Osteoporosis screening could be radiology’s vehicle to the population management discussion.

By David Lee, Debbie Zeldow, and Christine M. Hughes

The emerging shift in healthcare from volume to value is anchored on the tenet of population management. Today, discussions in hospital C-suites focus on the goal of improving the health of patients while lowering the overall cost of delivering that care. While radiology can be an integral component in this innovative model, some specialties and administrators view radiology as a cost center in the patient care chain of the future.  Osteoporosis screening programs using DXA testing and integrating into fracture management programs can bring radiology to the table in this population management discussion.

A Clear Need

Osteoporosis and associated fractures are a major public health concern in the United States.  The annual rate of osteoporotic fractures (over 2 million per year) currently exceeds the incidence of heart attack, stroke, and breast cancer combined.[1] Fractures from osteoporosis and low bone mass cost $19 billion a year with an expectant rise to over $25 billion per year by 2025 as the elderly population nearly doubles.[2]  It is one of the top 10 illnesses of highest cost to the Medicare system.[3]

Despite these facts, population management approaches to care have not been widely adopted in the open systems (versus closed systems like Kaiser and Geisinger) to reduce postfracture risk and costs. There continue to be missed opportunities for osteoporosis assessment and treatment, given that in 2012, only 25% of women age 67 or older received osteoporosis care—either a bone density test and/or a prescription for an antiosteoporosis medication—within 6 months after suffering from a fracture.[4]

A 5-year observational study evaluated the clinical and fiscal outcomes of the Geisinger Health System Osteoporosis Disease Management program. It was found that implementation of osteoporosis guidelines that included increases in bone mineral density (BMD) testing and treatment was associated with a significant decrease in the age-adjusted incidence of hip fractures and an estimated $7.8 million reduction in healthcare costs during this 5-year period.[5]

Another concept to consider is “patient-centeredness”—the idea that care should be designed around patients’ needs, preferences, circumstances, and well-being. For CEOs of healthcare organizations, patient-centered care is becoming a business imperative, with payments tied to performance on measures of patient satisfaction and engagement. Similar to the Geisinger program, Kaiser Permanente’s Healthy Bones program identifies and proactively treats patients at risk for osteoporosis and hip fractures and has demonstrated a 30% reduction in hip fracture rates for at-risk patients. Through their Healthy Bones program, education, and proactive prevention, patients can become proponents of their own health.[6]

IE-TableIncreased BMD testing rates are needed to identify those patients with fragility fractures with a goal of reducing the rate of subsequent fractures. Medicare Advantage’s Five Star Quality Rating System currently includes this preventive process measure: Osteoporosis Management: Osteoporosis management in women who had a fracture. Quality bonus payments are now being provided to high-performing Medicare Advantage plans as part of a national strategy to incentivize health plans to provide high-quality, efficient care. Focus on a coordinated plan of follow-up care for women admitted with a fracture provides an opportunity to improve on this performance measure.

Real World Successes in Population Management for Osteoporosis

The experience of healthcare systems suggests that increases in BMD testing reduce fracture rates and save money. Both Kaiser Permanente and Geisinger have implemented “Fracture Liaison Service” (FLS) programs demonstrating that follow-up of patients suffering from a fragility fracture lowers healthcare costs as well as prevents secondary fractures while increasing the rates of BMD testing and treatment. The National Bone Health Alliance is a leader in fostering the FLS model of care in the United States and has developed a resource center on this secondary fracture prevention model of care, Fracture Prevention CENTRAL, available at no cost at www.FracturePreventionCENTRAL.org.

Radiology in a Leadership Role

Working with the primary care physicians and OB/GYNs to educate their patients on the benefits of BMD screening helps the hospital to access an untapped potential of the eligible but underscreened population (Table 1).  Ideating and facilitating the development of a hip fracture program with the orthopedic department ensures a seat at the table in the population management planning discussion and moves radiology into a proactive leadership role.


David Lee, MPA, is Executive Director of the National Bone Health Alliance (NBHA). Based in Washington, DC, NBHA is a public-private partnership on bone health and includes 55 nonprofit, private, and governmental organizational participants all working toward a shared 20/20 vision to reduce fractures 20% by the year 2020.

Debbie Zeldow, MBA, is Senior Director, Clinical Programs at the National Bone Health Alliance (NBHA). She is responsible for all aspects of the organization’s fracture liaison service (FLS) secondary fracture prevention activities, including the FLS demonstration project, Fracture Prevention CENTRAL resource center, and new osteoporosis Qualified Clinical Data Registry.

Christine M. Hughes is Principal of Hadley Hart Group. Hughes is an industry consultant specializing in the economics of diagnostic imaging for more than 20 years.



1, 2. Burge R, et al.  Incidence and economic burden of osteoporosis-related fractures in the Unitid States, 2005–2025. J Bone Miner Res. 2007;22(3):465-75.

3. Blume SW, Curtis JR. Osteoporos Int. 2011;22(6):1835-4.

4. NCQA. Improving Quality and Patient Experience: The State of Health Care Quality 2013.

5. Lewiecki M, et al. More bone density testing is needed, not less. J Bone Miner Res. 2012;27(4):739–742.

6. Cosgrove DM, et al. Ten strategies to lower costs, improve quality, and engage patients: the view from leading health system CEOs.  Health Aff (Millwood). 2013;32(2):321-327.