Did changes in reimbursement for bone density tests affect the likelihood that women on Medicare received appropriate screening? If so, the question must be raised: when screening is recommended, how much to pay?
After the extensive media hype surrounding the change in the United States Preventative Services Task Force use, it seems that proponents of want to jump into the limelight. Last months Health Affairs features an article which analyzes Medicare claims data from 1996 to 2010 for DXA testing, also known as dexa scans, and the effect on use of DXA by changes in Medicare reimbursement rates.
This article points out that the rate of use of DXA, a test for fragile bones at risk for fracture, increased yearly from 1996 to 2007, with a peak in use in 2008, followed by decrease in use for 2009 and 2010. The authors remark that this pattern is likely reflective of the 56 percent overall decrease in Medicare reimbursement for DXA from 2007 to 2009 as a result of two pieces of legislation. First, the Deficit Reduction Act of 2006 reduced the reimbursement rate of DXA for outpatient centers (the facility fee) by 40 percent in an attempt to curb the increasing use of outpatient imaging tests. Second, CMS reduced the estimated value of the professional work component to reading DXA tests (the radiologists fee) during one of its regular RVU-balancing sessions that occurs every five years.
The article points out that the test was significantly under-utilized, evidenced by the fact that all elderly (estrogen-deficient) women are supposed to have this test but only 10 to 15 percent of all elderly female Medicare beneficiaries had at least one DXA test between 2002 and 2010. Also, perhaps most importantly, the study points out that while 7.5 percent of elderly female Medicare beneficiaries who did not receive a DXA test in 2005 had a fracture in the subsequent 3 years, only 6 percent of those who did have a DXA test had a subsequent fracture in the same time period (a 20 percent relative reduction).
The authors of this study therefore praise the Affordable Care Act because it temporarily increased Medicare reimbursement for DXA tests for 2010 and 2011 to 75 percent of the 2006 reimbursement level. They point out that while increases in DXA use have not yet been seen in the 2010 claims data, this effect is likely delayed and propose that the increased level of reimbursement should be extended for at least two more years in order to allow for the screening of more women at risk of osteoporosis and bone fracture.
Although this paper does not attempt to quantify cost-savings that would potentially be seen by increasing DXA use, the current reimbursement for each DXA test is just under $100, which, of course, is light-years less than the average cost of care for an elderly female who needs hospitalization and extended assistance after a fracture due to osteoporosis. Without conducting a formal cost effectiveness analysis, it appears to make sense that policy makers would want promote the use of DXA testing. However, the data this paper presents regarding claims data patterns does little to prove, or even suggest strong correlation, between DXA reimbursement and use of DXA testing, especially since there is no corresponding data to suggest increased testing now that reimbursement rates were increased, nor does it compare the rates of DXA use to other preventative tests in the same time period. It is very possible that the sharp decline in the economy from late 2007 through 2008 and the strong effect this likely had on use of health care services, particularly preventative tests, had just as large of an effect on DXA use as reimbursement rates. It is yet to be proven whether or not policy makers should support an extension of the increased Medicare reimbursement rates for DXA testing as a means to promote the use of this effective preventative test. However, the USPSTF recommends screening in women aged 65 or older and some other special populations. Therefore such screening should be covered; how much to pay is another matter.
Lisa Maurer, MD