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Diagnosis, treatment of osteoporosis key to decreasing hip fractures
Chief Medical Editor Douglas W. Jackson, MD, interviews Alan H. Morris, MD, about the problems associated with hip fractures
This month’s interview discusses and emphasizes the significant societal problems hip fractures represent and specific areas our profession should address on behalf of our patients. I asked my long-time friend, Dr. Alan H. Morris, for his insight. He has served our profession well for many years with his input and oversight of the health policy issues affecting the orthopedic surgeon and the patients we serve. In addition to this expertise, he served as co-chair with Joseph Zuckerman, MD, for the National Consensus Conference on Improving The Continuum of Care for Patients with Hip Fractures. Dr. Morris has served as a member and chair of AAOS Committee on Health Care Financing (1992-1996) and was chair of AAOS Council on Health Policy and Practice (1997-2003).
--- Douglas W. Jackson, Chief Medical Editor
— Douglas W. Jackson, MD
Chief Medical Editor
Douglas W. Jackson, MD: When I was doing a fair number of hip fractures years ago (in the 70s), more than 25% of the patients sustaining hip fractures did not survive that following year. The fixation, intraoperative imaging and technical aspects of hip fracture surgery have improved significantly since then. What do the statistics indicate now for the 350,000+ hip fracture hospitalizations?
Alan H. Morris, MD: Unfortunately, the mortality data for our hip fracture patients have not changed a great deal over the years. Four percent of hip fracture patients die during hospitalization. These are the patients who are most medically ill and the most functionally impaired. Within the first year after fracture, 10% to 35% die. Those with the most comorbidities account for the highest death rate. Of those surviving after the first year, 40% are in a nursing facility, 50% never regain their prefracture level of ambulation and 15% become nonambulatory. These statistics underscore the significant impact hip fracture has upon the quality of life for those surviving the initial hospitalization, and the stress placed upon the patient’s family as the patients move from levels of independence in their own home to total dependence in unfamiliar surroundings.
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Medicare Payments to Orthopedic Surgeons |
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| CPT code 1992 2002 | 1992 | 2002 |
| 27447 total knee | $1816 | $1514 |
| 27130 total hip | 1697 | 1452 |
| 27235 percutaneous pin fem neck | 977 | 909 |
| 27236 ORIF fem neck or prosthesis | 1103 | 1114 |
| 27244 ORIF troch fx, plate | 1090 | 1137 |
| 27245 ORIF troch fx, IM nail | n/a | 1403 |
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Source: Centers for Medicare
and Medicaid. Annual Physician/Supplier Procedure Summary Master File |
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It is staggering to consider future projections of hip fractures and their direct costs. Currently, we spend between $10.3 and $15.2 billion yearly to provide treatment for the 350,000 hip fractures. We expect the number of hip fractures to increase dramatically through 2040. The number of individuals older than 65 years will double and those older than 85 years will increase from 3 million to 15 million. The costs, which will be more than $32 billion in 2020, are estimated to increase more than threefold by 2040. These are numbers of epidemic proportions. Consider the costs of the projected worldwide rate of 6.3 million fractures in 2050.
Jackson: What cost containment measures can be instituted that are reasonable in hip fracture care?
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Morris: The first is preventing the initial hip fracture and the second is avoiding a second hip fracture. Disseminating fall prevention information, such as that available from the American Academy of Orthopaedic Surgeons and the National Osteoporosis Foundation, can be helpful. But the diagnosis and treatment of osteoporosis is the major factor for prevention and addressing this disease is the only way to halt the hip fracture epidemic.
Cost is a major obstacle in the long-term use of osteoporosis drugs. The current debate in the Congress concerning Medicare prescription drug benefits is of paramount importance to our seniors.
Falls and untreated osteoporosis are also factors in a second hip fracture. Falls occur in 2% to 11% of those patients having had an initial hip fracture. We can start addressing repeated falls by using hip protectors in the nursing home population. We know there is a significant loss of bone mineral density shortly after hip fracture and this loss continues during the first postoperative year. The need, therefore, for osteoporosis treatment is glaringly obvious.
Jackson: What are some of the current reimbursement issues?
Morris: In general, preventive measures (except, for example, for a few very specific instances with regard to diabetic testing and footwear) are not covered by Medicare. A fall assessment performed by a home care nurse who would evaluate not only the patient’s risk factors for falls but also assess the safety of the home environment is rarely reimbursed. Hip protectors, another preventive measure, are not reimbursed by Medicare. I have already mentioned Medicare prescription drug benefits as a particularly important and politically charged issue. Decreasing falls and treating osteoporosis will decrease the number of hip fractures. Prevention can be cost effective.
Ideally, we would like our patients to return to their home environment following hip fracture. We know that improvement in function occurs progressively during the first year after fracture. Return to prefracture levels of ambulation and function can occur when home care therapy works to achieve specific functional milestones. Medicare covers only a fixed number of home care therapy visits. Arbitrary timelines set by insurers are significant obstacles to preventing maximal outcomes.
Jackson: What is the impact of hip fracture care reimbursement on our orthopedic practices?
Morris: Hip fracture care has always been a significant part of the orthopedist’s practice. Part B Medicare Data shows us just how important it is. The percent of total payments by Medicare to orthopedists for surgical procedures places hip fracture treatment second only to payments for total knee arthroplasties. Total knee arthroplasty (CPT 27447) is 10.3% of payments while the hip fracture codes (CPT 27235, 27236, 27244, 27245) total 8.3% of payments. Total hip (CPT 27130) is next at 4.9%. Medicare payments for individual hip fracture procedures have not significantly decreased since 1992. Such is not the case with total joint procedures (see box).
Jackson: What can a clinician do to ensure that prevention programs and continuum of care programs are available for their patients and their community?
Morris: We must answer the question: “What can we do to improve the continuum of care?” Audience response from more than 300 orthopedists at the AAOS 2003 Annual Meeting Symposium “Hip Fractures in the Elderly: An International Health Care Crisis” yielded the following unsettling data:
- 77% of the audience had only 0% to 10% of their hip fracture patients undergoing an osteoporosis evaluation during hospitalization.
- 73% of the audience had only 0% to 25% of their hip fracture patients on osteoporosis medication at the time of discharge.
- Only 56% of the audience had clinical care pathways at their hospitals.
These statistics need to be changed if we are to improve care of our hospitalized patients. In our offices, we can take the first step in hip fracture prevention by evaluating at-risk patients.
Currently, the care of hip fracture patients, wherein patients move from an acute care setting through various rehabilitation phases, is fragmented and uncoordinated. New providers take over care as the patient is handed off. We seem to work in a vacuum with poor communication among providers. The most important recommendation I make to improve the continuum of care is communication. This costs the system nothing but will pay dividends in improving our outcomes.
For more information:
- Morris AH, Zuckerman JD. National Consensus Conference on Improving the Continuum of Care for Patients with Hip Fracture. J Bone Joint Surg. 2002;84-A:670-674.
- Hip Fracture in Seniors: A Call for Health System Reform. American Academy of Orthopaedic Surgeons Position Statement. May 1999.