The Necessity of a Managed Care Approach for Osteoporosis

Linda Repa-Eschen

TAKING CHARGE OF BONE HEALTH

Tuned in, turned on, and taking charge, the female baby boomer, eager to direct care for herself and her family, often accosts her “family doctor” armed with a fistful of “truth” downloaded from the Internet. All too often, the general internist or gynecologist must dispel her fears about breast cancer and the dangers of estrogen while simultaneously balancing contractual gag orders against medical knowledge and the popularized virtues of yams and soy proteins. Pressured by managed care to “practice efficiently,” the docin-practice hustles through early morning rounds at multiple hospitals—to add more double-booked, appointment-time-slots at the office—where he —or she—scrambles for 10 h between telephone calls and three or four exam rooms—to juggle a panel of “covered lives.” For these efforts, he— or she—is phlegmatically informed by a “gray-suit” that an excessive use of “resources” offset the practice's share of the “withhold.” The conscientious, albeit harried, physician struggles to balance the acute complications of hypertension, diabetes, heart disease, and cancer with niggling questions about asymptomatic bone loss. An elderly patient's nagging complaints about low back pain is often discounted as an aging woman's reluctance to accept the “normal” consequences of growing old. A middle-aged woman's concerns that she may repeat her mother's history of crippling osteoporosis are often soothed by attributing them to the typical mood swings of “the change” rather than an indicator of her risk for similar bone loss. Osteoporosis is often regarded as a vogue topic for continuing medical education courses with featured “bone” experts. But, this inevitable result of growing old is not a practical priority meriting focused medical evaluation in a hectic private practice. The facts, however, contradict these popular perceptions and will eventually demand a more proactive approach.

QUANTIFYING THE REAL RISK

Nearly 29 million American men and women age 50 and older are currently affected by significant bone loss. These 1997 estimates by the National Osteoporosis Foundation indicate that, for all ethnic groups, more than 10 million Americans already have osteoporosis, and nearly 19 million more have low bone mass and an increased risk for osteoporosis. By 2015 the numbers are expected to swell to more than 41 million Americans either afflicted with or at risk for osteoporosis. However, while bone loss for men and women begins in their thirties, it is not until menopause that bone loss accelerates for women and contributes largely to 1.5 million fractures of the hip, spine, and wrist each year (see Fig. 1–1). Within any given area in the United States, the 29 million affected men and women represent about 13 to 14% of those age 50 and older. Within an individual physician's practice, one in three women who is 50 years of age or older has osteoporosis. Eventually, one out of every two women and one in eight men over the age of 50 will have an osteoporosis-related fracture in his or her lifetime. Surprisingly, in spite of these numbers, only one in four women who is at increased risk for osteoporosis has discussed her bone health with her physician. Osteoporosis is often tagged as a “woman's disease”; there are no studies estimating conversations about osteoporosis between men and their physicians.

Data from the National Health, Nutrition, and Educational Survey III (NHANES III) have been used to extrapolate estimates of prevalence of bone loss among various ethnic groups (see Table 1–1) and can serve as indicators of local prevalence rates in a given locale. Estimating the prevalence rates among men is more difficult, and ranges vary from between a high of 24% for white men 80 years of age and older to a low of 5% for men of similar age from Asian, Hispanic, and American Indian heritage. More specifically, while there are wide geographical variations in the incidence of hip fractures worldwide, they are higher among white women living in northern Europe, particularly Sweden, and North America, including the United States, than in Asian or black populations. Overall, 1996 prevalence figures for all ethnic groups of those 50 and older indicate that of the 29 million affected Americans, 23.5 million women and 5.2 million men have either low bone mass or established osteoporosis. Some osteoporosis experts have estimated even greater prevalence among white, postmenopausal women alone, with as many as 9.4 million having osteoporosis and 16.8 million having osteopenia, that is, a vertebral bone mineral density (BMD) value in women below — 1.0 to —2.49 standard deviations. Marketing studies from the pharmaceutical industry estimate that as many as 21 million Americans have established osteoporosis, that is, a vertebral BMD value less than —2.50 standard deviations. Consensus among all estimates, though, projects that as few as 20% have been diagnosed and as few as 5%—or a little over 1 million—are actually receiving treatment.

A targeted screening program aimed at those women 50 and older could identify many of the undiagnosed 80%, or more than 16 million Americans. Comparatively, of the 50 million Americans with hypertension, almost two out of three have been diagnosed, and as many as one-half are being treated. In contrast, 9 of the 10 individuals—or 20 million Americans— with significant bone loss currently receive no treatment. In its early, asymptomatic stages, osteoporosis is not a sexy disease: its complications are uneventful and demand minimal medical intervention—hardly meriting the focused attention of well-honed medical acumen or the focused intervention of physicians harried by the demands of practice. Too often, the pain of an acute fracture prompts the diagnosis of osteoporosis. At this point, the targeted outcome of treatment is to stabilize the patient, prevent additional bone loss and new fractures, and attempt to strengthen an already debilitated skeleton.

The “approved” medical model for managing osteoporosis emphasizes symptomatic disease, acute “fracture” events, and vertebral bone loss so excessive as to be at least —2.5 standard deviations below the average for a young person of comparable age. Unfortunately, many third party payers have restricted their litmus test for payment related to bone loss and the management of bone health to this narrow definition and quantifiable measure of osteoporosis: any bone density value between 1 and 2.5 standard deviations below the reference group mean for a young normal (T-score) is defined as “osteopenia”—a diagnosis of early bone loss for which the measurement of bone mineral density is considered by most third party payers to be medically “unnecessary” and therefore “uncovered.” This pervasive “standard of care” for osteoporosis identifies only one out of every five individuals as having the disease and targets treatment for only five of every 100 afflicted. This practice is comparable to sticking an occasional Band-Aid on a truckload of cracked eggs, with the amount of eggs expected to multiply exponentially in the next 50 years.

GROWING NUMBERS MAGNIFY THE PROBLEM

In 1999, about 27% or 72 million of the U.S. population was over the age of 50, with those 65 and older comprising about 13% or nearly one in every eight Americans. By 2001 there will be over 80 million Americans over the age of 50 who will consume about 70% percent of the health care resources. Every 8 sec another of the 77 million baby boomers turns 50. By 2010, when the baby boomers begin to turn 65, “older” Americans will represent 20% or one in five of the population. As this wave of individuals born between 1946 and 1964 ages, the elderly population is likely to double by 2030. Similarly, minority populations, often inaccurately regarded as immune from significant bone loss, are projected to make up 25% of the elderly population. On average, women live 7 years longer than men and currently represent 59% of those over age 65 and 71% of those 85 and older. Today, the average Medicare patient “manages” three to four chronic conditions. Tomorrow, as their longevity increases and as a larger percentage of the population is 65 and older, the drain on limited health care resources to manage their chronic conditions will swell. Gradually, the advances of medical science are transforming the practice of medicine away from treatment for acute, isolated incidents...