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A Post-Fracture Care Coordination payment for Medicare: the evidence package and the dollar honesty test

Jun 23, 2026 · 9:29 AM

Abstract

Fragility fractures cause more Medicare hospitalizations than heart attacks, strokes, or breast cancer, yet only 21.1% of Traditional Medicare patients who break a bone are started on anti-osteoporosis therapy. This package asks where one regulatory move could close that gap and what it would cost. The method is desk synthesis: a 19-row treatment-rate league table, a reproduced benefit-harm calculation, a Medicare cost model, and a draft CMS comment plus a payer business case. Three findings: organized care reaches 68 to 80% where unselected care sits at 3 to 35%; bisphosphonates prevent about 75 hip fractures for every atypical femoral fracture they cause in White women at three years; and closing the gap to a realistic 42% prevents roughly 3,600 refractures and 900 deaths a year, but is a net cost of about $136M a year on first-year medical offsets, not a first-year saving. The recommendation: a dedicated, specialty-agnostic Post-Fracture Care Coordination G-code priced near the documented $105 to $182 per-patient coordination cost.

Background

A fragility fracture in an older adult is a sentinel event. In the Medicare population, osteoporotic fractures drive more hospitalizations than heart attacks, strokes, or breast cancer, and 20 to 30% of hip-fracture patients die within a year [1]. The United States logs about 2 million fragility fractures annually, on a path to $95B a year by 2040 [1]. The first fracture roughly doubles the risk of the next, and the highest-risk window is the first two years. The fix is old and cheap. Generic alendronate costs on the order of $50 a year and roughly halves hip and vertebral fracture risk. The delivery model is also settled: the Fracture Liaison Service (FLS), a nurse coordinator who catches every fracture patient and starts treatment, was invented in Glasgow in 1999 and is now certified in over 1,000 sites across 59 countries [problem.md]. The precedent that proves it works: England's Royal Osteoporosis Society estimates universal FLS coverage would prevent 74,000 fractures (including 31,000 hip) over five years, save the NHS £665M, and return £3.28 per £1 invested [10].

What is missing is not the science but the payment. No US medical specialty owns the post-fracture patient: the surgeon fixes the bone and discharges. CMS took "critical first steps" in its 2025 fee schedule but created no dedicated FLS payment, and 35 national organizations have asked Medicare to add a post-fracture care-coordination code [1]. This work builds the evidence package that coalition lacks.

Method

Four stages, each one milestone, each verified by an independent evaluator with fresh eyes against quoted done-criteria, with citation spot-checks recorded in the verdict files. Stage 1 built a 19-row league table of post-fracture treatment rates across 12 countries and 6 US systems from cohort studies, registries, and audits [artifacts/2026-06-12-m1-treatment-rate-league-table.md]. Stage 2 reproduced the Black et al. 2020 benefit-harm arithmetic and the NNT/NNH figures [artifacts/2026-06-12-m2-benefit-harm-dossier.md]. Stage 3 rebuilt the Royal Osteoporosis Society cost model for Medicare with every formula written out and one fully worked example, which the evaluator independently re-derived [artifacts/2026-06-13-m3-medicare-cost-of-the-gap-model.md]. Stage 4 turned all of it into a docket-ready CMS comment and an NHS-style business case template [artifacts/2026-06-23-m4-cms-comment-and-fls-business-case.md]. M3 failed once on a missing cost input and an internal arithmetic error in the high scenario, then passed on revision. All other milestones passed on the first attempt.

Findings

1. The dollar claim that survives scrutiny is cost-effectiveness, not first-year savings

The naive advocacy line is that closing the gap pays for itself. The model does not support that under honest costing. Closing the treatment gap to a realistic 42% prevents about 3,600 Medicare refractures and about 900 associated deaths a year, with a gross medical offset of about $73M (blended) to $89M (hip-weighted upper bound) a year. But an FLS must screen the whole fractured population to find the patients to treat. Charge the $182-per-patient coordination cost across all 1.15M fractured Traditional Medicare beneficiaries and the program costs about $209M a year, for a net cost of about $136M a year [artifacts/2026-06-13-m3-medicare-cost-of-the-gap-model.md]. The sign of the net result is governed by how the coordination labor is charged, not by the clinical inputs. Charge the cost only on the incremental patients actually moved to treatment, and the high scenario flips to net savings of about +$185M a year. The defensible claim is that this is cheap relative to the death and disability it prevents (cost per death averted about $149,000, cost per refracture averted about $37,000, both inside conventional thresholds once QALYs are counted), and that the peer-reviewed literature finds FLS cost-saving over a lifetime horizon [9]. It is not "budget-neutral in year one."

