As noted in the article by Sweet and colleagues in this issue of American Family Physician,1 in 2002, the U.S. Preventive Services Task Force (USPSTF) recommended routine screening for osteoporosis in all women 65 years and older and in women 60 to 64 years of age with extra risk factors for osteoporotic fractures.2 These recommendations were assigned a grade B, the same grade given to mammography for breast cancer screening.3 Despite the availability of these evidence-based guidelines, a longitudinal analysis of Medicare claims data showed that only 12.9 percent of female Medicare beneficiaries 65 years and older had diagnostic bone mineral density (BMD) testing in 2005.4 Internists and family physicians had the greatest increases in BMD testing rates (84 and 82 percent, respectively) among all medical specialties submitting Medicare claims between 1999 and 2005, but current rates still fall short of what the USPSTF encouraged.2
The low screening rates are the end product of a puzzling collection of motivating and inhibitory factors in osteoporosis care. Pharmaceutical research has led to the development of safe and cost-effective treatments (especially bisphosphonates),5–7 creating a greater incentive to screen for osteoporosis over the past decade. Clinical performance measures for BMD screening, osteoporosis treatment, and postfracture care8,9 have been planned, but not widely implemented, in the United States. At the same time, drastic legislative cuts in Medicare reimbursement of bone imaging threaten to further decrease the low rates of osteoporosis-related testing. The Centers for Medicare and Medicaid Services has proposed regulations that will cut payments for dual-energy x-ray absorptiometry (DEXA) from $139.46 in 2006 to $55 by 2010,10 which is well below the break-even point of $134 (2007 median total cost per DEXA procedure).11 Because two thirds of DEXA scans are ordered in community offices, patients in rural areas12 and those with low access to hospitals are expected to suffer the most from these changes, when community physicians can no longer support DEXA services in their offices.
These Medicare cuts could prove to be a penny-wise, pound-foolish decision that discourages BMD testing at a time when evidence supports a greater need for it. In particular, one study found that restoring DEXA reimbursement to the 2006 levels could potentially save the Medicare program $1.14 billion over five years because of the reduced number of osteoporotic fractures.13 The U.S. Congress has proposed new bills (Medicare Fracture Prevention and Osteoporosis Testing Act of 2007 [H.R. 4206] and the accompanying Senate bill S.2702) that would freeze DEXA rates at 2006 levels (approximately $140) while a study is conducted on how the cuts will affect patient access to quality osteoporosis testing14; however, the status of these bills is still pending.
How should we approach osteoporosis screening now, considering the mixed messages in primary care? As current financial disincentives make physicians more reluctant to order DEXA scans, it becomes even more important to target screening appropriately. We should encourage screening for all women 65 years and older as recommended by the USPSTF; screening with treatment is highly cost-effective for women in this age range.15 Screening for men has been proposed16,17; however, the cost-effectiveness of this approach depends on treatment costs and other factors,18 and routine screening in men has not been evaluated by the USPSTF. Mass screening in postmenopausal women and men younger than 65 years is not supported by evidence and should be avoided; however, clinical risk factors (low body weight, previous fracture, family history, glucocorticoid use, smoking, alcohol use, and rheumatoid arthritis) can be used to select patients younger than 65 years at higher risk of fracture who could benefit from BMD testing and treatment of osteoporosis.19
The next USPSTF report on osteoporosis screening is being prepared and will reflect further research advances, including findings in men, but important questions about implementation will remain. Hopefully, as new evidence expands our options to prevent and treat osteoporosis in women and men, primary care physicians will be able to implement evidence-based recommendations without financial barriers to appropriate care.