Fracture Prevention Is Broken -- The Silent Failure of U.S. Osteoporosis Care
How Decades of Siloed Efforts, Policy Paralysis, and Disconnected Care Undermined National Progress
Introduction
Osteoporosis afflicts over 10 million Americans and is implicated in nearly two million fractures each year [1] —many of which lead to disability, loss of independence, and premature death. Yet despite its scale and impact, osteoporosis remains one of the most underdiagnosed and undertreated conditions in modern medicine. The tools exist. The science is sound. But the system has failed to evolve.
For the past 20 years, the U.S. healthcare system has pursued fracture prevention through two levers: (1) increasing DXA screening, and (2) implementing Fracture Liaison Services (FLS). While well-intentioned, these strategies have not been scalable or economically sustainable. DXA access has collapsed under reimbursement cuts, and most FLS programs are chronically under-resourced, operationally fragile, and disconnected from referral source workflows.
The result is stagnation—fracture rates have not meaningfully declined, and the burden on patients, providers, and payers continues to grow.
US fracture prevention needs a strategic reset.
We must shift from reactive models based on policy and patchwork programs to proactive, scalable platforms embedded in the workflows where high-risk patients already are.
“Osteoporosis is the only major chronic disease routinely ignored until after catastrophe. No cardiologist waits for the heart attack—why do we wait for the fracture?”
A System Stalled: Metrics of Missed Opportunity
The intended goals of the early 2000s fracture prevention movement were clear: expand DXA screening, initiate treatment after fractures, improve adherence, and reduce hip fracture rates. However, nearly every measurable target has been missed.
DXA utilization dropped more than 25% from 2009 to 2012 [2] following Medicare reimbursement cuts. The COVID-19 pandemic further accelerated this decline, with academic centers reporting DXA volumes down as much as 76% [3] in April 2020 compared to the year prior. Even in 2023, scan volumes in many regions remained well below pre-pandemic levels.
Meanwhile, treatment gaps persist. Fewer than one in four Medicare beneficiaries receive osteoporosis treatment [4] within six months of a fragility fracture. Medication adherence rates remain dismal, particularly for oral bisphosphonates, where fewer than half of patients remain adherent [5] after one year. While hip fracture rates declined modestly [6] from the mid-1990s through 2012, they have since plateaued and, in some populations, begun to climb again.
These aren’t failures of science. They are failures of system design and coordination [7].
The Walled Garden Problem: Fragmentation Without a Unified Field
One of the most overlooked barriers to progress in fracture prevention is the proliferation of disconnected initiatives, each operating within its own siloed environment. Over the past two decades, numerous well-meaning efforts have emerged across clinical societies, advocacy groups, technology vendors, and academic programs—each claiming a role in the battle against osteoporosis. But instead of creating a cohesive national strategy, these initiatives have devolved into isolated “walled gardens”—ecosystems that are not interoperable, rarely coordinate, and often compete without agreement on what terrain is being disputed.
These programs tend to define their own success metrics and largely operate within a too narrow scope. A few promote fractured definitions of fracture prevention: some focus on secondary care after a break, others on screening asymptomatic patients, and others on innovating diagnostics or imaging techniques. The result is not synergy, but a crowded and confusing landscape where providers are unsure which model to follow, what standards apply, or where their own responsibilities begin and end.
Fragmentation has real consequences.
Rather than consolidating energy around shared national objectives—such as early risk identification, medication adherence, or surgical optimization—these separate ecosystems unintentionally dilute momentum. Without shared infrastructure or aligned incentives, even the most promising solutions will struggle to scale.
The deeper issue is that there is no common battlefield. No clear agreement exists on where the front lines of fracture prevention lie. Is it in the primary care? The Emergency Department? Endocrinology? Imaging center? The Orthopedic clinic? Women’s health? Without consensus, organizations and stakeholders continue to invest in parallel, often redundant efforts—each claiming innovation but none able to solve the problem at scale.
