By Alison B. King and Donna M. Fiorentino

THE CARE SPAN

Medicare Payment CutsFor Osteoporosis TestingReduced Use Despite Tests’Benefit In Reducing Fractures

ABSTRACT Bone imaging known as DXA (“dexa”)—dual energy x-rayabsorptiometry of the central skeleton—is considered the “gold standard”test for osteoporosis, which affects more than fifty million Americans.The tests are associated with improved clinical outcomes throughpreventing bone fractures. Cuts in Medicare Part B reimbursement forthe provision of this preventive imaging in a physician’s office began in2007 and reached 56 percent below the 2006 level in January 2010. Toencourage the use of DXA testing, the Affordable Care Act of 2010provided partial relief from the cuts for two years (2010–11). Our studyfound that after a decade of growth, DXA testing in all Part B settingsplateaued in 2007–09, resulting in 800,000 fewer tests than expected forMedicare beneficiaries—tests that might have prevented approximately12,000 fractures. Testing declined in 2010, when the start ofreimbursement relief under the Affordable Care Act was delayed, andincreased outpatient testing failed to offset reduced use in physicianoffices. Our findings strongly suggest that the payment cuts reducedbeneficiary access and that the tests were underused by elderly femaleMedicare beneficiaries despite strong association with fractureprevention.We recommend that Congress extend the payment reliefgranted under the Affordable Care Act for at least another two years.

Over the past two decades, non-invasive, reliable diagnostic testsof bone density and efficaciousmedications have transformedcare for osteoporosis from pallia-

tive to preventive and therapeutic. The study de-scribed in this article focused on the value ofbone density testing rather than on treatmentof osteoporosis, a disease of porous, fragilebones characterized by reductions in bone den-sity andquality that increase the riskof fractures.Bone density testing is used to identify peoplewith osteoporosis or the less severe conditionknown as “low bone mass.” The use of bone

density testing increased when congressionallymandated standards for Medicare coverage tookeffect in 1998,1 reducing regional discrepanciesin coverage for the test.In the United States, 52.4 million people were

estimated to have osteoporosis or low bonemassin 2010,2 resulting in more than two millionfractures in that year alone. The estimated$18.7 billion in direct medical costs of these frac-tures was largely borne by the Medicare pro-gram. Population growth is projected to increasethese costs to $25.3 billion in 2025, assumingconstant rates of testing and treatment.3

However, testing rates are threatened by a

doi: 10.1377/hlthaff.2011.0233HEALTH AFFAIRS 30,NO. 12 (2011): –©2011 Project HOPE—The People-to-People HealthFoundation, Inc.

Alison B. King(alisonbkingllc@gmail.com) isprincipal of Alison B. KingLLC, in McGraw, New York.

Donna M. Fiorentino is thelegislative counsel for theInternational Society forClinical Densitometry, in WestHartford, Connecticut.

December 2011 30: 12 Health Affairs 1

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reduction in Medicare reimbursement for themost common bone density test, dual energyx-ray absorptiometry of the central skeleton—that is, the hip, spine, and pelvis—hereafter re-ferred to as DXA (pronounced “dexa”). DXA ofthe central skeleton is used to screen for anddiagnose osteoporosis, predict fracture risk,and determine the need for and monitor re-sponse to treatment.On January 1, 2011, the Affordable Care Act of

2010 removed a barrier to bone density testing,along with other preventive services, by elimi-nating cost sharing forbeneficiarieswhoqualify.In response to concerns about access to testing,the act also partially restoredMedicare paymentfor DXA during 2010 and 2011.From2007 to 2010 payment to physicians pro-

viding DXA tests in their offices had been re-duced, reaching a nadir of 56 percent below pre-vious rates in early 2010. The full cuts willresume in January 2012 unless Congress againintervenes. The Preservation of Access to Osteo-porosis Testing forMedicare Beneficiaries Act of2011, now pending in Congress, would extendthe partial reversal in DXA payment cutsthrough 2013.The Affordable Care Act also authorized an

Institute of Medicine study of the ramificationsof the 2007–09 cuts on access to bone densitytests, to inform reconsideration of DXA reim-bursement before expiration of the two-year par-tial restoration on December 31, 2011. However,the Department of Health and Human Serviceshas not funded the study or contracted with theInstitute of Medicine for its execution. The littleevidence published to date indicates that the im-pact of the cuts on use became apparent in 2008.One study reported that DXA testing rates in-

creased annually from 2000 to 2007 and thenleveled off during 2008–09 among Medicarebeneficiaries with employer-sponsored supple-mental insurance.4 This suggests a lag in theeffect of the payment cuts. Data from the Medi-care Current Beneficiary Survey support thatidea, showing osteoporosis screening to behigher in 2008 than 2006 among female Medi-care beneficiaries age sixty-five and older.5

