Medicare保险减少并没有导致BMD筛检严重减少


  【24drs.com】虽然保险给付降低,Medicare保险的女性仍持续有接受骨质疏松筛检。骨折后诊断发现有骨质疏松的妇女比率,从2005年的5.4%增加到2008年的8.3%,骨密度(BMD)筛检比率则是从2005年的76.6%降低到2008年的65.0%,不过,筛检的保费给付是呈降低趋势。
  
  盐湖城犹他大学药物治疗结果研究中心Carrie McAdam-Marx博士等人在2月13日美国老年医学会期刊在线发表的研究结果,还不完全清楚骨折后此一诊断增加的原因,作者们认为,这可能是因为妇女到了发生骨折才被诊断出来;不过,另外的可能解释是,早期筛检的妇女(例如2005年)当时若没有骨质疏松,后来(例如2008年)就不会再度筛检,但是之后发生了骨折。
  
  美国老年医学会前理事长Sharon A. Brangman医师提出她的解释,她认为大部分医师的立足点在于何者对其病患最佳;因应给付缩减的议题对老年医学而言已经不是新闻,因为Medicare基本上不给付老年人的复合照护。
  
  这篇研究根据一个大型的住院保户资料库(MarketScan),该资料库的560万名女性中,研究者聚焦在65岁以上妇女,持续有雇主部份负担的Medicare保险计画,且在2004年时没有骨质疏松诊断治疗史,共纳入了405,093名妇女(平均年纪74.1 ± 6.7岁)、5年期间的资料。
  
  在2005年1月1日至2008年12月31日这段期间,37.9%的病患接受了1次以上的BMD检测,各年度的检测率分别是2005年12.9%、2006年11.4%、2007年11.8%、2008年11.6%;BMD检测率最高的是最年轻的妇女,这些比率和检测指引一致,但之前的研究显示,2005年的筛检比率为13%且在2006-2007年倾向增加。
  
  总共有18.3%(n = 74,179人)妇女在这研究期间有骨质疏松新诊断。
  
  作者们表示,对于评估BMD筛检和骨质疏松诊断而言,5年算是短期,此外,保户资料库缺乏有关骨质疏松和骨折风险因素的资料,包括BMD检测结果、饮酒与酒瘾情况、抽菸史。
  
  Medicare保险给付降低源自2005年的美国削减赤字法案(DRA),不过这并非针对BMD检查,估计DRA可以降低放射科医师的收入达平均1%,之前的一篇研究发现,65岁以上、有雇主负担退休健康福利妇女,在2005年DRA法案减少给付之后并未显著减少BMD筛检。
  
  具体而言,2007年减少的诊间影像检查服务Medicare给付,预计将在5年内节省2.8亿美元。进行这篇研究是因为,2007年减少诊间影像检查服务Medicare给付之后,担心BMD筛检比率会因而降低,不过,作者们发现,筛检率并未随著给付减少而降低。
  
  Brangman医师解释,一直都有关于利益冲突的顾虑,拥有筛检设备的医师是否就一定会转介检查?这篇研究认为,医师持续遵守有关筛检的国家指引,就Medicare的观点这最好,因为降低了Medicare的花费;至于对病患而言也是好的,因为病患的照护并未减少 。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=6736&x_classno=0&x_chkdelpoint=Y
  

Medicare Reductions Have Not Led to Significant BMD Screening Decline

Medscape Medical News

February 17, 2012 — Medicare-eligible women have continued to get screened for osteoporosis, despite a reduction in reimbursement. The proportion of women diagnosed with osteoporosis after fracture (from 5.4% in 2005 to 8.3% in 2008), as opposed to by bone mineral density (BMD) screening (from 76.6% in 2005 to 65.0% in 2008), has increased, however, with the reduction in screening reimbursement.

The reasons for this increase in diagnosis postfracture are not entirely clear, according to new findings by Carrie McAdam-Marx, PhD, from the Pharmacotherapy Outcomes Research Center, University of Utah, Salt Lake City, and colleagues, published online February 13 in the Journal of the American Geriatrics Society. The authors suggest that it may be a result of women not being diagnosed until a fracture occurs. However, an alternative explanation would be that women screened earlier (eg, in 2005) who did not have osteoporosis at the time were not candidates for repeat screening (eg, in 2008), but went on to have a fracture.

Sharon A. Brangman, MD, past-president of the American Geriatrics Society, spoke with Medscape Medical News about the study, and offered her explanation of the data: "I think most doctors are basing their care on what's best for the patient." She explained that the concept of coping with reimbursement restrictions is not new for gerontologists because Medicare typically does not reimburse for the complexities of care for older adults.

The study was based on a large administrative claims database (MarketScan). Of the 5.6 million women in the database, the study focused on women aged 65 years and older with continuous employer-sponsored supplemental Medicare plan enrolment who had no claims history of osteoporosis diagnosis or treatment in 2004. It included a fixed cohort of 405,093 women (average age, 74.1 ± 6.7 years) for a 5-year period.

During the January 1, 2005, to December 31, 2008, study period, 37.9% of patients received 1 or more BMD test. Over the course of the study, 12.9% received the test in 2005, 11.4% in 2006, 11.8% in 2007, and 11.6% in 2008. BMD testing rates were highest in the youngest women. These rates are consistent with testing guidelines, although previous studies demonstrated a screening rate of 13% in 2005 and a trend toward increased screening in 2006 and 2007.

A total of 18.3% (n = 74,179) women received a new diagnosis of osteoporosis during the study.

The authors acknowledge that 5 years is a short period of time for assessing overall BMD screening and osteoporosis diagnosis. They also note that the claims database lacked data on osteoporosis and fracture risk factors, including BMD test results, alcohol use and abuse, and smoking.

The Medicare reimbursement reduction stemmed from the 2005 US Deficit Reduction Act (DRA), which was not specific to BMD testing. The DRA was estimated to reduce radiologists' income by an average of 1%. A previous study found that BMD screening in women aged 65 years and older who had employer-sponsored retiree health benefits did not significantly decline after DRA 2005 reimbursement reductions.

The more specific, 2007 reduction in Medicare reimbursement for office-based imaging services was projected to save $2.8 billion dollars over the course of 5 years. This study was performed in reaction to concern that BMD screening rates would decline after the 2007 Medicare reimbursement reduction for office-based imaging services. The authors found, however, that screening did not decrease at a rate relative to reimbursement reductions.

Dr. Brangman explained that there is always a concern about conflict of interest when a physician owns the screening equipment and is making a referral for the screening test. This study suggests that physicians continue to follow national guidelines with regard to screening. From a Medicare perspective, this is perfect because it decreases Medicare costs. It is also good from the patient perspective because patient care is not compromised.

The study was supported in part from an educational research grant by Novartis. Dr. McAdam-Marx and 3 coauthors have disclosed receiving salaries paid in full or in part by the Pharmacotherapy Outcomes Research Center, which received a research grant from Novartis to conduct this study. Dr. Brangman reports no conflict of interest.

J Am Geriatr Soc. Published online February 13, 2012.

    
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