This study’s aim was to assess whether the 2007 reduction in Medicare reimbursement for office-based imaging services impacted overall osteoporosis-related BMD testing in Medicareeligible women, and whether changes in screening rates could have led to women not being diagnosed until the occurrence of a fracture. Our study showed that 37.9% of Medicare-eligible women with employer-sponsored Medicare supplemental insurance received a BMD test between 2005 and 2008, consistent with other published national quality reports relative to employer-sponsored insurance.11
A reduction in testing was seen from 2005 to 2006 (12.9% to 11.4%) prior to reimbursement reductions, but BMD testing rates were relatively constant in the three following years (11.4% in 2006, 11.8% in 2007 and 11.6% in 2008) that encompassed the implementation of DRA 2005-related imaging reimbursement reductions.
These findings are similar to recent findings in a study by O’Malley, et al., which was also based on the MarketScan database.20
In both studies, the screening rates in 2005 were approximately 13%. The O’Malley study similarly concluded that BMD testing rates remained relatively constant from 2006 to 2008. However, the O’Malley study observed a steady year to year increase in BMD screening rates prior to 2007, suggesting a tapering of BMD testing gains seen in previous years.
This increasing testing trend prior to 2007 was not identified in the current study due in large part to the use of a shorter observation period. It is also a likely artifact of using a fixed cohort rather than a dynamic cohort as used in the O’Malley study. Baseline BMD screening is recommended at age 65,9
and Medicare covers BMD testing every 2 years for women who meet testing criteria. Thus, women in the current study who were screened in 2005 would not have been candidates for screening in 2006. Meanwhile women newly eligible for BMD screening were not entering the study.
This study went on to evaluate whether the proportion of women diagnosed with osteoporosis by BMD screening rather than fracture changed with reimbursement reductions. Our analyses revealed a shifting in the proportion of women diagnosed with osteoporosis away from women diagnosed subsequent to BMD screening which declined over time and towards diagnosis following a fracture or toward an unspecified reason diagnosis. However, overall screening rates generally remained constant over the reimbursement reduction period; therefore the increase in osteoporosis diagnoses made after a fracture was not necessarily due to women who were not screened.
There are other possible explanations for this trend that do not suggest quality of care was negatively impacted. For instance, women previously screened who were not candidates for repeat screening24
but later fractured, could account for some of this shift. BMD screening strength lies in its ability to identify who is at greatest risk for fracture due to low bone density. However, many women who fracture have a BMD level above the osteoporosis diagnosis cutoff. 25,26
This fact that BMD testing leveled off but did not decline may reflect the impact of this reimbursement reduction on provider income. Authors of a recent survey of radiologists regarding the impact of the DRA (not specific to BMD testing) concluded that the DRA would only reduce radiologists’ income by 1% on average.18
While this survey also noted that there was considerable variability around this income reduction, the DRA may not have had a negative impact on physician income as anticipated. Another recent survey comprised mostly of physicians who performed in-office DXA exams found that 63% of physicians performed the same number or more exams after the reimbursement reductions.27
Furthermore, not all physicians conduct BMD tests in their office practice, thus, DXA reimbursement amount may not be a consideration for many practitioners who prescribe BMD tests.
That BMD screening in women age 65+ with employer sponsored retiree health benefits did not significantly decline after DRA 2005 reimbursement reductions is an important finding. It suggests that while quality of osteoporosis care as measured by rates of screening has not been negatively impacted, efforts to improve osteoporosis screening may face more barriers to success than in the past. Further research is warranted to determine whether DRA and Medicare Physician Fee Schedule reimbursement changes since this time, such as those proposed in the 2010 Medicare Physician Fee schedule planned reduction, reduce BMD screening rates as well as long term efforts to improve osteoporosis screening, treatment, and fracture outcomes.28
A strength of this study is that it is based on a large administrative claims database, which is particularly useful for evaluating issues related to healthcare resource utilization. The MarketScan data used in this and the O’Malley20
study represented a geographically diverse group of women who were not limited to a single carrier or managed care organization for supplemental coverage. The use of this data, however, introduces several limitations. First, the MarketScan database is limited to patients with employer-sponsored supplemental coverage, who may differ from those without employer-sponsored supplemental coverage in terms of osteoporosis risk and diagnosis and thus, the likelihood of receiving BMD screening. Supplemental insurance reimbursement rates, as well as those for women enrolled in a Medicare Advantage (MA) plan may not be affected by or reflective of Medicare reimbursement rates and changes, and thus not directly impacted by Medicaid DXA reimbursement reductions. However, many women in this study were enrolled in a fee-for-service plan and many likely qualified for Medicare reimbursement of BMD tests. The true impact of any Medicare reimbursement reductions on BMD testing in Medicare-aged women may not be fully reflected in this study.
Because our larger study also included women who were not Medicare eligible, a commercial claims database was utilized. However, it would be beneficial to repeat this study in Medicare claims data or the Medicare Current Beneficiaries Survey (MCBS). Like MarketScan, data on services paid for by either Medicare or a supplemental carrier are included in Medicare-specific databases. However, using Medicare claims or the MCBS would allow for the inclusion of women without employer-sponsored supplemental coverage.
Next, the study included data on a fixed cohort of patients for a 5-year period, which is a relatively short period of time for assessing overall BMD screening and osteoporosis diagnoses. Only women who were healthy enough to survive 5 years were included. These “healthy survivors” may also be at low risk for osteoporosis and thus less likely to be screened and/or diagnosed with osteoporosis during the observation period. In addition, to maximize the study observation period based on the data available analyses, the pre-index period was limited to one year. This year may not have been sufficient to identify all previous osteoporosis diagnoses and treatments, thus some study participants may have had osteoporosis at the start of the study.
Finally, data available from claims databases lack clinical information on numerous osteoporosis or fracture risk factors including actual BMD test results, alcohol use/abuse, smoking, and maternal fracture history. Medical claims data may not indicate whether patients have been screened for osteoporosis based on non-BMD risk factors. This limitation is most obvious when considering osteoporosis drivers, and the relatively large number of women diagnosed with osteoporosis based on factors other than a recently reimbursed BMD test or fracture.