As the American population ages, the problems associated with old age will become more commonplace. High on the list of these conditions is osteoporosis, which afflicts 10 million Americans, according to the National Osteoporosis Foundation (NOF). Another 34 million are at risk for the disease. About 80% of those affected by osteoporosis are women. In 2001, osteoporosis cost the US economy $17 billion. And that amount is expected to climb as high as $140 billion by 2040.1 “Osteoporosis is going to be an enormous problem as the next few decades evolve, and therefore avoiding fractures and taking care of people at risk are clearly going to be at issue if we’re going to have a cost-effective health care service,” says Brian C. Lentle, MD, a radiologist, chairman of the quality committee at BC Women’s and Children’s Health Center, Vancouver, British Columbia.
Though the disease is a growing problem, there are treatments available including bisphosphonates, calcitonin, and estrogen/hormone replacement therapy. And radiology is in a unique position to take a more active role in diagnosing and monitoring treatment for this potentially devastating disease. Osteoporosis is diagnosed via bone mineral density (BMD) testing, using a simple, inexpensive, and effective x-ray technology that is a natural fit within the menu of radiologic services offered at imaging centers and hospitals today.
|Brian C. Lentle, MD
For Weinstein Imaging Associates, a woman’s imaging practice in Pittsburgh,? the decision to add BMD in 1996 was a natural one because of osteoporosis’s prevalence in women. “This test is an ideal fit for the types of services we have been offering, with patients coming from gynecologists’ offices and from primary care physicians,” explains Thomas Chang, MD, a radiologist at Weinstein Imaging Associates. “Those are the people who are most likely to order this sort of test. And since a large percentage of our patients are women, this is appropriate for that patient population.” BMD is offered at each of the practice’s three sites, which together screen about 40 BMD patients a week.
Charlotte Radiology, a 60-radiologist practice in Charlotte, NC, introduced BMD 4 years ago at the behest of its orthopedic radiologists. It was a well- timed addition. “The marketplace at the time was not really developed in providing high-quality bone mineral testing,” says Mark Jensen, CPA, MBA, the practice’s administrator. “There were various options that the patients were accessing or doctors were using, but there wasn’t a good high-quality&exam being done that provided baseline measurement. With the evolution of alendronate into the marketplace for treating osteoporosis, there became a more sensitized market awareness of measuring for BMD because there was FDA-approved treatment.”
Though awareness of the test is growing among referring physicians and patients, according to Chang, less than 50% of women who should get a BMD test are doing so. “The number of patients who get bone density tests is far lower than the number of patients we see for other testsso there’s a long way to go,” he says.
|Thomas Chang, MD
There may be a long way to go, but, from a technological and economic perspective, BMD is an attractive option for practices looking to expand their services.
Simple and inexpensive
Though each practice model has to face different challenges in reimbursement, administration, and marketing, they, by and large, use the same technologydual energy x-ray absorptiometry (DEXA)which, according to Michael T. DiMuzio, PhD, executive director of North Shore Osteoporosis Center, Deerfield, Ill, is the medical standard for the test. “The precision and accuracy of the DEXA instrument cannot be surpassed by any of the other [methods],” he says. “Clinical trials looking at drugs, looking at efficacy of treatment options, have all used DEXA as their gold standard, so following treatments, or even establishing the diagnoses of osteoporosis, has all been done using DEXA equipment. The World Health Organization has used DEXA to establish the criteria for diagnosing osteoporosis.” Other methods of testing include ultrasound and CT.
At a cost of $50,000 to $100,000, DEXA machines are affordable for most organizations, and are available for lease or purchase. An added attraction of DEXA is the limited amount of peripheral equipment that is needed. Because the systems are all digital, in addition to a table and the DEXA unit, the only other requirements are a paper printer and a workstation. DEXA technology also has a relatively small footprint, taking up, at minimum, a 10 ft by 10 ft space, though DiMuzio adds that at North Shore a 20 ft by 20 ft space was committed to the equipment.
|Mark Jensen, CPA, MBA
Another benefit of using the noninvasive DEXA technology is that it is standardized from company to company with the primary difference being in the competing units’ software. “The software can increase your ability to do different things with the instrument,” says DiMuzio. “There are basic things you can doyou can measure hips and spinesbut nowadays there are some sophisticated ways of analyzing these structures with lateral measurements, using structural software to be a little more focused on the risk factors.”
Technology is not the only factor that has to be weighed when adding BMD to a practice. Staff and space must be available to make the test economically sound. At Weinstein Imaging Associates, instead of adding staff, doctors and technologists already with the practice were tapped to administer the test. These individuals received additional training. “All of us are certified by the International Society for Clinical Densitometry,” says Chang. “That’s another plus that doctors and patients look for: some sort of special certification.”
For other practices, space and staff questions have required different answers. After Charlotte Radiology purchased its DEXA unit, it initially used its mammography technologists to perform the test. As volume increased, it added dedicated staff to do it.
|Michael T. DiMuzio, PhD
But the addition of new equipmentand perhaps staffis worth the cost, because, as every practice model has discovered, BMD can be made to pay.
Economics of BMD
BMD testing has a better reimbursement schedule than mammography, which, in many cases is a loss leader for practices. There are two Medicare CPT codes for BMD screening: 76075 for hip and spine testing, and 76076 for wrist testing. According to DiMuzio, reimbursement from private insurers falls in line with that of Medicare, which is $129 in DiMuzio’s market. And even if it did not, “people are so enthusiastic about osteoporosis testing, they will pay for it out of their pocket,” he says. Aiding the universality of reimbursement is 1997 federal legislation mandating that Medicare cover bone density testing. Unlike screening mammography, which can be self-referred, BMD testing requires a physician referral, and that means individual practices have to work with physicians to build a referral base.
