Skip to main content
SpringerLink
Log in

Fracture Reduction Affects Medicare Economics (FRAME): Impact of increased osteoporosis diagnosis and treatment

  • Original Article
  • Published:
Osteoporosis International Aims and scope Submit manuscript

Abstract

Osteoporosis is a common, debilitating disease affecting US Medicare beneficiaries, yet diagnosis and treatment lag behind medical advances. We estimated the cost of fractures to the Medicare program and the impact of increasing osteoporosis diagnosis and treatment. A Markov model was used to predict fracture incidence and costs in postmenopausal women aged 65 years and older, over 3 years (2001–2003). Only 1.80 million women were estimated to receive a Medicare-reimbursed bone mineral density (BMD) test in 2001. We evaluated the budget impact of testing an additional 1 million women from Medicare and patient perspectives. These women were stratified into high-risk (osteoporotic with prevalent vertebral fracture) and moderate-risk (without prevalent vertebral fracture) groups. During 2001–2003, an estimated 2.39 million fractures occurred among the 5.11 million women aged 65+ with osteoporosis, at a cost to Medicare of $12.96 billion. We projected that BMD testing of an additional 1 million women in 2001 would result in treatment of 440,000 new patients with a bone-specific medication, preventing over 35,000 fractures over the 3 years. The decrease in fractures would produce a net discounted savings to the Medicare budget of $77.86 million. Medicare’s hospital inpatient cost would decrease by $115.41 million and long-term care cost by $43.51 million, more than offsetting incremental outpatient cost of $81.07 million. Patients would benefit from fracture avoidance, but their out-of-pocket medical costs would increase by $63.49 million during 2001–2003, or $1,771 per fracture avoided. Sensitivity analyses showed that savings to the Medicare program varied in proportion to the unit cost of fractures, fracture risk of the populations tested, treatment rate, and adherence to therapy. Increased osteoporosis diagnosis may produce savings for the Medicare program if interventions are targeted to women at elevated risk for fracture and may be budget neutral if all older women are screened.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Casebeer L, James N (2002) Practice pattern variation in the prevention and treatment of osteoporosis. Curr Opin Rheumatol 14:453–457

    Article  PubMed  Google Scholar 

  2. Gehlbach SH, Bigelow C, Heimisdottir M, May S, Walker M, Kirkwood JR (2000) Recognition of vertebral fracture in a clinical setting. Osteoporos Int 11:577–582

    CAS  PubMed  Google Scholar 

  3. Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA (2000) Treatment of osteoporosis: Are physicians missing an opportunity? J Bone Joint Surg Am 82-A:1063–1070

    Google Scholar 

  4. Kamel HK, Hussain MS, Tariq S, Perry HM III, Morley JE (2000) Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. Am J Med 109:326–328

    Article  CAS  PubMed  Google Scholar 

  5. Feldstein AC, Nichols GA, Elmer PJ, Smith DH, Aickin M, Herson M (2003) Older women with fractures: patients falling through the cracks of guideline-recommended osteoporosis screening and treatment. J Bone Joint Surg Am 85:2294–2302

    PubMed  Google Scholar 

  6. National Center for Health Statistics (2001) Healthy People 2000 Final review. Public Health Service, Hyattsville, MD, USA, pp 3, 161

  7. Federal Register June 24, 1998 (Vol 63, No. 121) 42 CFR Part 410 Medicare program: Medicare coverage of and payment for bone mass measurements; Interim Final Rule, USA, pp 34320–34328

  8. Centers for Medicare and Medicaid Services (June 2001) Medicare Part B Extract and Summary System (BESS) data reported for calendar 2000

  9. US Census Bureau, national population projections, detailed files, total population by age, sex, race, Hispanic origin, and nativity: (NP-D1-A) Annual projections of the resident population by age, sex, race, and Hispanic origin: Middle Series, 1999 to 2100

  10. US Preventive Services Task Force (2002) Screening for osteoporosis in postmenopausal women: Recommendations and rationale. Ann Intern Med 137:526–528

    PubMed  Google Scholar 

  11. National Osteoporosis Foundation (2002) America’s bone health: the state of osteoporosis and low bone mass in our nation. National Osteoporosis Foundation, Washington, DC

  12. Tosteson ANA, Jonsson B, Grima DT, O’Brien BJ, Black DM, Adachi JD (2001) Challenges for model-based economic evaluations of postmenopausal osteoporosis interventions. Osteoporos Int 12:849–857