This survey is a poor gauge of DXA use underPart B, however, because it includes any osteo-porosis test during a woman’s lifetime, such as aheel scan in a pharmacy. Moreover, the self-re-ported survey rates are approximately four timeshigher than Medicare DXA claims, despite thefact that DXA constituted more than 95 percentof all Medicare bone density claims in 2005.6

Thus, a paucity of data has, until now, pre-vented a clear assessment of access to DXA test-ing both before and after the Medicare paymentcuts. To add to the confusion, although DXAwas

described by the surgeon general in 2004 as the“gold standard” test for osteoporosis and frac-ture risk,7 the Medicare Evidence Developmentand Coverage Advisory Committee has ques-tioned whether bone density testing improvespatients’ outcomes.8,9 Policy makers need dataon the value of DXA testing and trends in itsuse to evaluate Medicare Part B payment policy.Our study examined the impact of the2007–09

Medicare Part B payment cuts on DXA use in thecontext of historical use trends.We also analyzedwhether use in the hospital outpatient settingcompensated for any reductions in use in physi-cian offices.We then addressed two fundamentalgaps in information needed to guide Medicarepayment policy. First, does DXA testing affectclinical outcomes—specifically, the incidenceof osteoporosis-related (“fragility”) fractures?Second, has DXA been under- or overused inthe target population of elderly women, bothnationally and at the state level?

Medicare Coverage And PaymentsCoverage Since 1998 five categories ofMedicarebeneficiarieshavequalified forbonedensity test-ing: estrogen-deficient women at clinical risk forosteoporosis, people with vertebral abnormal-ities or vertebral fracture, people with hyper-parathyroidism, people receiving or expectingto receive high-dose steroids formore than threemonths, and people being monitored for re-sponse to drug therapy.10 Among these benefici-aries, elderly women and women younger thanage sixty-five who have elevated fracture risknowmeet criteria for the waiving of cost sharingfor DXA.11 Effective January 1, 2011, the Afford-able Care Act eliminated Medicare Part B costsharing for preventive services rated at grade Aor B by the US Preventive Services Task Force—that is, services recommended by the task forceand receiving one of the two highest ratingsbased on the quality and quantity of evidencethat the service provides a net benefit.Because osteoporosis research has focused on

women, who account for the majority of osteo-porosis-related fractures, the task force con-cluded that the data on men were insufficientto support the creation of screening recommen-dations for them.11 Few men of any age or non-elderly disabled people qualify for Medicare-reimbursed DXA testing at this time, and mencontinue to incur DXA cost sharing.Payments Two separate legislative and regu-

latory actions reduced Medicare reimbursementfor DXA tests conducted in physician offices dur-ing 2007–09. First, the Deficit Reduction Act of2006 limited Part B imaging payments to hospi-tal outpatient rates. The law addressed concerns

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2 Health Affairs December 2011 30: 12

about the dramatic increases in overall imagingin physician offices. Although it did not specifi-cally mention DXA, it lowered the payment foroffice-based DXA by 40 percent in 2007.Second, in a routine five-year review, the Cen-

ters forMedicare andMedicaidServices changedthe methods it used for calculating practice ex-penses and downgraded the physician work in-volved in interpreting the results of DXA testingby one-third, as recommended by the AmericanMedical Association’s Relative Value UpdateCommittee.12

Over the objections of some specialty soci-eties,13 that committee discounted survey datafrom the American College of Radiology thatsupported maintaining physician work at 2006levels. The societies also criticized the use of out-dated equipment costs for DXA and the newmethodology’s disproportionate impact on ser-vices with high direct relative to indirect costs.Changes stemming from the five-year reviewwere phased in from 2007 to January 1, 2010.Between2006andJanuary 1, 2010,Medicare’s

national average payment for DXA testing inphysician offices decreased from $139.46 to$61.70, and the average payment for office-basedvertebral fracture assessment decreased from$39.41 to $27.42. The latter is a software additionto DXA machines that allows imaging of thespine to detect vertebral fractures. On January 1,2010, the average payment for DXA testing in aphysician’s office was 74 percent of the averagehospital outpatient payment.The Affordable Care Act specifically restored

Part B payment for office-based DXA tests, dur-ing2010 and2011 only, to 70percent of the 2006level.Thiswasoneof several provisions intendedto protect access to specificMedicare services. In2011 the national payment rates for office-basedDXA testing and vertebral fracture assessmentwere $97.51 and $27.86, respectively.