For Charlotte Radiology, the addition of BMD testing has been bother an area of growth and a challenge. “It’s provided another revenue stream,” says Jensen. “But it’s been an incremental increase. What has impacted BMD in [our market] are two things: the cost of buying the equipment/training/interpretation is relatively low compared to other radiology modalities, and the ability of nonradiologists to provide their own examination has evolved, so that where there were once very few providers, now there are a lot of providers of BMD testing.” This has increased the level of competition for patients and referrals within the Charlotte market. To be competitive, Charlotte Radiology has focused having using subspecialist radiologists to interpret the exams, use technologists specially trained in performing BMD, have purchased top-of-the-line equipment, and emphasize the quality of the test.
Weinstein Imaging Associates has had different challenges. Only one of its three sites is currently profitablea function of demographics, says Chang.
In Canada, BMD is offered through the nation’s national health service, which like Medicare in the United States is administered by the provincial, ie, state, health services, so indications for BMD testing vary from province to province. “We in British Columbia are just going through a process of revising our guidelines, so that we’re trying to make it clearer and clearer what the indications for densitometry are,” says Lentle. “Like any of these tests there’s a fine line to draw between population health and overuse.” There is a provision in the guidelines that does allow for individuals to pay for the test themselves. However, Lentle says that this rarely happens because most providers can find a reason under the current guidelines in which to order the test.
According to Lentle, BMD testing is currently reimbursed at a level that makes it economically viable for organizations.
Success in implementing such a service, Lentle says, is dependent on the practitioner’s knowledge and communication skills. “One thing has become very clear to me,” he says, “you have to know about osteoporosis, you can’t just do it as a radiological test. That may be true of all radiology, but it’s particularly true of osteoporosis. You have to provide a quality service, and you have to communicate with your physicians. You need to let them know what you’re doing because the precision of your test impacts on their decision whether to continue or change a particular form of [disease] management.”
While DiMuzio agrees with Lentle that providing quality examinations and building relationships with referring physicians are key factors in being successful, his North Shore Osteoporosis Center, which has been offering BMD testing for the last 8 years, has built its reputation with its focus on customer service.
As part of its service, North Shore Osteoporosis Center goes over the test immediately with patients, counseling them about their treatment options, but leaving the specific choice of treatment to the patients and their physicians. This patient empowerment has been one of the key factors in the success of its BMD testing service, says DiMuzio.
Many radiology practices, however, send results directly to the referring physician. After performing the test, Weinstein Imaging Associates sends the results and an assessment to the referring physician. Patients are recommended to get a follow-up BMD test 1 to 2 years after the initial one. Charlotte Radiology also leaves counseling duties to the referring physician.
Along with building a good reputation, practices have also had to include traditional marketing efforts to get the word out about BMD testing.
Marketing the Message
Marketing options can range from addressing public forums to putting up billboards and taking out print advertisements. Marketing can be directed at both referring physicians and patients.
Since 92% to 95% of its patients are female, North Shore Osteoporosis Center directs most of its marketing efforts at gynecologists. DiMuzio says that the center has “backed off” from advertising to the public, but maintains there has been strong word of mouth about the center’s services among patients.
To build public awareness, Chang reports that Weinstein Imaging Associates is doing local advertising and has worked to educate the public and build referrals from physicians.
Charlotte Radiology’s marketing efforts are more direct and include distributing brochures to patients at the practice’s breast centers, going to health fairs, and speaking to special interest groups, as well as marketing directly to physicians.
Lentle says his marketing efforts to physicians have been indirect, mainly coming in the form of professional presentations at meetings. He says that the hospital’s testing service has been helped by various advocacy groups raising awareness among patients.
While any practice can offer BMD, Jensen argues that, depending on geographical location, it is best suited for outpatient imaging centers. “With an examination like thisit does not take a long time, it’s not very complex, it’s not very acute in terms of emergency needit can be scheduled,” he says. “It’s done more easily in an outpatient setting; it’s more patient convenient.”
However, Lentle sees distinct advantages to having the BMD testing service sited in a hospital. “I think the advantage of my setting, and it’s not an absolute advantage, but a relative one, is that we work very closely with the osteoporosis clinic,” he says. “I make myself available to the clinic. We meet with the physicians who are in the direct care side of the clinic operation. I think if one looks down the road, we’ll move globally to risk assessment including risk factors, bone density, and perhaps geometric factors and bone quality, and maybe you can do those a little better in a hospital setting where you have an osteoporosis clinic.”
Though radiology is a natural fit for BMD, it does not belong to the radiologist like mammography does, and it does not need to, says DiMuzio. “I think one of the important people involved is the technologist&they’re at the forefront of establishing the image for the final analysis of the bone density,” he says. “But the interpretation can go across fields.” At the North Shore Osteoporosis Center, an internist interprets the results.
Part of the reason for this lack of specialty ownership may be the test’s simplicity. “It’s not rocket science,” says Lentle. “It’s low radiation exposure, it’s noninvasive, and the task of interpreting it is not very complex. The real issue with bone densitometry is securing the technical quality and positioning. I think [radiologists] do bring a particular understanding of patient positioning and precision determinations, because you really need to have someone who’s there and connected with the service and not rushing off to operating rooms.
Chris Wolski is associate editor of Decisions in Axis Imaging News.
- DiMuzio MT. A road map to national bone health. Decisions in Axis Imaging News. 2002;15(3):40-42,50.