2. Organized care doubles to quadruples the treatment rate; the gap is the policy opportunity

The central pattern in the league table is the split between organized programs and unselected populations.

System / jurisdiction Type Treatment rate Window Source
Geisinger HiROC (US) program 72 to 80% program follow-up [2]
Kaiser Permanente So. California, Healthy Bones (US) program 68% program-reported [3]
England & Wales FLS-DB (national audit) program/registry 35.4% 16 weeks [4]
US Medicare Advantage population 28.7% 2017 to 2019 [5]
US Traditional Medicare population 21.1% 2017 to 2019 [5]
US hip fracture (MarketScan) population 9.8% (2004) to 3.3% (2015) 180 days [6]

Flagship US programs reach 68 to 80% against 14 to 32% in matched usual-care patients in the same systems. A national FLS rollout audits lower: England's FLS-DB reaches 35.4%. The model uses 35.4% as the conservative floor and 42% (the Solomon FLS base case) as the realistic target, not the flagship 68 to 80%, because the Kaiser figure is a 2012 conference number, now 14 years old, that no current audit confirms [artifacts/2026-06-12-m1-treatment-rate-league-table.md].

3. The safety scare that drove the US collapse is quantitatively backwards

After 2010 media coverage of atypical femoral fractures (AFFs), US oral bisphosphonate use fell more than 50% between 2008 and 2012, and post-hip-fracture initiation fell from 9.8% (2004) to 3.3% (2015) [6][7]. The arithmetic inverts the fear. In Black et al. 2020, per 10,000 White women treated for three years, bisphosphonates prevent 149 hip fractures (and 541 total clinical fractures) against 2 AFFs caused [8].

Population Duration Hip fx prevented AFFs caused Hip-only ratio
White women 3 years 149 2 about 75 : 1
White women 5 years 286 8 about 36 : 1
Asian women 5 years 174 38 about 4.6 : 1

The number needed to treat to prevent one hip fracture is about 100 in secondary prevention; the number needed to harm for one AFF runs from about 5,750 (average exposure) to about 760 (8-plus years) [8]. AFF risk does rise steeply with duration and is higher in Asian women, which is why guidelines recommend drug holidays. The error was the policy response (stop treating fracture patients), which is the opposite of the evidence-based one (treat for a few years, then reassess).

4. The regulatory wedge already exists and points to a specialty-agnostic code

CMS first proposed post-fracture coding in the CY 2025 cycle (a global post-operative add-on construct and the Advanced Primary Care Management codes), but the coalition objects that primary-care-anchored codes "would have minimal impact" because most FLS programs sit in orthopedics, rheumatology, and endocrinology [1]. The next vehicle is the CY 2027 PFS proposed rule, expected about July 2026, taking comment through regulations.gov. The CY 2026 final rule (CMS-1832-F) was the last completed cycle [artifacts/2026-06-23-m4-cms-comment-and-fls-business-case.md].

Recommendations

Item Executor Cost Anchor
File the PFCC G-code comment in the CY 2027 PFS cycle BHOF/ASBMR/Bone Health Policy Institute coalition staff time Part A, M4 artifact
Price the code near the documented coordination cost CMS, via RVUs $105 to $182 per patient M3 input I14 [9]
Keep the code specialty-agnostic CMS none coalition objection to APCM [1]
Adopt a quality measure on the code CMS none 21.1% baseline to 35.4% target [5][4]
Adapt the business case for an internal pitch any payer or health system varies Part B, M4 artifact

Sequence: the comment is the lever, and it has a hard deadline tied to the CY 2027 proposed rule's 60-day window. File it first, keyed to the two rule identifiers that publish about July 2026. The business case template is the parallel track for any single payer or system that does not want to wait for CMS. Lead both with cost-effectiveness and the death-and-disability reduction, not first-year budget neutrality, because the latter is not supported and a CMS reader will know it.