    Article  CAS  PubMed  Google Scholar 

  13. Burge RT, King AB, Balda E, Worley D (2003) Methodology for estimating current and future burden of osteoporosis in state populations: application to Florida in 2000–2025. Value Health 6:574–583

    Article  PubMed  Google Scholar 

  14. Cummings SR, Black DM, Thompson DE, Applegate WB, Barrett-Connor E, Musliner TA, Palermo L, Prineas R, Rubin SM, Scott JC, Vogt T, Wallace R, Yates AJ, LaCroix AZ, for the Fracture Intervention Trial Research Group (1998) Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures. JAMA 280:2077–2082

    Article  CAS  PubMed  Google Scholar 

  15. Chesnut CH 3rd, Silverman S, Andriano K, Genant H, Gimona A, Harris S, Kiel D, LeBoff M, Maricic M, Miller P, Moniz C, Peacock M, Richardson P, Watts N, Baylink D, for the PROOF Study Group (2000) A randomized trial of nasal spray salmon calcitonin in postmenopausal women with established osteoporosis: the prevent recurrence of osteoporotic fractures study. Am J Med 109:267–276

    Article  CAS  PubMed  Google Scholar 

  16. Ettinger B, Black DM, Mitlak BH, Knickerbocker RK, Nickelsen T, Genant HK, Christiansen C, Delmas PD, Zanchetta JR, Stakkestad J, Glüer CC, Krueger K, Cohen FJ, Eckert S, Ensrud KE, Avioli LV, Lips P, Cummings SR, for the Multiple Outcomes of Raloxifene Evaluation (MORE) Investigators (1999) Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: Results from a 3-year randomized clinical trial. JAMA 282:637–645

    Article  CAS  PubMed  Google Scholar 

  17. Third National Health and Nutrition Examination Survey, 1988–1994. US Department of Health and Human Services, National Center for Health Statistics, Hyattsville, MD, USA

  18. Melton LJ 3rd, Kan SH, Frye MA, Wahner HW, O’Fallon WM, Riggs BL (1989) Epidemiology of vertebral fractures in women. Am J Epidemiol 129:1000–1011

    PubMed  Google Scholar 

  19. Nationwide Inpatient Sample, Release 6 (1997) Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, USA

  20. Melton LJ 3rd, Lane AW, Cooper C, Eastell R, O’Fallon WM, Riggs BL (1993) Prevalence and incidence of vertebral deformities. Osteoporos Int 3:113–119

    Google Scholar 

  21. Melton LJ 3rd, Chrischilles EA, Cooper C, Lane AW, Riggs BL (1992) How many women have osteoporosis? J Bone Miner Res 7:1005–1010

    PubMed  Google Scholar 

  22. Melton LJ 3rd, Thamer M, Ray NF, Chan JK, Chesnut CH 3rd, Einhorn TA, Johnston CC, Raisz LG, Silverman SL, Siris ES (1997) Fractures attributable to osteoporosis: report from the National Osteoporosis Foundation. J Bone Miner Res 12:16–23

    PubMed  Google Scholar 

  23. Kanis JA, Johnell O, Oden A, Jonsson B, Dawson A, Dere W (2000) Risk of hip fracture derived from relative risks: an analysis applied to the population of Sweden. Osteoporos Int 11:120–127

    CAS  PubMed  Google Scholar 

  24. Social Security Administration Office of the Chief Actuary, period life tables for 1996, 1999. [Period life tables calculated using death counts from the National Center for Health Statistics, Center for Disease Control, and from population from the US Census Bureau]

  25. Keene GS, Parker MJ, Pryor GA (1993) Mortality and morbidity after hip fractures. Br Med J 307:1248–1250

    CAS  Google Scholar 

  26. MarketScan Database, The MEDSTAT Group, Ann Arbor, MI, USA

  27. Pressman A, Forsyth B, Ettinger B, Tosteson ANA (2001) Initiation of osteoporosis treatment after bone mineral density testing. Osteoporos Int 12:337–342

    Article  CAS  PubMed  Google Scholar 

  28. Actonel package insert, March 2003

  29. Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, Bauer DC, Genant HK, Haskell WL, Marcus R, Ott SM, Torner JC, Quandt SA, Reiss TF, Ensrud KE, for the Fracture Intervention Trial Research Group (1996). Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet 348:1535–1541

