Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.

Commentary & Perspective

Commentary & Perspective on
"Knowledge and Opinions of Orthopaedic Surgeons Concerning Medical Evaluation and Treatment of Patients with Osteoporotic Fracture"
by John G. Skedros, MD, et al.

and on
"Effective Initiation of Osteoporosis Diagnosis and Treatment for Patients with a Fragility Fracture in an Orthopaedic Environment"
by Earl R. Bogoch, MD, et al.

Commentary & Perspective by
Laura L. Tosi, MD*,
Children's National Medical Center, Washington, D.C.

Two articles in this issue of The Journal, as well as announcements by the Centers for Medicare and Medicaid Services (CMS), offer both good news and bad news about improving the care of patients who sustain fragility fractures.

First, the good news. Both papers very clearly identify the two treatment principles associated with this problem: The first is that fracture begets fracture. In other words, the presence of a fragility fracture is the best predictor of future fracture. The second and very encouraging principle is that treatment works.

The article by Skedros et al., based on a survey of 171 orthopaedic surgeons in the western United States, reflects an increasing willingness by members of our profession to initiate evaluation and preventative treatment for fragility fractures. The article by Bogoch et al. indicates that, in a well-designed interdisciplinary program for which sufficient funding is available, it is possible to achieve a major increase in the percentage of patients who receive appropriate evaluation and care. Bogoch et al. report that more than 95% of patients who were part of the Osteoporosis Exemplary Care Program in a Canadian academic medical center, a program managed by a coordinator with a Master of Science degree in Rehabilitation Science and featuring extensive provider and patient education, received appropriate care. Both articles should be a source of celebration that positive change can happen.

Now, the bad news. One finding common to both authors is that, at the present time, most orthopaedic surgeons are not trained to take action to ensure that fracture patients receive appropriate evaluation and follow-up care. With respect to fragility fracture care, the political process is actually ahead of the game: CMS is acting before science can offer comprehensive recommendations regarding the best-possible outcomes, at an acceptable cost, for the care of patients who have sustained a fragility fracture.

On October 28, 2005, CMS announced its Physician Voluntary Reporting Program1. Slated to begin in January 2006, the program lists thirty-six evidence-based practice measures for outpatient care that CMS will track as part of its effort to "pay for quality of the health care provided to our beneficiaries, not simply the amount (of care provided)."2

The initial measures that are part of this "pay-for-performance" initiative cover a broad spectrum of patient-care issues: inpatient and outpatient care, including primary care, surgery, and specialty care. Five of the thirty-six measures are aimed at improving osteoporosis prevention and fragility fracture care: osteoporosis screening in elderly female patients; screening of elderly patients for falls; prescription of calcium and vitamin-D supplements for patients with osteoporosis, antiresorptive therapy and/or parathyroid hormone treatment for newly diagnosed osteoporosis; and bone-mineral density testing and osteoporosis treatment and prevention following osteoporosis-associated nontraumatic fracture3.

"Pay-for-performance" (also known as value-based purchasing) is a revolutionary and exciting approach for improving health care and ensuring that treatment is based on evidence-based guidelines. For those whose goal is to improve osteoporosis prevention and fragility fracture care, such a system should help draw attention to an important health concern—one that for too long has been ignored by both patients and physicians. We should be dancing in the streets. Pay-for-performance should be the future focus of medical reimbursement (i.e., "If I do better, I should expect a better reward."). This will be true, however, only if the performance measures chosen create the intended effects. The measures will have a strong influence on practice: What is measured is what is done.

Unfortunately, in its eagerness to move forward with this initiative, CMS has not completed its homework. For many of the measures, CMS provides no evidence that they are founded on a larger, research-based theory spelling out which measures predict good outcomes. Likewise, CMS does not demonstrate that high levels of achievement are feasible (especially when patient compliance issues are considered); that the incentives will actually improve patient outcomes and reduce costs; or that data can be easily collected and documented. Moreover, instead of moving forward deliberately, through the use of pilot tests that can be evaluated and revised, CMS is essentially engaging in a national demonstration project.

Two recently published papers in the Journal of the American Medical Association illustrate why we need a carefully considered approach. Boyd et al.4 analyzed the applicability of clinical practice guidelines to the care of older individuals who have multiple comorbid diseases (including osteoporosis) and found that adhering to these guidelines could have undesired effects. The authors emphasized that older patients need their own measures that take into account the fact that they often have multiple complex morbidities. Rosenthal et al.5, in their evaluation of a trial physician pay-for-performance program, found that there was little gain in quality for the money spent and that the program largely rewarded those with higher performance at baseline.