As a result, we face an ecosystem marked not just by inefficiency, but by incoherence. Progress depends on developing a shared set of values and a practical bone health model—one that aligns incentives, integrates across care settings, and functions within the realities of today’s clinical and financial infrastructure.
An Ad Hoc Garden That Never Grew
In recent years, industry stakeholders—well-intentioned but strategically misaligned—have made multiple seed investments in emerging digital tools, diagnostics, awareness campaigns, and service concepts for fracture prevention. These initiatives often sought to spark innovation or identify promising projects, but they were rarely part of a coordinated or system-level approach. Instead of cultivating a shared infrastructure or advancing a unified strategy, capital was dispersed across isolated projects—each planted in its own walled garden, hoping something would take root.
It largely didn’t work.
Without a clear strategic framework guiding these investments, the resulting landscape has been scattershot and unsustainable. Promising ideas withered not due to clinical limitations, but because they were expected to grow in isolation—without the support of shared goals, aligned incentives, or practical delivery mechanisms.
ASOP argues that this fragmented funding approach must end. Valuable capital is being squandered.
The better path forward is to establish a comprehensive investment strategy—one that prioritizes scalable, clinically integrated solutions aligned with a broader vision for fracture prevention. Instead of gambling on disconnected pilots and hoping for organic success, the field must coordinate around shared goals, practical implementation pathways, and sustainable delivery models.
Only then can these investments yield lasting impact.
Legislative Paralysis: A Decade Without Reform
Since 2007, when CMS sharply cut reimbursement rates for DXA testing in outpatient settings, stakeholders have fought to restore fair payment. These efforts culminated in bipartisan legislation such as the Increasing Access to Osteoporosis Testing for Medicare Beneficiaries Act [8] (H.R. 3517 and S. 1943), introduced in 2021. Despite widespread support and extensive lobbying—including significant and active support from industry [9] —these bills never advanced out of committee.
The consequences have been significant. DXA testing sites have closed, particularly in rural and community-based settings. Many primary care physicians no longer refer patients because the infrastructure to deliver these tests no longer exists in their networks. Even when tests are ordered, reimbursement uncertainty discourages follow-through. The diagnostic pipeline has withered—not for lack of clinical need, but because the financial and administrative barriers remain too high.
The repeated failure of legislative strategies reveals a sobering truth: fracture prevention cannot depend on Congress. The incentives, timelines, and staffing models in American medicine don’t align with the pace of policy reform. Any new model must succeed on its own operational merits—within the market as it exists today.
A Missed Opportunity Hidden in Plain Sight
While policymakers debated DXA reimbursement and advocates lobbied for broader access to post-fracture care, the largest and most predictable high-risk population was moving through the healthcare system largely unnoticed. Each year in the United States, more than 2.5 million orthopedic procedures are performed on patients aged 50 and older. These include joint arthroplasties, spine fusions, and fracture repairs—all of which involve patients who are statistically more likely to have underlying bone fragility.
Recent studies suggest that nearly half of this surgical population—up to 45 percent—meet criteria for high fracture risk, using clinical guidelines from the American Association of Clinical Endocrinologists and others. These patients are not hypothetical. They are already being seen, evaluated, operated on, and discharged—without ever being assessed for the very condition that makes their surgeries riskier and their recoveries more fragile.
“Fracture prevention in the U.S. isn’t failing because we lack the science—it’s failing because we never built a system to deliver it.”
Orthopedic clinics and surgical encounters represent the most underutilized touchpoint in the fracture prevention ecosystem. They are high-volume, data-rich, and already equipped with care coordination infrastructure. Yet osteoporosis is rarely considered within this setting—largely because it has never been operationalized as a core component of surgical optimization.
The American Society of Osteoporosis Providers (ASOP) proposes a fundamental shift in strategy. Rather than waiting for policy fixes or relying on fragmented, under-resourced coordination models, ASOP’s Bone Health Optimization Platform (BHOP) moves fracture prevention upstream. It integrates directly into existing orthopedic workflows, using preoperative screening as an opportunity to identify and treat patients at elevated risk before they suffer another—or their first—osteoporotic fracture.
