Ask an orthopedic surgeon whether bone health matters, and the answer is almost always yes. Ask who should manage it, and the answer changes.
“Most will say it’s important,” said Douglas R. Dirschl, MD, professor and chair of the Joseph Barnhart Department of Orthopedic Surgery at Baylor College of Medicine in Houston, who has served as a national spokesperson on bone health for about 15 years. “Most, if pressed, would also say it’s really important that someone else manage this.”
That gap sits at the center of a problem Dr. Dirschl has watched evolve for more than a decade. Patients, payers and providers now recognize poor bone health as a threat. What the field still lacks is a clear owner and a way to get paid for preventing fractures rather than treating them.
Dr. Dirschl is one of a growing number of orthopedic and spine experts urging patients, payers and providers to treat bone health as a crisis rather than an afterthought, a push that has some surgeons ordering bone-density scans before they book the operating room.
A problem often handed off
When Dr. Dirschl began advocating for bone health, the first hurdle was recognition. Consumers, insurers and clinicians did not treat it as a problem worth attention. That has shifted but has not gone away, he said, and two newer barriers have emerged that advocates did not anticipate a decade ago: who owns bone health, and how anyone gets reimbursed for it.
On ownership, orthopedics is a telling case. Surgeons tend to see bone health as adjacent to their work rather than part of it.
“What I do is fuse a spine or replace a hip,” Dr. Dirschl said, describing the mindset. “Someone else can do the bone health thing.”
That division of labor holds even though optimizing a patient’s bone health before spine fusion or hip replacement improves outcomes, he said.
Prevention on a short clock
The reimbursement problem is structural. U.S. healthcare pays for treating injury and illness, while most bone health work is preventive. Insurers, Dr. Dirschl said, still tend to focus on what a patient will cost next week or next month, not on a fracture that may happen years from now.
He recalled pitching a national bone health initiative to major insurance executives roughly eight years ago. Their response: Half of their members turn over every three years. Preventing a fracture five or 10 years out was sound public health, they told him, but not in their business interest.
Medicare has engaged more, he said, but it still measures care largely in 90-day episodes. The benefits of bone health optimization do not show up in that window.
What it looks like at the bedside
Dr. Dirschl’s practice now centers on fractures and their complications, so most of his patients arrive already injured. He works from an assumption backed by national data: Anyone older 50 with a low-energy fracture probably has osteopenia or osteoporosis.
The bone health conversation starts immediately. Every patient goes on vitamin D. Many are referred for a DEXA scan, and for patients older than 65 or 70 with a fracture, he recommends moving straight to treatment.
“I’m not getting a DEXA on everyone. I’m not getting blood studies on everyone,” he said. “But I’m having the conversation with everyone.”
That conversation often extends to the next generation. Because peak bone mass arrives in a person’s early 30s, he counsels older patients to make sure their daughters and granddaughters are doing what they can to reach it.
For elective surgery, the opportunity is clearer still. A small number of surgeons use the lead time between scheduling and surgery to start patients on bisphosphonates, an approach Dr. Dirschl said is backed by strong data. Total joint surgeons remain hard to convince. Spine surgeons are more receptive, he said, though adoption there is still low.
Stretching the horizon
Dr. Dirschl does not claim a formula for changing reimbursement.
“Any one of us could solve that if we had enough levers,” he said. “The problem is none of us have that authority.”
He sees two arguments with promise. The first is outcomes measured over a longer horizon. The effect of bone health optimization on hip replacement and spine fusion cannot be measured in 90 days, he said, but it can be measured within a couple of years. Incentives built around that timeline could shift the math.
The second is the growing focus on healthspan and longevity. Staying functional requires strong bones and strong muscles, and bone health drives fracture reduction.
That argument carries new urgency as GLP-1 use climbs. Those drugs can erode bone and muscle mass, he said, which risks deepening an existing epidemic of osteopenia and osteoporosis.
“We’re going to create an even greater epidemic than we have now of poor bone mass … unless we get on top of this,” he said.
Competing with shinier things
Part of the challenge is bone health lacks the appeal of newer technology. Dr. Dirschl recalled patients at the University of Chicago demanding robotic knee replacements whether or not they were indicated.
“In America, if something is more high-tech, it must be better,” he said.
Bone health offers no such pull. “Bone health is crazy important,” he said. “But bone health isn’t very shiny.”
None of that requires orthopedic practices to overhaul their models overnight. But it does reframe the question. For a condition with a growing patient base, solid evidence and no clear owner, the opening may belong to whoever is willing to claim it.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
