devoting their annual advertising budgets to reforming healthcare due to the fact that preventive medicine is leading to a leveling off of the drop off in both chronic disease and cancer rates. It’s a subject addressed in a video running on YouTube.

  • Fausto Intilla

    Science Daily — Researchers have discovered that the structure of human bones is vastly different than previously believed — findings which will have implications for how some debilitating bone disorders are treated.
    Researchers from the University of Cambridge, the Animal Health Trust in Newmarket, and the BAM Federal Institute of Materials Research and Testing, Berlin, have discovered that the characteristic toughness and stiffness of bone is predominantly due to the presence of specialized sugars, not proteins, as had been previous believed. Their findings could have sweeping impacts on treatments for osteoporosis and other bone disorders.
    Scientists have long held the view that collagen and other proteins were the key molecules responsible for stabilizing normal bone structure. That belief has been the basis for some existing medications for bone disorders and bone replacement materials. At the same time, researchers paid little attention to the roles of sugars (carbohydrates) in the complex process of bone growth.
    For this research, funded by the Biotechnology and Biological Sciences Research Council (BBSRC), the UK and Berlin teams studied mineralization in horse bones using an analysis tool called nuclear magnetic resonance (NMR). They found that sugars, particularly proteoglycans (PGs) and glycosaminoglycans (GAGs), appear to play a role which is as important as proteins in controlling bone mineralization – the process by which newly-formed bone is hardened with minerals such as calcium phosphate.
    Osteoporosis is a chronic and widespread disease in which mineral formation is disturbed, leading to brittle bones, pain, and increased fractures. Osteoarthritis, a hallmark of which is joint cartilage and GAG depletion, is also accompanied by abnormal bone mineralization.
    Both of these diseases can be debilitating, often crippling, to older people — a problem which will only intensify as our population ages. Among the young, especially sportsmen and women, bone and joint injuries prove the most intractable and are also the ones most likely to develop into afflictions (such as osteoarthritis) later in life.
    Dr David Reid, from the Duer Group, Department of Chemistry,at the University of Cambridge, who played a significant part in the research, said, “We believe our findings will alter some fundamental preconceptions of bone biology. On a practical level they unveil novel targets for drug discovery for bone and joint diseases, new biomarkers for diagnosis, and new strategies for developing synthetic materials that could be used in orthopaedics.
    “They may also strengthen the rationale for the current popularity of over-the-counter joint and bone pain remedies such as glucosamine and chondroitin, which are based on GAG sugar molecules.”
    Note: This story has been adapted from material provided by University of Cambridge.
    Fausto Intilla

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