For decades, hospitals have become increasingly sophisticated at repairing fractures. They have invested in orthopedic service lines, surgical technology, care pathways and recovery programs designed to improve outcomes after injury.
According to Shannon Carpenter, MD, they may be focusing on the wrong end of the problem.
“The first fracture is a failure of prevention,” she said. “The second fracture is neglect.”
Dr. Carpenter, an orthopedic surgeon, founder of The Bone Health Clinic in Lenexa, Kan., and creator of the Demand the Scan campaign, believes healthcare is approaching a fundamental shift in how it thinks about osteoporosis, fracture care and value-based medicine.
For years, osteoporosis has largely been treated as a downstream issue, something addressed after a patient breaks a hip, fractures a vertebra or arrives in the emergency department following a fall. But as hospitals assume greater financial accountability for fracture episodes and the population continues to age, Dr. Carpenter argues that preventing fractures may soon become just as important as treating them.
Why fracture prevention is becoming a hospital issue
The conversation around osteoporosis has traditionally centered on patients, primary care physicians and endocrinologists. Dr. Carpenter believes it is about to become a hospital leadership issue as well. The catalyst, she said, is the growing shift toward value-based reimbursement.
Under CMS’ Transforming Episode Accountability Model, or TEAM, hospitals are increasingly accountable for the cost and quality of certain surgical episodes, including femur fracture care.
The challenge is that many organizations remain focused on optimizing fracture treatment while paying relatively little attention to the disease often causing those fractures in the first place. “They say this is increasing the value of care, but it’s really not,” Dr. Carpenter said. “The right answer would be to treat bone health. That is what is really going to save Medicare money.”
To her, osteoporosis represents one of the clearest examples of a healthcare system built around reaction rather than prevention. Hospitals spend enormous resources treating the consequences of poor bone health, yet many patients leave the hospital without a plan to address the underlying disease.
“The stats are currently that 90% of patients leave the hospital after a fragility fracture with no diagnosis and no follow-up,” she said. “Ninety percent.”
That number continues to surprise healthcare leaders when she shares it. But for Dr. Carpenter, it reflects a deeper structural problem.
“We’re waiting until something breaks,” she said.
The patients are already there
One reason Dr. Carpenter believes the issue has remained overlooked is that hospitals often view osteoporosis as someone else’s responsibility. Meanwhile, the highest-risk patients are already moving through their systems every day.
“I think just capturing those patients is what is being overlooked by health system leaders right now,” she said. “Those patients are in their hospital right now, and they’re seeing them, but they’re not capturing them.”
The challenge is not simply identifying patients after a fracture occurs. It is building the infrastructure necessary to intervene before the next fracture happens. That includes fracture liaison services, coordinated follow-up programs, bone health clinics and systems capable of tracking patients long after discharge. Those programs require investment, physician leadership and organizational commitment.
They also require time.
“I don’t think hospitals are prepared,” Dr. Carpenter said. “I think they’re going to be scrambling.” Even organizations that recognize the challenge today may struggle to respond quickly.
“Even if you’re not one of the chosen hospitals for TEAM, buckle up,” she said. “It takes a while to make these changes.”
The ‘silver tsunami’ is accelerating the problem
The urgency extends beyond reimbursement. It is also demographic. Americans are living longer than ever before, creating a growing population at risk for osteoporosis-related fractures. Women, in particular, now spend decades in postmenopausal life, a reality that did not exist for previous generations.
“The average lifespan of a woman in the 1970s was 62 years old,” Dr. Carpenter said. “It’s now 82 years old.” Yet, healthcare’s approach to bone health has not evolved at the same pace.
Dr. Carpenter often compares osteoporosis today to where cardiovascular disease prevention once stood: clinically important, enormously expensive and widely prevalent, but not yet receiving the level of systematic prevention efforts it ultimately required. “Medicine just hasn’t kept up with it,” she said. The consequences extend far beyond broken bones.
Fragility fractures can trigger loss of independence, nursing home placement, repeat hospitalizations and increased mortality. For many patients, the fracture becomes the beginning of a cascade of health challenges rather than a single isolated event.
“You can replace a heart at this point,” Dr. Carpenter said. “But we can’t replace your spine.”
Why bone health may be reaching a tipping point
For much of her career, Dr. Carpenter felt like she was talking about osteoporosis before the broader healthcare system was ready to listen. She believes that is changing.
One reason is the growing national conversation around menopause and women’s health. “I think the whole perimenopause, menopausal movement has taken over the world,” she said. “Because of that, bone health is being elevated, where it was mainly ignored.” Another is growing recognition that bone density can serve as a powerful predictor of future fracture risk.
Together, those trends have created an opportunity to move bone health out of specialty clinics and into mainstream healthcare conversations. Dr. Carpenter compares the moment to the public awareness movement that transformed breast cancer screening.
“To me, that was the patient-facing movement that really had breast cancer come to the surface and people cared about it,” she said. That idea helped inspire Demand the Scan, a campaign encouraging women to receive a baseline bone density scan around the time of their first mammogram.
The goal is not simply to increase screening rates. It is to shift the conversation about bone health years earlier. “We’ve done so much education around mammograms,” she said. “We don’t need to reinvent the wheel.”
Women generally reach peak bone mass between ages 30 and 35. Identifying low bone density before menopause creates an opportunity for intervention through nutrition, exercise, resistance training and other preventive strategies before significant bone loss occurs.
“The real important part of that is not the scan as much as the fact we’re bringing the conversation of bone health into midlife where it belongs instead of reactive,” Dr. Carpenter said.
A shift that may be impossible to avoid
Dr. Carpenter believes the next chapter of bone health will be shaped by three forces: an aging population, increasing financial accountability and a growing emphasis on prevention.
For years, osteoporosis has existed on the periphery of healthcare conversations despite affecting millions of Americans and driving enormous healthcare spending.
That may no longer be sustainable. As hospitals face growing accountability for fracture outcomes and Medicare confronts the costs associated with an aging population, Dr. Carpenter believes prevention will increasingly become a strategic priority rather than a niche clinical concern.
The science is not new. The patients are not new. The fractures are not new.
What is changing, she argues, is healthcare’s willingness to absorb the consequences of waiting until something breaks. “We’re at our moment where it’s going to change,” she said. “Because we can’t afford for it not to change.”
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