Study Data And MethodsAnalyses We analyzed trends in Medicare DXAclaims for all Part B enrollees during 1996–2010by service setting, to evaluate the budgetary im-plications of payment changes. We assessed el-derly women’s access to DXA testing and clinicaloutcomes. Using detailed claims data for 2002–08,we determined the number of uniquewomentested each year, cumulative testing frequencyover the seven-year period, and 2008 testingrates in urban and rural areas nationwide andin the forty-eight states where rural sample sizewas sufficient for analysis.We also compared clinical outcomes over three

years in cohorts of women who either did or didnot have DXA testing in 2005, to detect possible

differences in the rate of osteoporosis-related(“fragility”) fractures. The fracture analysis in-cluded elderly women who had no indication offracture of any type during 2003–05 and no in-dication of osteoporosis in 2003–04, and whowere continuously enrolled in fee-for-serviceMedicare during 2003–08.Women with a Medi-care-reimbursedDXA test in 2005were assignedto theDXA cohort. Of the 394,217 elderlywomenin our sample, 44,800 were tested in 2005, and349,417 were not.We identified fragility fractures during 2006–

08 by the International Classification of Diseases,Ninth Revision, Clinical Modification (ICD-9-CM) codes for closed fractures, excluding frac-tures associatedwith cancer and trauma (Appen-dix 1 online).14 We determined the proportion ofwomen in each cohort with any fragility fractureduring 2006–08. (Before the 2008 data wereavailable, we conducted the same analysis forthe period 2002–07, on women tested in2004, rather than 2005.)Data Sources We obtained data for Medicare

fee-for-service enrollees only. Enrollment infor-mation came from Medicare Trustees’ annualreports.15 Data on DXA use during 1996–2010came from theMedicarePhysician/Supplier Pro-cedure Summary Master File for Current Pro-cedural Terminology codes 77080 and 77082(which were coded as 76075 and 76077 priorto 2007). This file is readily available and pro-vides a long time series of aggregate service usein fee-for-service Medicare.16

Regardless of site, each fee-for-service DXAtest should be associated with a payment forinterpreting the results (the “professional com-ponent” service). Payment for the cost of per-forming the test (the “technical component” ser-vice) also may be generated. We counted thenumber of physician test interpretations—thenumber of professional-only or combined pro-fessional-technical bills, excluding deniedclaims. We adjusted the preliminary data filefor 2010 for file completeness.For analysis of DXA access and clinical out-

comes in elderly women, we used a 5 percentsample of Medicare beneficiaries—the Medicare5 percent limited data set standard analytic files.This allowed us to adjust national claims for sexand multiple tests per person and to evaluaterural versus urban testing rates, frequency oftests, and fracture incidence. We extrapolatedour sample data, which were available for2002–08 only, to 2009 and 2010.

Study ResultsUse Of DXA And Impact Of Payment Cuts Theuse rate for DXA tests underMedicare Part B, for

December 2011 30: 12 Health Affairs 3

all beneficiaries in all settings, grew by doubledigits each year from a low rate in 1996 through2002,quadruplingduring theperiod (Exhibit 1).It peaked in 2008. The annual change in the userate averaged 6.5 percent during 2003–06 andthen slowed, ending with !4.4 percent in 2010.Had the 6.5 percent growth continued after2006, 800,000more DXA tests would have beenperformed during 2007–09, reaching a rate of101 per thousand beneficiaries in 2009(Exhibit 1).The percentage of elderly women tested before

and after the payment cuts paralleled changes intesting rates for the total fee-for-service popula-tion. In 2002, 11.3 percent of elderly femaleMedicare beneficiaries had at least one DXA test(Exhibit 2). Growth in the testing rate slowed in2007 and 2008, plateaued in 2009, and declinedby 3.7 percent in 2010, when 14.1 percent of thebeneficiaries were tested.Detailed claims data for 2002–08 showed a

slight shift in age and sex distribution of DXAtests as the use of testing increased faster inmenand nonelderly women than in elderly women.Use by men grew from 7.9 percent of all tests in2002 to 10.3 percent in 2008. Use by nonelderlywomengrew from6.0 percent of all tests in 2002to 7.1 percent in 2008. Thus, elderly women rep-resented only 82.7 percent of DXA tests in 2008.DXA Use In Physician Offices And Hospi-

tals Slowing growth and subsequent declinein the use of office-based DXA testing wasresponsible for the observed plateau in overalltesting during 2007–09 and the decrease in2010. In the period 2005–06, the two years be-foreDXApayment cuts, the annual change in the

testing rate for all beneficiaries averaged 8.7 per-cent in physician offices and 5.3 percent in hos-pital outpatient facilities. Following the cuts, theannual change averaged !0.7 percent and5.6 percent during 2007–09 in physician officesand hospital outpatient facilities, respectively,and !6.1 percent and !1.3 percent in 2010.During the period we examined, 1996–2010,

testing rates in the hospital outpatient settinggrew faster than rates in private offices duringtwo intervals: 1996–2001 and 2007–10. In 1996,80 percent of tests were conducted in physicianoffices. During the next several years, the por-tionofoffice-based testsdropped toabout70per-cent, where it hovered for nearly a decade. By2010 it had reached the lowest point in the studyperiod, 66 percent (see Appendix 2 online).14