    Article  CAS  PubMed  Google Scholar 

  30. Harris ST, Watts NB, Genant HK, McKeever CD, Hangartner T, Keller M, Chesnut CH 3rd, Brown J, Eriksen EF, Hoseyni MS, Axelrod DW, Miller PD, for the Vertebral Efficacy With Risedronate Therapy (VERT) Study Group (1999). Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. JAMA 282:1344–1352

    Article  CAS  PubMed  Google Scholar 

  31. McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C, Adami S, Fogelman I, Diamond T, Eastell R, Meunier PJ, Reginster JY, for the Hip Intervention Program Study Group (2001) Effect of risedronate on the risk of hip fracture in elderly women. N Engl J Med 344:333–340

    Article  CAS  Google Scholar 

  32. IMS Health. National prescription data for 2001 for women ≥ 65 years with an osteoporosis diagnosis and prescription for a bone-regulating medication

  33. Osteoporosis Prevention, Diagnosis, and Therapy (2000) NIH consensus statement 2000, March 27–29 17(1):1–36

  34. Ray NF, Chan JK, Thamer M, Melton LJ 3rd (1997) Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation. J Bone Miner Res 12:24–35

    CAS  PubMed  Google Scholar 

  35. Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, Licata A, Benhamou L, Geusens Piet, Flowers K, Stracke H, Seeman E (2001) Risk of new vertebral fracture in the year following a fracture. JAMA 285:320–323

    Article  CAS  PubMed  Google Scholar 

  36. National Osteoporosis Foundation (1998) Physician’s guide to prevention and treatment of osteoporosis. Excerpta Medica, Belle Mead, NJ, USA

  37. Hoerger TJ, Downs KE, Lakshmanan MC, Lindrooth RC, Plouffe L Jr, Wendling B, West SL, Ohsfeldt RL (1999) Healthcare use among US women aged 45 and older: Total costs and costs for selected postmenopausal health risks. J Womens Health Gend Based Med 8:1077–1089

    CAS  PubMed  Google Scholar 

  38. US Congress, Office of Technology Assessment (1994) Hip fracture outcomes in people age 50 and over—background paper, OTA-BP-H-120. US Government Printing Office, Washington, DC

  39. Chrischilles E, Shireman T, Wallace R (1994) Costs and health effects of osteoporotic fractures. Bone 15:377–386

    Article  CAS  PubMed  Google Scholar 

  40. Federal Register, November 2, 1999 (Vol 64, No. 211). 42 CFR Parts 410, 411, 414 et al. Medicare Program; Revisions to payment policies under the Physician Fee Schedule for Calendar Year 2000; Final Rule, USA, pp 59379–59590

  41. National Osteoporosis Foundation (1988) Osteoporosis: review of the evidence for prevention, diagnosis and treatment and cost-effectiveness analysis. Introduction. Osteoporos Int [Suppl 4]:S7–80

  42. Phillips S, Fox N, Jacobs J, Wright WE (1998) The direct medical costs of osteoporosis for American women aged 45 and older, 1986. Bone 9:271–279

    Article  Google Scholar 

  43. Stucki B, Mulvey J (2000) Can aging baby boomers avoid the nursing home? American Council of Life Insurers (ACLI), Washington, DC

  44. MetLife Mature Market Institute (2002) MetLife market survey on nursing home and home care costs. Westport, CT, USA

  45. Expanded MEDPAR-Skilled Nursing Facility File (2000) US Department of Health and Human Services. Health Care Financing Administration. Office of Information Services. Baltimore, MD, USA

  46. National Drug Data File (January 8, 2001) First DataBank, San Bruno, CA, USA

  47. Colby CJ, Levin TR, Boyko WL (1999) Cost of acid-related disorders associated with alendronate use for osteoporosis in a large managed care organization. [Abstract T332] Amer Soc Bone Min Res, 21st Annual Meeting, St. Louis, MO, USA

  48. Gould MK, Dembitzer AD, Sanders GD, Garber AM (1999) Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis. A cost-effectiveness analysis. Ann Intern Med 130(10):789–799

    CAS  PubMed  Google Scholar 

  49. Consumer Price Index, US City Average. Washington, Bureau of Labor Statistics, US Department of Labor

  50. Adler GS, Shatto A (2002) Screening for osteoporosis and colon cancer under Medicare. Health Care Financing Review 23:189–200

