Linking vertebral fractures to osteoporosis is critical to treatment. In our research*, we found that many patients suffered multiple fractures prior to being diagnosed, and those with multiple fractures suffered worst outcomes than those diagnosed at the time of the initial fracture or prior to a fracture.
We also discovered that in many cases, a DEXA scan isn't ordered until weeks or months after the fracture and that it is only ordered at the insistence of the patient.
Given the challenge's focus on older adults experiencing their first fracture, we then journey mapped the billing process for Medicare, the government provided healthcare for senior citizens in the United States, to see if it provided clues for why this might be the case. We found several challenges to care:
1. There is a natural gender bias. Medicare only covers preventive DEXA scans in postmenopausal women. The US Preventative Services Task Force doesn't recommend preventive testing for men, as the research is inclusive to the benefit.
2. The DEXA scan is covered by Medicare Part B, which covers outpatient services. This has several implication: (a) if a patient is kept is admitted to the hospital, the test may not be covered, and if they are kept as outpatient or "under observation," and need to be discharged to a skilled nursing facility or other rehabilitation, Medicare won't pay for those services (b) testing may be pushed until later in the care process to the primary care physician during the follow up process.
3. If conducted at the time of the fracture, Medicare will only reimburse for vertebral fractures. If someone suffers from a broken arm, toe or non-vertebral bone do to osteoporosis, it is unlikely testing will be done at the time the fracture presents itself.
Given Medicare's requirements and healthcare networks are unlikely to bill for testing not covered by Medicare, we propose that in patients who suffer a vertebral fracture and are over the age of 65, responding doctors assume the fracture was caused by osteoporosis, conduct a DEXA scan to confirm or rule out the disease, and adjust the care plan accordingly.
This stands in contrast to the current method where the primary care physician has to actively connect the fracture to the disease, sometimes weeks or months after the initial fracture.
*We created a global focus group of 42 females and 25 males from submitted patient stories obtained online from the International Osteoporosis Foundation and Osteoporosis Canada, and evaluated their experiences to find patterns in care.