DXA Testing Of Elderly Women Nationally,the annualDXA testing rate for elderlywomen inMedicare Part B in all settings was about 14 per-cent during 2006–10. In 2008 rates varied morethan twofold across states, ranging from a low of8.1 percent in Vermont to a high of 19.0 percentin Arizona. In the country overall, and in forty-one of the forty-eight states with sufficient data,DXAuse amongelderlywomen in rural areaswassignificantly lower than in urban areas(p < 0:05) (Appendix 3 online).14

Cumulative testingdata for2002–08producednegligible evidenceof overuse.During the seven-year period, 47.9 percent of elderly women didnot have a single test, and 25.4 percent weretested only once (Exhibit 3).DXA Testing And Clinical Outcomes Among

elderly female Medicare beneficiaries with norecent record of osteoporosis or fracture, those

Exhibit 1

Number Of DXA Tests Per 1,000 Medicare Fee-For-Service Beneficiaries, 1996–2010

SOURCE Authors’ analysis of data from Medicare Physician/Supplier Procedure Summary Master Files, 1996–2010. NOTES DXA is dualenergy x-ray absorptiometry of the central skeleton. Total includes claims from “all other” settings, such as independent clinic, mobileunit, and unknown setting. Beneficiaries include males and females of all ages. The projected trend line was plotted only for the2007–09 period, when testing growth was stable in the hospital outpatient setting.

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who received a DXA test in 2005 had a 19.6 per-cent lower fracture rate during the followingthree years (2006–08) than elderly women nottested in 2005—a highly significant difference(p < 0:0001). Similarly, women who were testedin 2004 had an 18.9 percent lower fracture rateduring 2005–07 than those who were not tested.The fracture rate measured the number of

women with one or more fractures over thethree-year period, to avoid duplicate countingof women who incurred multiple fractures.Women who were tested in 2005 had a 6.0 per-cent fracture rate, compared to 7.5 percent forwomenwhowere not tested. For all of the elderlywomen in our sample, the fracture rate for2006–08 was 7.3 percent.

DiscussionThis study provides data to help inform a pend-ing congressional decision: whether or not toextend, for another two years or longer, partialrelief from cuts in Medicare payments for DXAosteoporosis testing provided in physician offic-es.We evaluated the impact ofmultipleMedicarePart B payment changes on access toDXA testingand, more fundamentally, whether evidencesupports improving access. That is, we askedwhetherDXA testing improves clinical outcomesand whether it is under- or overused.Impact Of Payment Cuts On DXA Use▸▸PAYMENT CUTS: Prior to cuts in Medicare

payment, DXA testing grew continually for theperiod 1996–2006 in both physician office andhospital outpatient settings. Between 2007 and2009, when Medicare payment for office-basedDXA testing was cut substantially, 800,000fewer tests were administered toMedicare bene-ficiaries thanwouldhavebeenexpectedbasedonearlier growth trends. The attenuation of office-based DXA testing during 2007–09, when DXAuse continued to grow in hospital outpatientfacilities by more than 5 percent each year,strongly suggests that Medicare’s office-specificpayment cuts caused the decline in overall test-ing observed in 2009.Our study corroborates a previous report that

growth in DXA testing flattened after the pay-ment cuts among people with Medicare supple-mental insurance (including both fee-for-serviceand managed care enrollees), as well as amongyounger, commercially insured adults.4 This in-dicates a possible spillover effect in which theclosure of office-based DXA services resultingfromMedicare cutsmay have reducedDXA avail-ability to people with commercial insurance.DXA closures included providers who removedDXA from the services theyoffered andproviderswho shut down their practices completely.

There were no technological or medical devel-opments regarding DXA efficacy or safety thatwould explain the decrease in DXA use after thepayment cuts. In 2008 the advent of the WorldHealth Organization’s fracture risk assessmenttool, FRAX,17 prompted the suggestion thatosteoporosis screening costs might be reducedby basing diagnosis and treatment decisions insome cases solely on clinical risk factors.18

However, use of the tool alone may under-estimate fracture probability in several patientgroups.19 Additionally, US medical guidelinesrely on the World Health Organization’s defini-tion of osteoporosis, which is based on a bonedensity score.20 Although the toolmaybe ausefuladjunct, it is not a replacement forDXA testing.19

DXA testing has remained the preferred method

Exhibit 2

Elderly Female Fee-for-Service Medicare Beneficiaries Who Had At Least One DXA Test,2002–10

Year Number Percent

2002 1,627,286 11.32003 1,922,628 12.02004 2,091,242 12.52005 2,188,244 13.12006 2,301,443 13.82007 2,346,733 14.22008 2,341,870 14.62009 2,351,425 14.62010 2,321,810 14.1

SOURCE Authors’ analysis of data from Medicare Physician/Supplier Procedure Summary MasterFiles, 2002–10, and Medicare 5 percent Limited Data Set standard analytic files, Claims andEnrollment, 2002–08. NOTES DXA is dual energy x-ray absorptiometry of the central skeleton.“Elderly” is age sixty-five or older.

