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Shifting the Diagnostic Paradigm: Ruling Out Osteoporosis

Order DEXA scans for all fractures in elderly patients, given the high probability of osteoporosis.

Photo of Adam Papin
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What challenges or opportunities are you trying to address within the problem? (200 characters or less)

We propose ordering a DEXA scan for all at-risk patients at the time of fracture, making it easier to connect initial fractures to osteoporosis than it would be by conducting the scan during rehab.

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.

Who is your target end user and why will they be interested? (650 characters or less)

We approached our target end users by mapping the entire healthcare ecosystem that surround the osteoporosis care network. This included not just patients, caregivers, and physicians, but also hospital administrators, billing assistants, and Medicare Administrative Contractors. Once we started journey mapping all these different users, we concluded that for any future patient journey map to be adopted in an impactful, scaleable way, it has to work within the unique financial framework of the United States' Medicare system and its "fee-for-service" system. By initially focusing on patients whose DEXA scans are covered by Medicare, the piloting organization would incur limited costs in conducting research. Once the solution is validated, the value created could be used in lobbying elected officials to adjust and expand Medicare's coverage of DEXA scans to broader audiences.

How is your idea scaleable? (650 characters or less)

Any change to the diagnostic process for osteoporosis would have to validated in trials. However, once such validation occurred, it would be quite scalable. Precisely, because moving the DEXA scan closer to the initial fracture falls within current Medicare billing and reimbursement practices, and could ultimately create greater value for the healthcare system, key stakeholders should support the initiative.

What do/will you measure to know if your solution worked? (500 characters or less)

We propose a randomized diagnostic research study to determine whether ordering a DEXA scan at the time of initial fracture diagnosis for all fracture patients* leads to higher diagnosis rates for osteoporosis than a control group. (*Patients meeting the DRG reimbursement requirements for DEXA scans under Medicare). In a concurrent study, measure whether those diagnosed with osteoporosis at the initial fracture have better long-term outcomes than traditional patients, and whether such early detection creates greater value for the healthcare network.

What is the current stage of development of your idea?

  • Blueprint: We are exploring the idea and gathering the inspiration and information we need to test it with real users.

If you were to become a Top Idea, would you want to actively participate in piloting your idea?

  • I want my idea piloted, and I prefer to do my own piloting in collaboration with the health system and with assistance from the Challenge partner

Company / Organization Name, if applicable (140 characters or less)

Adam Papin

Tell us about yourself or your team (500 characters or less)

I am a designer living in rural Ohio, in the United States. While I don't have much experience in the healthcare system, I was drawn to the complexity of the problem, and thought my design skills might help contribute to solutions. As someone who suffered from a milk allergy as a child, I've also wondered about my risk of developing osteoporosis as I age.

Location (50 characters)

Bryan, Ohio, United States

What is your legal / organizational structure?

  • We are individuals

How did you hear about the Challenge?

  • OpenIDEO website


Join the conversation:

Photo of Estela Kennen

Hi Adam. I wrote a proposal that has very strong overlap with yours, though yours emphasis why getting DEXA screens is problemátic and mine emphasizes a mechanism for getting them scheduled.

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