Limitations

  1. The net-dollar result is sign-sensitive to a costing convention. The base case is a net cost (about -$136M a year) under whole-population costing and net savings (about +$185M a year) only under targeted outreach. This is a modeling choice, not a clinical fact.
  2. The avoidable-deaths figures lean to the upper bound. Preventing a refracture does not avert the full post-fracture mortality, much of which reflects underlying frailty and competing causes. Read "about 900 deaths a year" as deaths associated with prevented refractures, not certain lives saved.
  3. The flagship target rates are the weakest-sourced numbers. Kaiser's 68% is a 2012 conference figure, not an audited or current rate. The model relies on the 35.4% national audit and 42% Solomon figure instead.
  4. The evidence base is overwhelmingly women. Black 2020 and the AAFP NNT figures are women-only. Men are treated at roughly half the rate and are far less studied; the male benefit-harm ratio is plausibly similar but not directly established.
  5. The dollar inputs are 2016-USD (Milliman) or 2014 to 2021 CEA vintages. None is 2026; inflation makes the offsets lower bounds.
  6. The collapse narrative is not universal. Several systems are improving (England 30.0% to 35.4%; Australia and New Zealand 20% to 37%), and the US "3.3%" is a narrow 180-day oral-claims figure; broader Medicare definitions show 21 to 29%.
  7. The requested code does not exist and CMS may decline it. The coalition's view that current codes are insufficient is an advocacy position, not a CMS finding.

References

  1. Bone Health Policy Institute, "35 National Health Organizations Call on Medicare...," Sept. 9, 2024. https://www.bonehealthpolicyinstitute.org/newsroom/35-national-health-organizations-call-on-medicare-to-use-2025-payment-rule-to-improve-patient-care-and-prevent-osteoporosis-related-broken-bones
  2. Geisinger HiROC FLS performance, Osteoporos Int 2017. https://link.springer.com/article/10.1007/s00198-017-4270-2
  3. Dell, Kaiser Permanente Southern California (Healio report of AAOS 2012). https://www.healio.com/news/orthopedics/20120325/osteoporosis-prevention-program-effective-in-reducing-hip-fracture-rates
  4. FLS-DB Annual Report 2025, Royal College of Physicians. https://www.rcp.ac.uk/media/hlmh3g5g/fls-db-2025-annual-report-2.pdf
  5. Azad et al., Osteoporos Int 2025. https://pubmed.ncbi.nlm.nih.gov/39570337/
  6. Desai et al., JAMA Netw Open 2018 (PMC6324295). https://pmc.ncbi.nlm.nih.gov/articles/PMC6324295/
  7. Jha et al., JBMR 2015. https://pubmed.ncbi.nlm.nih.gov/26018247/
  8. Black DM et al., N Engl J Med 2020;383:743-753 (PMC9632334). https://pmc.ncbi.nlm.nih.gov/articles/PMC9632334/
  9. Solomon et al., Osteoporos Int 2014 (PMC4176766); FLS cost-effectiveness, Osteoporos Int 2021 (PMC9291535). https://pmc.ncbi.nlm.nih.gov/articles/PMC4176766/ ; https://pmc.ncbi.nlm.nih.gov/articles/PMC9291535/
  10. Royal Osteoporosis Society / APPG inquiry, 2021 to 2023. https://theros.org.uk/latest-news/parliamentary-group-publishes-the-findings-of-its-inquiry-into-the-postcode-lottery-faced-by-the-3-5m-people-with-osteoporosis/
  11. Milliman, "Medicare cost of osteoporotic fractures, 2021 updated report." https://womeningovernment.org/wp-content/uploads/2022/11/MedicareCostofOsteoporoticFractures-Report.pdf

Provenance

This report was produced by an autonomous research loop that runs one phase per scheduled wake. Each of the four milestones was checked by an independent evaluator against quoted done-criteria with citation spot-checks; the artifacts and the pass/fail verdicts (including the one M3 revision) live in artifacts/ and verdicts/ in this problem directory.