Exhibit 3

Distribution Of Elderly Female Fee-for-Service MedicareBeneficiaries By Cumulative Number Of DXA Tests,2002–08

SOURCE Authors’ analysis of Medicare Physician/SupplierProcedure Summary Master Files, 2002–08, and Medicare 5 per-cent Limited Data Set standard analytic files, Claims and Enroll-ment, 2002–08. NOTES DXA is dual energy x-ray absorptiometryof the central skeleton. “Elderly” is age sixty-five or older.

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for osteoporosis screening and monitoring re-sponse to treatment in the United States.▸▸PARTIAL PAYMENT RESTORATION: At the

time of our study, it was too early to evaluatethe effects of the partial payment restoration.In 2010, when payment for office-based DXAtests was partially restored to 70 percent of2006 levels, the portion of elderly women tested(14.1 percent) was lower than in 2008 or 2009(Exhibit 2), and DXA testing decreased in boththe office and hospital settings.The magnitude of the DXA testing drop in

2010 (4.4 percent overall) and its impact acrosssettings might reflect negative economic condi-tions that could have reduced the women’s over-all use of medical services. The effect on DXAmight have been disproportionately large be-cause preventive services are often consideredless essential than therapeutic services and werestill subject to cost sharing in 2010.The persistence of a large gap between office

testing rates,whichdropped6.3percent in2010,and hospital outpatient rates, which decreasedby only 1.3 percent in the same year, may beexplained by lengthy delays before providers re-ceived payment increases for 2010 claims. Mostnotably, retroactive payments for DXA tests per-formed during the first half of 2010 were notmade until 2011, after the Medicare and Medic-aidExtendersAct of 2010appropriated the fundsnecessary for reprocessing the claims.Moreover, because the temporary relief did

not stabilize payment at a higher level, providersface the resumption of severe cuts in Janu-ary 2012. A longer amount of time is needed toevaluate whether partial payment restorationcan help stem the observed decline in the useof office-based DXA services.Shifts In DXA Testing Settings Historical

trends shed light on our finding that growth inhospital outpatient testing only partially offsetdeclines in physician office testing.Over the pastfifteen years, Medicare-reimbursed DXA testshave been provided predominantly in physicianoffices. Before the 2007 payment cuts, only20–30 percent of tests were performed in thehospital outpatient setting. Although this sharegrew to 33 percent in 2010, our data suggest thatthe shift in DXA use to the hospital outpatientsetting cannot, at least in the short run,maintainaccess to this service.Implications for Providers and Benefici-

aries In rural areas, where DXA testing rateslagged behind those in urban areas, residentsare particularly vulnerable to reduced availabil-ity of office-based DXAs. Previous research hasshown that travel distances of five miles or morereduce the likelihood of getting a DXA test.21

Rural DXA providers were among the providers

who shut their offices completely or stopped of-feringDXA followingMedicare’s payment cuts,22

perhaps because they lacked economies of scale.Although weeding out some small-volume

providers may be appropriate, DXA closure re-ports came from large and small practices alike.Relative to many other imaging services, office-based DXA has a low equipment use rate, beingin use only 13 percent of the time, on average, in163 practices surveyed in 2007 by the LewinGroup.23

That survey found that economies of scaleceased when a practice performed more than1,500 tests per year. It also found that only 14per-cent of the survey respondents would break evenat a Medicare payment rate of $82 per test in2007. More recent data are needed to assesswhether the 2010 payment rate for office-basedDXAs, which exceeded the hospital outpatientrate by 20 percent, sufficed to compensate forhigher overhead in the office setting.Overuse Or Underuse To evaluate whether

DXA testing is under- or overused, we assessedtesting rates and frequency in elderly women forthe period 2002–08. During this time, clinicalguidelines recommended bone density testingfor all elderly women,11,24 with the follow-up in-terval determined by each woman’s fracture riskand clinical course.24 Since 1998 Medicare hascovered DXA testing every two years, or moreoften to monitor response to treatment. (In2006DXAbecame the only test covered formon-itoring treatment response.)Our analysis provided negligible evidence of

overuse of DXA testing, either before or after theMedicare payment cuts. About 14 percent of el-derly female Medicare beneficiaries were testedin 2010 (Exhibit 2). During 2002–08 only one inten elderly women had repeated DXA tests attwo-year intervals, and fewer than one in a hun-dred was tested more frequently (Exhibit 3).Growth in DXA testing stopped in 2009, fol-

