In the United States, 54 million people age 50 and over either have or are at risk of developing osteoporosis. Approximately one in two women and up to one in four men over the age of 50 will break a bone in her or his remaining lifetime. These injuries can cripple and even kill older Americans, as almost one in three hip-fracture patients and about 20 percent of all fracture patients die within a year. Despite these sobering facts, fewer than 12 percent of all eligible women on Medicare today receive the exam that can detect and help diagnose this debilitating condition.3 In recent years, misaligned payment policy has increasingly restricted access to this essential screening, posing serious health risks to older Americans.
A brief, inexpensive test, known as central dual-energy X-ray absorptiometry (DXA), has long been the gold standard for diagnostic testing, allowing health care providers to detect and effectively treat osteoporosis. However, Medicare’s reimbursement rates for DXA scans have declined by more than 70 percent since 2007, from approximately $140 to just over $40 currently, making this specific screening modality no longer economically feasible for many clinicians to offer. Due to decreasing reimbursement rates from 2008 to 2019, over 10,000 health care providers nationwide found it was no longer financially viable to continue to offer DXA testing, representing a 44 percent decrease overall.
This ongoing decline in DXA testing availability has significantly threatened patient access to bone health screening and subsequent care. Further compounding the years of exaggerating problems, the COVID-19 pandemic disrupted osteoporosis screening across the country, like many other health care operations. According to a global survey commissioned by organizations including the National Osteoporosis Foundation, 33 percent of providers were forced to postpone a DXA exam due to the pandemic. These delays may only further increase the proportion of undiagnosed bone health issues due to diminishing screening access, potentially translating to higher fracture incidence and more hospitalizations.
The consequences of undetected bone health issues are costly on both a human and economic level. Osteoporosis-related problems don’t end with hospital visitations, as 50 percent of hip fracture patients are unable to walk without assistance after surgery and 40 percent of those who survive a fracture never return to pre-fracture functional status, often needing long-term nursing home care. Financially, providing care for osteoporotic fractures among Medicare beneficiaries in 2018 cost an estimated $57 billion, with an expected increase to over $95 billion in 2040.
Diminishing reimbursement for DXA testing affects all older Americans and could potentially widen existing health care disparities. Minority communities typically undergo scans less frequently than other groups, putting these populations at higher risk of having osteoporotic issues go undiagnosed and untreated. In fact, 29 percent fewer Black women are tested for osteoporosis when compared to white women. Furthermore, a recent analysis of osteoporotic issues among Medicare beneficiaries found Black individuals had higher hospitalization rates and higher death rates following fractures compared to national averages. While the disease is 50% more prevalent in Hispanic Americans, specifically Mexican Americans, than in white patients, these individuals are less likely to receive a DXA scan before a fracture and even less likely to receive one after a fracture in comparison.
Health experts and professional medical societies have been trying to address this widening care gap through legislation for years, yet little progress has been made on Capitol Hill toward a long-term solution. Originally brought forth in 2018 and now recently reintroduced in Congress in May, the Increasing Access to Osteoporosis Testing for Medicare Beneficiaries Act (H.R. 3517 / S. 1943) would restore the minimum Medicare reimbursement for DXA testing to 70 percent of the original level. Although the legislation has previously stalled, Congress now has the opportunity to enact this crucial bipartisan bill, enabling providers to maintain the necessary testing equipment and helping to ensure patient access to these essential exams.
Osteoporosis-related bone breaks will continue to occur and will only worsen as the nation ages. I encourage representatives to make sure this issue is a priority and I implore our elected leaders in Congress to reconsider H.R. 3517 / S. 1943 this year. Ensuring appropriate access to potentially life-saving osteoporosis screening is a bipartisan matter and has had strong support from both sides of the aisle in the past. This is a growing problem with long-lasting consequences that has been compounded by the pandemic, and any further cuts to screening could prove fatal for many older Americans.
Dr. Andrea Singer is Chief of the Division of Women’s Primary Care and Director of Bone Densitometry and the Fracture Liaison Service at MedStar Georgetown University Hospital.