    PubMed  Google Scholar 

  51. US Preventive Services Task Force (1996) Guide to clinical preventive services: Report of the US Preventive Services Task Force, 2nd ed. Williams & Wilkins, Baltimore, MD, USA

    Google Scholar 

  52. Bone health and osteoporosis: a report of the Surgeon General. Rockville, MD. US Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General, Washington, DC

  53. Andrade SE, Majumdar SR, Chan KA, Buist DSM, Go AS, Goodman M, Smith DH, Platt R, Gurwitz JH (2003) Low frequency of treatment of osteoporosis among postmenopausal women following a fracture. Arch Intern Med 163:2052–2057

    Article  PubMed  Google Scholar 

  54. National Committee for Quality Assurance (2003) Osteoporosis management in women who had a fracture. HEDIS 2004 technical specifications—vol 2, item 10284–100–04:100–102, Washington, DC

  55. Siris ES, Miller PD, Barrett-Connor E, Faulkner KG, Wehren LE, Abbott T, Berger ML, Santora AC, Sherwood LM (2001) Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. JAMA 286:2815–2822

    Article  CAS  PubMed  Google Scholar 

  56. Dargent-Molina P, Favier F, Grandjean H, Baudoin C, Schott AM, Hausherr E, Meunier PJ, Breart G (1996) Fall-related factors and risk of hip fracture: the EPIDOS prospective study. Lancet 348:145–149

    Article  PubMed  Google Scholar 

  57. Stone KL, Seeley DG, Lui LY, Cauley JA, Ensrud K, Browner WS, Nevitt MC, Cummings SR; Osteoporotic Fractures Research Group (2003) BMD at multiple sites and risk of fracture of multiple types: long-term results from the Study of Osteoporotic Fractures. J Bone Miner Res 18:1947–1954

    PubMed  Google Scholar 

  58. Dufresne TE, Chmielewski PA, Manhart MD, Johnson TD, Borah B (2003) Risedronate preserves bone architecture in postmenopausal women in 1 year as measured by 3D microcomputed tomography. Calcif Tissue Int 73:423–432

    CAS  PubMed  Google Scholar 

  59. Rubin RJ, Mendelson DN (1996) A framework for cost-sharing policy analysis. Pharmacoeconomics 10[Suppl 2]:56–67

  60. US Congress, Office of Technology Assessment (1993) Benefit design in health care reform: Background paper—patient cost-sharing. US Government Printing Office, OTA-BP-H-112, Washington, DC

    Google Scholar 

  61. US General Accounting Office (2003) Prescription drug discount cards. Savings depend on pharmacy and type of card used. US Government Printing Office, GAO-03–912, Washington, DC

  62. Thomas CP, Wallack SS, Leung MY, Ritter GA (2003) PBM-administered prescription drug discount cards: savings for uninsured seniors. Brandeis University, Waltham, MA, USA

  63. Laschober MA, Kitchman M, Neuman P, Strabic AA (2002) Trends in Medicare supplemental insurance and prescription drug coverage, 1996–1999. Health Affairs W127–W138

  64. US General Accounting Office (2001) Medigap insurance: Plans are widely available but have limited benefits and may have high costs. US Government Printing Office, GAO-01–941, Washington, DC

    Google Scholar 

  65. Braithwaite RS, Col NF, Wong JB (2003) Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc 51:364–370

    Article  PubMed  Google Scholar 

  66. Kaiser Commission on Medicaid and the Uninsured (2004) Dual eligibles: Medicaid’s role for low-income Medicare beneficiaries. Kaiser Family Foundation, Menlo Park, CA, USA

    Google Scholar 

  67. Borisova NN, Doyle JJ, Brezovic CP, Sheer RL (2003) Cost analysis of gastrointestinal events in patients receiving bisphosphonate therapy in a managed-care setting; [abstract]. J Manag Care Pharm 9(2):183

    Google Scholar 

  68. Writing Group for the Women’s Health Initiative Investigators (2002) Risks and benefits of estrogen plus progestin in healthy postmenopausal women. JAMA 288:321–333

    Article  PubMed  Google Scholar 

  69. Newman ED, Starkey RH, Ayoub WT, Davis CM 3rd, Diehl JM, Hanus PM, Wood GC, Frey CM (2003) Osteoporosis disease management: best practices from the Penn State Geisinger health system. JCOM 7:23–28

    Google Scholar 

  70. Federal Register November 15, 2004 (Vol 69, No. 219) 42 CFR Parts 403, 405, 410 et al. Medicare program: Revisions to payment policies under the physician fee schedule for calendar year 2005; Final Rule, USA, pp 66235–66915

Download references

Acknowledgments

The authors thank Karen Worley for consultation, Dan Worley and Eric Balda for programming, and Lorraine Rice for administrative assistance.