lowing a seven-year period during which onlyhalf of elderly women were tested. Our studyfound a higher cumulative testing rate (52.1 per-cent) than the 31.3 percent observed by JeffreyCurtis and colleagues for 1999–2005.6 That dif-ference may be due to our study’s later timeframe (2002–08) and to differences in methods.Nonetheless, given the prevalence of osteo-

porosis (25 percent) and low bonemass (48 per-cent) previously reported in elderly US women,1

one would expect three-fourths of them to havehad at least one DXA test over seven years—ahigher figure than either study found.Quality measures also indicate that DXA test-

ing is underused. In 2009 only 20.7 percent ofelderly women in Medicare health maintenanceorganizations received either aDXA test or treat-

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ment for osteoporosis within six months after afracture.25 In fee-for-service Medicare, healthprofessionals reported that only 41 percent ofelderly women had been screened with DXA atleast once since age sixty or had been treatedwith osteoporosis medication, and only 37 per-cent had been tested or treated after a fracture.26

Separating DXA testing rates from treatmentrates in these osteoporosis quality measuresmay prove useful in conducting future evalua-tions of DXA use.Impact On Clinical Outcomes We found the

fracture rate to be nearly 20 percent lower inelderly women who had a DXA test than in thosewho had not, in a national Medicare populationover three years—a period short enough to mat-ter to health plan administrators and budget an-alysts. This finding is consistent with resultsfrom prospective randomized trials and obser-vational studies that link DXA testing with in-creased osteoporosis treatment27–29 and de-creased fractures.30–32

Budget Implications Policies that reduce ac-cess to DXA testing may decrease Medicare PartB spending yet impose greater costs on the over-all Medicare program by impeding fracture pre-vention efforts. For example, we estimated that800,000 DXA tests were “lost” during 2007–09because of the decline in office-based testing.Had those tests taken place, they might haveprevented fractures in approximately 12,000Medicare beneficiaries—an estimate based onthe observed difference in fracture rates betweenelderly women who had a DXA test and thosewho did not.Although our study did not measure fracture

costs, research has shown budget savings whenintegrated health systems paired DXA testingwithmanagement of patients at risk for fracture.A Kaiser health plan reported a 37 percent de-crease in hip fractures in men and women, com-pared with projected rates for their members, inthe fifth year of an intervention that increasedDXA testing by 247 percent and treatment by135 percent.32 Similar benefits were seen whenGeisinger Health Plan implemented osteoporo-sis practice guidelines.Considerable budget savings are possible if

DXA testing were to be integrated with care co-ordination in the Medicare program to improvefracture prevention. Inclusion of both DXA test-ing andFRAX results in electronic health recordswould help ensure appropriate follow-up andwould build evidence for refining guidelineson testing frequency. And althoughmost qualityinitiatives focus on elderly women, they shouldnot overlook men and nonelderly women, whocollectively account for nearly one fifth of Medi-care-reimbursed DXA tests.

Policy ConsiderationsOur findings strongly suggest that after morethan a decade of consistent growth in the useofDXA testing, cuts inMedicarePart Bpaymentsfor office-based DXA tests reduced beneficiaryaccess to this preventive service. The results alsodemonstrate that based on current clinicalguidelines, DXA testing has not been overused.Rather, it has been underused by elderly femaleMedicare beneficiaries. Furthermore, for the el-derly women who used it, it has been associatedwith a clear clinical benefit: fracture prevention.Additional time is needed to evaluate whether

the partial restoration of the cuts to Part B pay-ments for DXA tests performed in physician of-fices—which brought payments up to 70 percentof 2006 levels for 2010and2011—will reverse theobserved decline in testing. Just as there was alag before the impact of the cuts was clear, it maytake several years for increases in payment toreverse this trend.A two-year extensionof thepartial restoration,

covering 2012 and 2013, might provide a mini-mally sufficient period to assess the impacts ofpayment increases for providers, both alone andin conjunction with waived copayments for con-sumers, and to evaluate long-term solutions. Inforging those solutions, mammography mayprovide a useful model for targeted policies re-garding imaging to improve prevention. Mam-mography was the only imaging service ex-empted from Medicare payment cuts under theDeficit Reduction Act, and its use has been sub-ject to extensive evaluation.To properly guide Medicare Part B payment

policy for DXA tests, additional research isneeded on the geographic distribution of DXAtesting facilities; DXA costs in physician officesand hospital outpatient facilities; quality-of-caremeasures that distinguish DXA testing ratesfrom osteoporosis treatment rates; frequencystandards for DXA testing; beneficiary surveysto understand obstacles to DXA access; and DXAuse and fracture rates.Our population-level analysis of fracture rates

would be strengthened by future studies thatadjusted for baseline fracture risk and potentialconfounders such as income, which is positivelycorrelated with self-reported osteoporosisscreening rates.5 It is true that people who arehealthier andwealthier tend to usemore preven-tive services than others do. However, previousresearch indicates thatwomenwhoobtain aDXAtest have a greater fracture risk than would beexpected based on the overall prevalence of os-teoporosis.26,28,30,31