The Economics of Optimization: What’s at Stake
If ASOP’s BHOP model were implemented at scale across orthopedic practices, it would create a new, sustainable pipeline for osteoporosis diagnosis and treatment. Using conservative assumptions, the impact would be profound.
Of the 2.5 million orthopedic procedures performed annually in patients over 50, approximately 1.1 million are likely to involve patients with elevated fracture risk. If BHOP successfully prompts screening and initiates treatment in just half of these patients—562,500 individuals each year—the return on investment for the healthcare system and therapeutic stakeholders becomes immediately clear.
Pharmaceutical therapies represent a significant growth opportunity when fracture prevention is integrated into orthopedic workflows. With over 500,000 high-risk patients potentially entering treatment through BHOP annually, the incremental pharmaceutical market could exceed $2 billion per year. This estimate reflects a blended mix of lower-cost agents—like biosimilars of antiresorptive drugs—and higher-value anabolic therapies for more severe cases. The revenue potential doesn’t come from new drugs or new science—it comes from finally reaching the patients who were already there but never treated. Rather than relying on policy shifts or payer incentives, this is a growth strategy grounded in access, scale, and clinical alignment—entirely outside of the legacy FLS and DXA infrastructure that has proven so difficult to scale.
The Practice-Level Business Case: BHOP vs. Legacy FLS Models
For healthcare practices, implementing a fracture prevention strategy is no longer just a clinical priority—it’s an operational and financial decision. When comparing the Bone Health Optimization Platform (BHOP) to traditional Fracture Liaison Service (FLS) models, the differences are both structural and economic.
FLS programs often rely on dedicated staff, such as nurse coordinators, along with customized EHR workflows and complex coordination across specialties. These programs typically operate outside standard reimbursement channels, with financial returns tied to long-term outcomes that primarily benefit payers. For many independent or outpatient practices, especially those not embedded in large health systems, FLS is difficult to sustain and scale.
BHOP, by contrast, is designed to fit within existing clinical operations. It integrates osteoporosis screening and treatment directly into preoperative workflows, identifying high-risk patients at a point of care they already visit. From there, patients are enrolled in reimbursable care management services such as Remote Therapeutic Monitoring (RTM) and Chronic Care Management (CCM), creating immediate value.
A single orthopedic group performing 2,000 joint replacements and 400 spine surgeries annually represents a compelling case study in the potential of preoperative fracture risk optimization. By identifying at-risk patients in advance and routing them through a dedicated bone health pathway, practices can unlock both direct revenue and broader system savings.
Assuming 80% of these surgical patients are screened preoperatively, nearly 2,000 individuals would enter the optimization workflow each year. Data from front-end AI tools suggest that roughly 60% of these patients meet clinical criteria for osteoporosis treatment—translating to over 1,200 treatment-eligible individuals.
Financial modeling based on a 50/50 mix of anabolic and antiresorptive therapies shows that practices can generate over $2.1 million in net revenue across three years. In parallel, reductions in complications and readmissions yield an additional $3.2 million in potential cost avoidance—some of which may flow back to the practice depending on the structure of value-sharing arrangements with surgical centers and hospital partners.
Altogether, the total three-year financial impact exceeds $5.3 million. These are not theoretical gains—they reflect a realistic, scalable opportunity to turn clinical risk identification into operational and financial value. And unlike traditional FLS models, this approach is embedded directly into surgical workflows, not layered on after the fact.
Why BHOP Succeeds Where Other Models Fall Short
The distinction between BHOP and traditional FLS models isn’t just about location—it’s about design.
FLS programs are typically reactive, launching only after a fracture has occurred. They depend heavily on individual champions, are labor-intensive, and often collapse when staff turnover disrupts continuity. Their processes are layered onto existing systems rather than integrated into them, making them hard to sustain and harder to scale.
BHOP reverses this approach. It is proactive, identifying patients at risk before they fracture. It operates within existing clinical encounters—especially preoperative assessments—requiring no new billing codes or policy changes. It leverages digital screening tools and existing reimbursement pathways like RTM and CCM to support therapy initiation, patient education, and longitudinal follow-up.