Author information

Authors and Affiliations

  1. Public Policy, Procter & Gamble Pharmaceuticals, P.O. Box 191, Norwich, NY, 13815, USA

    Alison B. King

  2. Department of Medicine, University of Alabama at Birmingham, MT 401, 1530 3rd Ave S., Birmingham, AL, 35294-1170, USA

    K. G. Saag

  3. Procter & Gamble Pharmaceuticals, 8700 Mason-Montgomery Rd, Mason, Ohio, 45404, USA

    R. T. Burge & N. Goel

  4. Ohio State University, Columbus, Ohio, USA

    R. T. Burge

  5. Center for Outcomes and Effectiveness Research and Education (COERE), University of Alabama at Birmingham, MT 401, 1530 3rd Ave S., Birmingham, AL, 35294-1170, USA

    M. Pisu

  6. University of Texas Medical Branch, Galveston, TX, USA

    N. Goel

Authors
  1. Alison B. King
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. K. G. Saag
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. R. T. Burge
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. M. Pisu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. N. Goel
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alison B. King.

Additional information

A related study, which employed the same economic model but evaluated current BMD testing rates in the Medicare program, was presented at the ACR Annual Meeting on October 28, 2002. An abstract of that study was published in the Abstract Supplement for the meeting (Arthritis Rheum 46 [Supplement 9]:S583, abstract 1,567)

Appendices

Appendix A: Fracture incidence rates per 10,000 women

Age

Hip*

Vertebral [20]

Wrist [21]

65

18.91

116.00

57.85

66

22.83

125.00

55.80

67

28.70

134.00

53.76

68

26.66

146.40

56.40

69

32.88

158.80

59.05

70

40.86

171.20

61.69

71

46.81

183.60

64.34

72

58.45

196.00

66.98

73

66.00

211.40

63.94

74

71.72

226.80

60.90

75

83.98

242.20

57.86

76

97.36

257.60

54.82

77

114.49

273.00

51.78

78

117.04

290.60

51.96

79

143.28

308.20

52.14

80

167.80

325.80

52.33

81

193.09

343.40

52.51

82

245.55

361.00

52.69

83

245.61

378.20

55.92

84

267.66

395.40

59.14

85

453.77

412.60

62.37

86

398.01

429.80

65.59

87

381.15

447.00

68.82

88

352.69

464.20

72.05

89

332.45

481.40

75.27

90

627.02

498.60

78.50

91

529.10

515.80

81.72

92

434.56

533.00

84.95

  1. *Calculated from Nationwide Inpatient Sample, 1997 [19]

Appendix B: Relative risk of fracture in women, by age band, risk group, and fracture type

Age (years)

Moderate risk women with low BMD

High risk women with low BMD and prevalent vertebral fracture

Hip

Vertebral

Wrist

Hip

Vertebral

Wrist

65–69

4.176

2.050

1.668

6.407

5.657

1.560

70–74

2.725

1.655

1.432

4.034

4.078

1.345

75–79

2.725

1.655

1.432

3.914

3.729

1.350

80–84

1.828

1.354

1.241

2.528

2.747

1.176

85–89

1.828

1.354

1.241

2.415

2.440

1.184

90–92

1.333

1.156

1.108

1.762

2.083

1.057

  1. (*Proportion with low BMD: [17]; relative risk: [23] and SOF data, personal communication, D.M. Black, July 26, 2002)

Rights and permissions

Reprints and permissions

About this article

Cite this article

King, A.B., Saag, K.G., Burge, R.T. et al. Fracture Reduction Affects Medicare Economics (FRAME): Impact of increased osteoporosis diagnosis and treatment. Osteoporos Int 16, 1545–1557 (2005). https://doi.org/10.1007/s00198-005-1869-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00198-005-1869-5

Keywords

Search

Navigation