Medicare保險減少並沒有導致BMD篩檢嚴重減少


  【24drs.com】雖然保險給付降低,Medicare保險的女性仍持續有接受骨質疏鬆篩檢。骨折後診斷發現有骨質疏鬆的婦女比率,從2005年的5.4%增加到2008年的8.3%,骨密度(BMD)篩檢比率則是從2005年的76.6%降低到2008年的65.0%,不過,篩檢的保費給付是呈降低趨勢。
  
  鹽湖城猶他大學藥物治療結果研究中心Carrie McAdam-Marx博士等人在2月13日美國老年醫學會期刊線上發表的研究結果,還不完全清楚骨折後此一診斷增加的原因,作者們認為,這可能是因為婦女到了發生骨折才被診斷出來;不過,另外的可能解釋是,早期篩檢的婦女(例如2005年)當時若沒有骨質疏鬆,後來(例如2008年)就不會再度篩檢,但是之後發生了骨折。
  
  美國老年醫學會前理事長Sharon A. Brangman醫師提出她的解釋,她認為大部分醫師的立足點在於何者對其病患最佳;因應給付縮減的議題對老年醫學而言已經不是新聞,因為Medicare基本上不給付老年人的複合照護。
  
  這篇研究根據一個大型的住院保戶資料庫(MarketScan),該資料庫的560萬名女性中,研究者聚焦在65歲以上婦女,持續有雇主部份負擔的Medicare保險計畫,且在2004年時沒有骨質疏鬆診斷治療史,共納入了405,093名婦女(平均年紀74.1 ± 6.7歲)、5年期間的資料。
  
  在2005年1月1日至2008年12月31日這段期間,37.9%的病患接受了1次以上的BMD檢測,各年度的檢測率分別是2005年12.9%、2006年11.4%、2007年11.8%、2008年11.6%;BMD檢測率最高的是最年輕的婦女,這些比率和檢測指引一致,但之前的研究顯示,2005年的篩檢比率為13%且在2006-2007年傾向增加。
  
  總共有18.3%(n = 74,179人)婦女在這研究期間有骨質疏鬆新診斷。
  
  作者們表示,對於評估BMD篩檢和骨質疏鬆診斷而言,5年算是短期,此外,保戶資料庫缺乏有關骨質疏鬆和骨折風險因素的資料,包括BMD檢測結果、飲酒與酒癮情況、抽菸史。
  
  Medicare保險給付降低源自2005年的美國削減赤字法案(DRA),不過這並非針對BMD檢查,估計DRA可以降低放射科醫師的收入達平均1%,之前的一篇研究發現,65歲以上、有雇主負擔退休健康福利婦女,在2005年DRA法案減少給付之後並未顯著減少BMD篩檢。
  
  具體而言,2007年減少的診間影像檢查服務Medicare給付,預計將在5年內節省2.8億美元。進行這篇研究是因為,2007年減少診間影像檢查服務Medicare給付之後,擔心BMD篩檢比率會因而降低,不過,作者們發現,篩檢率並未隨著給付減少而降低。
  
  Brangman醫師解釋,一直都有關於利益衝突的顧慮,擁有篩檢設備的醫師是否就一定會轉介檢查?這篇研究認為,醫師持續遵守有關篩檢的國家指引,就Medicare的觀點這最好,因為降低了Medicare的花費;至於對病患而言也是好的,因為病患的照護並未減少 。
  
  資料來源: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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