Bone Mineral Density: What is Impact of Change in Physician Reimbursement? Interview with:
Susan Jaglal, PhD
Senior Scientist
Toronto Rehabilitation Institute

University of Toronto,
Toronto, Ontario What are the main findings of the study?

Dr. Jaglal: Bone Mineral Density (BMD) tests are used to both diagnose osteoporosis and assess and individual’s risk of fracture. While the tests play an important role in bone health, they are sometimes ordered inappropriately. For example, while women age 40-44 are typically not at risk of fragility fracture or in need of Bone Mineral Density testing, these individuals received almost half the Bone Mineral Density tests performed in Ontario in 2007/2008.

Policy changes have been made in recent years in an effort to curb unnecessary testing of low risk individuals in both the United States and Canada. Policy efforts in Ontario included a 2008 fee schedule change that limited repeated testing among low-risk patients and included a new fee code for a “baseline” tests. Patients were limited to 1 baseline test in their lifetime.

The goal of the present study was to determine the impact of this fee schedule change on Bone Mineral Density testing rates. The study was based on an analysis of provincial administrative data including physician billings, hospital discharges, and emergency department visits.

Results demonstrated that while fee schedule changes were associated with a decrease in BMD testing rates, the decreases affected both low and high-risk patients. Most decreases were seen in testing rates of low-risk women. However, the associated decrease in testing among high-risk patients (e.g., those over 65 or with a recent fracture) is concerning, as high-risk patients benefit from screening and monitoring of Bone Mineral Density. What should clinicians and patients take away from your report?

Dr. Jaglal: Current clinical guidelines for Bone Mineral Density testing need to be better communicated to both clinicians and patients. Osteoporosis Canada currently suggests baseline Bone Mineral Density testing for all men and women who are over age 65. Men and women who are over 50 and have clinical risk factors for fracture, like low body weight or history of fragility fracture, should also be tested. Clinicians should be aware that men and women under age 50 typically should not be tested unless major risk factors for bone loss exist.

While it is important to curb testing rates among low risk women (i.e., those under age 50), this cannot be done at the expense of testing individuals who are genuinely at risk. Testing rates for individuals following a recent fragility fracture were low before fee schedule changes and are now lower. Similarly, testing rates in Ontario for eligible seniors remain below 50% and have been declining among women since fee schedule changes. These two groups of at-risk patients need to be better identified in practice and screened.  What recommendations do you have for future research as a result of this study?

Dr. Jaglal: Why the change in the Ontario fee schedule reimbursement was associated with such a dramatic decrease in the rate of testing among patients with recent fracture is of particular concern. Additional research to understand the failure to enforce guidelines in this patient population is required. What is not known from this study is the appropriateness of testing. Future research needs to determine if those who were not tested more likely to have normal Bone Mineral Density. This would require information on BMD test result.


Susan Jaglal, Gillian Hawker, Ruth Croxford, Cathy Cameron, Anne-Marie Schott, Sarah Munce, and Sonya Allin

Impact of a change in physician reimbursement on bone mineral density testing in Ontario, Canada: a population-based study cmajo 2:E45-E50; published online March 31, 2014, doi:10.9778/cmajo.2013-0052


Last Updated on April 23, 2014 by Marie Benz MD FAAD