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ConclusionStable, reasonable Medicare payment rates arecritical to beneficiaries’ access to preventive ser-vices and providers’ efficient delivery of them.This study provides evidence that the 40–56 per-cent cuts in Medicare Part B payments for DXAtests in physician offices exceeded reductionsthat might improve efficiency. The cuts impededbeneficiaries’ access to DXA testing, which re-cent data indicate remains an underused preven-tive service. The brief, unstable period of partial

payment restoration provided by the AffordableCare Act during 2010 and 2011 has been in-adequate to assess the value ofMedicare policiesthatmaintain access to office-basedDXA testing.Payment relief should therefore be extended.The observed correlation of DXA testing with

fracture reduction in a national Medicare popu-lation holds promise for substantial progress infracture prevention in the Medicare program ifpolicies encourage appropriate access to the testand coordination of care across providers.

▪

This research was funded in part by theAlliance for Better Bone Health (Procterand Gamble Pharmaceuticals and sanofi-aventis) and Warner ChilcottPharmaceuticals. Alison King was anemployee of Procter and GamblePharmaceuticals, which was acquired byWarner Chilcott Pharmaceuticals. She

was hired by Capitol Counsel to providetechnical expertise to the FracturePrevention Coalition. Donna Fiorentinoserves as legislative counsel to theInternational Society for ClinicalDensitometry, a member of the FracturePrevention Coalition. The authorsreceived no compensation for work on

this article. The authors appreciate thedata analysis, multiple updates, andexpert counsel of Christopher Hogan ofDirect Research, as well as AndrewLaster’s invaluable support andcomments.

NOTES

1 King AB, Saag KG, Burge RT, PisuM,Goel N. Fracture Reduction AffectsMedicare Economics (FRAME): im-pact of increased osteoporosis diag-nosis and treatment. Osteoporos Int.2005;16(12):1545–57.

2 National Osteoporosis Foundation.America’s bone health: the state ofosteoporosis and low bone mass inour nation. Washington (DC): TheFoundation; 2002.

3 Burge R, Dawson-Hughes B,Solomon DH, Wong JB, King A,Tosteson A. Incidence and economicburden of osteoporosis-related frac-tures in the United States, 2005–2025. J Bone Miner Res. 2007;22(3):465–75.

4 O’Malley CD, Johnston SS,Lenhart G, Cherkowski G, Palmer L,Morgan SL. Trends in dual-energy x-ray absorptiometry in the UnitedStates, 2000–2009. J Clin Densitom.2011;14(2):100–7.

5 Agency for Healthcare Research andQuality. National healthcare dispar-ities report 2010. Rockville (MD):AHRQ; 2011. (Pub. No. 11-0005).

6 Curtis JR, Carbone L, Cheng H,Hayes B, Laster A, Matthews R, et al.Longitudinal trends in use of bonemass measurement among olderAmericans, 1999–2005. J BoneMiner Res. 2008;23(7):1061–7.

7 Department of Health and HumanServices. Bone health and osteo-porosis: a report of the surgeongeneral. Washington (DC): HHS;2004. p. 192.

8 Medicare Evidence Developmentand Coverage Advisory Committee.Transcript, MEDCAC meeting4/20/2008: Medicare evidentiarypriorities [Internet]. Baltimore(MD): Centers for Medicare andMedicaid Services; [updated 2008May 20; cited 2011 Nov 14]. Available

from: https://www.cms.gov/faca/downloads/id42c.pdf

9 Medicare Evidence Developmentand Coverage Advisory Committee.Score sheet, MEDCAC meeting4/20/2008: Medicare evidentiarypriorities [Internet]. Baltimore(MD): Centers for Medicare andMedicaid Services; [updated 2008May 20; cited 2011 Nov 14]. Availablefrom: https://www.cms.gov/faca/downloads/id42b.htm

10 Bone mass measurement: conditionsfor coverage and frequency stan-dards. 42 C.F.R. Sec. 410.31.

11 US Preventive Services Task Force.Screening for osteoporosis: US Pre-ventive Services Task Force recom-mendation statement. Ann InternMed. 2011;154(5):356–64.

12 Department of Health and HumanServices. Medicare program: revi-sions to payment policies, five-yearreview of work relative value units,changes to the practice expensemethodology under the physician feeschedule, and other changes to pay-ment under Part B; revisions to thepayment policies of ambulance ser-vices under the fee schedule forambulance services; and ambulanceinflation factor update for CY 2007;final rule. Fed Regist. 2006;71(231):69623–70274.

