Dual-energy X-ray absorptiometry, known as DXA or DEXA, is the go-to bone density test for osteoporosis. However, since 2007, the Centers for Medicare and Medicaid has been slashing reimbursement for the test. The physician practice rate has now hit an all-time low and the hospital rate may soon come down to that level as well, but there are alliances fighting to bring that amount back to a sustainable level.

At the current reimbursement rate, practices offering DXA are losing money, causing many to discontinue the service.

Osteoporosis and low bone mass are currently estimated to be a major public health threat for almost 44 million women and men aged 50 and older in the U.S., according to the International Osteoporosis Foundation.

Yet less and less people are getting the tests because of decreased access.

Organizations such as the International Society for Clinical Densitometry (ISCD) and the National Bone Health Alliance (NBHA) have made their pleas to CMS to raise reimbursement rates, but they claim the agency won’t listen. To make matters worse, there may be another round of cuts just around the corner.

How did we get here?
The cuts started in 2007 when the Federal Deficit Reduction Act cut all imaging services, taking DXA from $139 to $82 in one year. At the same time, CMS implemented the results of the review of reimbursement rates that it conducts every five years, and also implemented a new formula for calculating practice expense.

The majority of the DXA fee is related to the practice expense. When CMS began to phase in the new methodology for calculating practice expense, it caused the DXA rate to decline over the next five years, says Donna Fiorentino, legislative counsel for ISCD.

But with the introduction of the Affordable Care Act in 2010, there was some relief. Congress included a provision that partially restored DXA rates to $98. However, the payment relief expired on March 1, 2012 when Congress failed to include a provision that would have extended it for another year.

The reimbursement rate now stands at $49 with two other payment cuts on deck. “It’s just unbelievable what the numbers look like now,” says Fiorentino.

Starting in January, DXA and vertebral fracture assessment (VFA) may be bundled. VFA is a test that is performed to identify vertebral abnormalities and it gives the doctors another piece of information to diagnose osteoporosis.

Medicare has decided that if a doctor performs both DXA and VFA on the same day, those services will be bundled, meaning they will be billed together at a lower rate than if the two services were billed separately.

Additionally, the Medicare Payment Advisory Commission recommended this past March to decrease the hospital reimbursement rate for imaging services to match the office rate, if that rate was lower. For DXA, that would mean that the hospital rate would decline from $101 to $49.

“It’s just peculiar. The numbers are kind of all over the place,” says Fiorentino. “They clearly don’t reflect anything to do with the cost anymore, it’s just this random leveling of the playing field — whoever is higher gets cut.”

Physicians and patients are suffering
Fiorentino said that she has seen an 18.7 percent decline in the number of physician practices offering the service from 2008 to 2012.

Many of those sites had leases so they have already returned their machines. Those who don’t have a lease may still have their machines, but many have discontinued their maintenance contracts. “What a lot of doctors tell us is that they thought ‘OK, I will keep the machine and I will keep doing DXAs, but I’m not going to pay the $7,000 for the maintenance contract so when the machine goes, that’s it,’” says Fiorentino.

She says that because less physician practices are offering it, there has been a slight shift to hospitals, but not enough to make up for the loss. In part, hospitals are typically further from patients’ homes than doctors’ offices and with the patient base being elderly, the distance necessary to travel is a major factor in utilization of the service. According to ISCD data, because of the decline in the number of physicians offering DXA in their offices, DXA testing for older women using Medicare has dropped by 12 percent from 2008 to 2012.

But it’s even more of a problem now because testing was already underutilized before that time. ISCD found that over a nine year period, 41 percent of older women using Medicare had no DXA test.

“For a preventative service, for Medicare in particular, this is such a failure of public policy,” says Fiorentino. “It’s like the framework for the care of osteoporosis patients is imploding and that is not an exaggeration.”

David Lee, director of NBHA, has seen firsthand how the cuts have affected the patients. He says that before, patients were able to go down the hall to get a DXA scan after a doctor visit but now, especially if they live in a rural community, they may have to travel three to four hours to get it in a hospital.

“For some folks, especially if you think of those in their 70s and 80s and beyond that may need follow-ups with DXAs — it’s probably not going to happen,” he adds.

Lee says that 54 percent of the entire population of people aged 50 and above either have low bone mass or full-blown osteoporosis. In the U.S., there are two million osteoporotic fractures per year, which is currently costing the economy about 17 billion dollars and is estimated to go up to 25 billion by 2025.

With demographics shifting to an older population, those numbers are going to continue to grow. Despite that, the seriousness of osteoporosis is still underestimated.

“Osteoporosis and low bone mass, I would say, really isn’t that recognized by patients,” says Lee. “We’ve gotten feedback on the consumer side and they feel like it’s a regular part of aging and there’s nothing you can do to prevent fractures caused by osteoporosis.”

What about the manufacturers?
Since physicians are discarding their old DXAs and refusing to purchase new ones, it’s having a telling effect on the manufacturers. GE Healthcare is one of the leaders in the DXA market and they say that their U.S. sales have flattened out as a result of the cuts.

However, there is some hope. They are seeing continued growth in Asia — particularly China, and Latin America, says Tom Webb, product manager for DXA at GE. In the U.S., they are starting to take a different approach with DXA.

“We are indeed looking at the adjacent markets that would help expand our reach into areas that perhaps aren’t typically related to osteoporosis care or acute bone care,” says Webb. Those areas are orthopedic surgery and body composition.

GE has released software updates called enCore Version 14 for its DXA systems that includes measurement capabilities for visceral fat and enCore Version 15, which adds simplified reporting structures and simplified options.

The most recent release is Version 16, which received FDA clearance in May. It allows physicians to take total body scans for every pediatric age and also includes Orthopedic Knee, which measures bone mass density periprosthetically.

Hologic, another leader in the market, is also going in that direction. In 2011, the company included the National Health and Nutrition Examination Survey whole body reference data into its Discovery DXA systems so that they can be used for body composition studies.

The company also released another update last July called Horizon that has a very low noise detector. Whether it’s used for body composition studies or bone density evaluations, it provides much better image quality for obese patients.

But not every company is affected by the cuts. Integrity Medical Systems Inc., a used equipment company based in Florida, has recently seen their sales go up.

David Denholtz, CEO of the company, says that about a year ago they were seeing less and less sales but that in the last four or five months, the market has picked up. The reason is because the prices of the machines have dropped as low as $20,000.

“If it drops low enough and it becomes easy enough to get one, you’ll get one and you’ll take the risks,” he says.

The bulk of his customers are existing businesses rather than newer ones because they know their throughput, which makes it easy for them to calculate how quickly another machine could start turning a profit. However, even for those customers, profit will dry up if reimbursement is cut again.

Fighting for the cause
For the past two years, the ISCD, NBHA, National Osteoporosis Foundation and other organizations have gathered together to confront Congress and explain that the cuts are affecting everyone from the patients to the manufacturers. But it hasn’t been an easy task.

“It’s a tough atmosphere in Washington to get people’s attention about the magnitude of the problem we’re facing,” Fiorentino says.

But she says that even if reimbursement improves, she’s not too sure that things will improve right away. “Now we’ve gone over a seven year period and those physicians are gone. They are not going to come back because there are such hard feelings and such a loss of money,” she says. “It is going to take a while to get back to where we were in 2008.”

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