Encouragingly, Bogoch et al. and Skedros et al. have already begun to fill in the gaps in the CMS plan. Bogoch et al. demonstrate that, in a university hospital practice, it is possible to achieve high levels of patient education with regard to two issues that are vital to bone health: the importance of bone-density screening, and the need for appropriate medical therapy for patients with a fragility fracture. But those good outcomes come at a considerable effort. It required hiring a full-time coordinator and carrying out an intensive educational effort. Moreover, bone-density screening and prescriptions led to additional short-term increases in costs.

The costs are financed by the government in the Canadian system in which Bogoch et al. practice. But in the U.S. system, the private and public good are divided. The CMS announcement offers no resources to provide the coordination that will be required to manage these patients appropriately. Indeed, the financial actions of CMS speak much louder than its words. As a result of the Balanced Budget Act of 1997, CMS will actually reduce physician reimbursement under Medicare by 4.4% in 2006, and by a total of 26% over the next seven years! Furthermore, CMS itself acknowledges that there is no immediate information-technology support for the reporting codes it proffers. If experience with the Health Insurance Portability and Accountability Act is a guide, software vendors will not add updates immediately. At best, this will make it necessary for physicians to assume the costs of participating in a "voluntary" program; at worst, it will impair the quality of data that CMS seeks and therefore undercut the program.

The orthopaedic profession should present the Bogoch article to CMS as required reading. CMS will find it reassuring insofar as it demonstrates that improved process quality can be achieved. However, CMS decision-makers will also acknowledge that the short-term costs involved require a program to fund them.

Over the long term, any initial costs associated with the program will be more than recovered by a reduced prevalence of fragility fractures—costs which now total an estimated $12 billion to $18 billion per year in health-care costs alone6. The anticipated cost reductions will benefit the Medicare program in the form of reduced hospitalization and treatment needs and in the form of individual Americans who will avoid debilitating illness. This is a good investment.

CMS leaders would likewise benefit from reading the paper by Skedros et al., who question whether what CMS is prescribing is the province of the orthopaedist or the primary care physician. If the process outcome is the product of a team, then the measures need to be focused on team performance and the incentives must encourage the formation and effective functioning of teams. This is likely to require an increase in current payments, which will ultimately be recovered by savings from the prevention of future fragility fractures—another good investment.

Skedros underscores another important point: Contrary to what CMS assumes, there is no unanimity among practitioners regarding appropriate practice standards. This is all the more reason for CMS to finance pilot studies, so that we can begin collecting and assessing the data necessary to establish appropriate practice standards and guidelines. A single nationwide "demonstration" is not a pilot: It is a commitment to a particular course of action that may not produce the desired results.

The goals of the CMS démarche are laudable, but we must work with CMS as well as with groups that care deeply about osteoporosis and fragility fracture care (primary care, rheumatology, endocrinology, and obstetrics-gynecology as well as advocacy groups such as the National Osteoporosis Foundation) to design a strategy for effective change. Work by researchers such as Bogoch and Skedros can serve as a basis for insisting that CMS invest in incentives that will produce the results the nation needs and for ensuring financial support for the necessary infrastructure (e.g., coordination and procedures, staff, and information technology) essential to achieving them. CMS must be prepared to invest more money in the short run if it hopes to reap multiples of that investment in the long run. Only then can we unite the private and public good.

*The author did not receive grants or outside funding in support of their research for or preparation of this manuscript. The author received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Osteoporosis Advisory Board member for Merck; lecturer for Merck on fragility fracture care). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

References

1. Centers for Medicare and Medicaid Services. Medicare takes key step toward voluntary quality reporting for physicians. News Release. 2005 Oct 28. http://www.cms.hhs.gov/media/press/release.asp?Counter=1699.
2. Glendinning D. Medicare tests pay-for-performance. AMA News. 2005 Feb21. www.ama-assn.org/amednews/2005/02/21/gv10221.htm.
3. Centers for Medicare and Medicaid Services. Physician voluntary reporting program. Fact Sheet. 2005 Oct 28. http://www.cms.hhs.gov/media/press/release.asp?Counter=1701.
4. Boyd CM, Darer J, Boult C, Fried, LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005; 294:716-24.
5. Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: from concept to practice. JAMA. 2005;294:1788-93.
6. United States Department of Health and Human Services; Office of the Surgeon General. Bone health and osteoporosis: a report of the Surgeon General (2004). Rockville, MD: United States Department of Health and Human Services, Office of the Surgeon General; 2004. http://www.surgeongeneral.gov/library/bonehealth/content.html.