13 Binkley N, Laster A, InternationalSociety for Clinical Densitometry,Middletown, CT. Letter to: K Weems(Centers for Medicare and MedicaidServices, Baltimore, MD). 2007Aug 31.

14 To access the Appendix, click on theAppendix link in the box to the rightof the article online.

15 Boards of Trustees of the FederalHospital Insurance and FederalSupplementary Medical InsuranceTrust Funds. Annual reports. Wash-

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16 To order the Medicare file, see Cen-ters for Medicare and MedicaidServices. Physician/Supplier Pro-cedure Summary Master File [Inter-net]. Baltimore (MD): CMS; [cited2011 Nov 10]. Available from:https://www.cms.gov/nonidentifiabledatafiles/06_physiciansupplierproceduresummarymasterfile.asp

17 Kanis JA. FRAX WHO Fracture RiskAssessment Tool [home page on theInternet]. Sheffield (England):World Health Organization Collabo-rating Centre for Metabolic BoneDiseases, University of Sheffield;[cited 2011 Oct 27]. Available from:http://www.shef.ac.uk/FRAX/

18 Leslie WD, Majumdar SR, Lix LM,Johansson H, Olden A, McCloskey E,et al. High fracture probability withFRAX usually indicates densitomet-ric osteoporosis: implications forclinical practice. Osteoporos Int.2011 Mar 2. [Epub ahead of print].

19 International Society for ClinicalDensitometry, International Osteo-porosis Foundation. 2010 officialpositions on FRAX [Internet]. Mid-dletown (CT): ISCD; [cited 2011Oct 27]. Available from: http://www.iscd.org/Visitors/pdfs/Official%20Positions%20ISCD-IOF%20FRAX.pdf

20 National Osteoporosis Foundation.Clinician’s guide to prevention andtreatment of osteoporosis. Washing-ton (DC): The Foundation; 2010.

21 Curtis JR, Laster A, Becker DJ,Carbone L, Gary LC, Kilgore ML,et al. The geographic availability andassociated utilization of dual energyx-ray (DXA) testing among olderpersons in the US. Osteoporos Int.2008;20:1553–61.

The Care Span

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22 American Association of ClinicalEndocrinologists, International So-ciety for Clinical Densitometry. DXAtesting undermining osteoporosisprevention. Jacksonville (FL): AACE;2009 Mar.

23 El-Gamil A, DaVanzo JE, Dobson A.Assessing the costs of performingDXA services in the office-basedsetting [Internet]. Falls Church(VA): Lewin Group; 2007 Oct 31[cited 2011 Oct 27]. Available from:https://www.aace.com/sites/default/files/DXAFinalReport.pdf

24 American Association of ClinicalEndocrinologists Osteoporosis TaskForce. American Association ofClinical Endocrinologists medicalguidelines for clinical practice forthe prevention and treatment ofpostmenopaual osteoporosis: 2001edition, with selected updates for2003. Endocr Pract. 2003;9:561.

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ABOUT THE AUTHORS: ALISON B. KING & DONNA M. FIORENTINO

Alison B. King isprincipal of AlisonB. King LLC.

In this month’s Health Affairs,Alison King and Donna Fiorentinowrite about the impact of cuts inMedicare Part B reimbursement onthe use of DXA (pronounced“dexa”) imaging—dual energy x-rayabsorptiometry of the centralskeleton—considered the “goldstandard” test for osteoporosis. Thepayment cuts to this type ofimaging began in 2007 andreached 56 percent by January2010. The result, according to theauthors, was 800,000 fewer tests

during 2007–09 than expected forMedicare beneficiaries. Theforgone tests might have preventedapproximately 12,000 fractures.The authors began collaborating

on osteoporosis testing issuesfollowing a 2007 meeting of sixnonprofit societies, including theInternational Society for ClinicalDensitometry. At that meeting,King presented her research on theburden of osteoporosis in theUnited States and the impact offractures on the Medicare program.King is president of Alison B.

King LLC, a McGraw, New York,company that consults in healthanalytics, strategy, andcommunications. She is also asenior consultant for theAmundsen Group, a pharmaceuticalstrategy consulting firm. Her areasof expertise include health carereform, health policy, and patient

assistance programs. She has adoctorate in nutritional sciencesfrom Cornell University.

Donna M.Fiorentino is thelegislative counselfor theInternationalSociety for ClinicalDensitometry.

Fiorentino is the legislativecounsel for the InternationalSociety for Clinical Densitometry,in West Hartford, Connecticut,where she manages public policyactivities for the organization. Shehas a law degree from theUniversity of Connecticut School ofLaw.

December 2011 30: 12 Health Affairs 9