In short, BHOP succeeds because it doesn’t ask practices to build something new—it enables them to do more with the systems they already have.
Defining Success: National Metrics for a Modern Bone Health Strategy
To move beyond fragmentation and make meaningful progress, the U.S. must adopt a set of clear, measurable goals that reflect both preventive priorities and operational realities. ASOP proposes the following national targets to reorient the field and anchor a new standard of care:
Screen 75% of adults — specifically, women aged 65+ and men aged 70+ — using DXA or validated fracture risk tools (e.g., FRAX, opportunistic AI imaging).
Initiate osteoporosis treatment in at least 50% of patients within 90 days of a qualifying fragility fracture, shifting the post-fracture window from neglect to action.
Achieve 60% medication adherence at one year, leveraging injectable therapies, care management, and digital tools such as Remote Therapeutic Monitoring (RTM).
Preoperatively assess 80% of patients undergoing orthopedic procedures (i.e. arthroplasty and spine fusion) for underlying bone fragility as part of routine surgical optimization.
Certify at least 7,000 Bone Health Providers by 2027, establishing a national clinical workforce trained to manage fracture risk across specialties and settings.
These are not aspirational ideals. They are practical, measurable, and achievable—if the system is restructured to support them. Meeting these benchmarks would reverse two decades of stalled progress and create the foundation for a durable, accountable fracture prevention strategy.
One Last Thing — Bone Health Needs a Home
For too long, bone health has existed in clinical limbo—acknowledged as important but claimed by no one. The absence of a formal subspecialty has left fracture prevention adrift, with no clear leadership, no standardized training, and no professional accountability. That must change.
To bring structure, legitimacy, and lasting progress to the field, a new clinical subspecialty—Bone Health and Fracture Prevention—must be formally developed and certified. Certification isn’t just a tool for quality improvement; it is the cornerstone of a fully recognized discipline. It defines who is responsible, what they must know, and how they are trained. It provides clarity to hesitant providers, direction to health systems, and confidence to those tasked with building bone health service lines from the ground up.
Many clinicians understand the need for intervention but don’t act—held back by uncertainty over ownership, integration, and return on investment. Certification resolves that hesitation by establishing a clearly defined skill set, a unified clinical pathway, and a sustainable operational model. It transforms fracture prevention from an ambiguous responsibility into a professional domain with standards, boundaries, and leadership.
The American Society of Osteoporosis Providers (ASOP) is actively advancing this transformation. Its certification program for Bone Health and Fracture Prevention—already in pilot implementation—establishes core competencies in DXA interpretation, pharmacologic therapy, opportunistic imaging, and digital monitoring. It defines scope of practice, promotes cross-specialty alignment, and creates a shared foundation for training and continuing education.
By formalizing this subspecialty, we create the leadership infrastructure required to coordinate national guidelines, align technologies, and integrate fracture prevention into everyday clinical care. Just as cardiology, palliative care, and geriatrics evolved from emerging concerns into structured specialties through certification, bone health now requires the same leap.
It’s not just about training—it’s about building a field. Certification is how we begin.
Conclusion
The fracture prevention movement is stuck. Legacy programs have failed to scale. Policy reform has stalled. Competing organizations duplicate effort without clarifying their collective mission.
“In a country where two million fragility fractures occur annually, fewer than 25% of patients receive treatment afterwards. That’s not a gap—it’s systemic neglect.”
Meanwhile, a vast, predictable stream of high-risk patients flows through orthopedic practices—untouched by current models.
The Bone Health Optimization Platform offers a path forward: scalable, embedded, and clinically aligned. It doesn’t ask practices to change how they operate—it builds fracture prevention into what they already do.
If fracture prevention is to succeed, we must stop waiting on Congress, grants, or goodwill. It must enter the operating room, the pre-op visit, and the surgical checklist. That is where the opportunity lives—and where the future must be built.
References:
Burge R et al. "Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025." J Bone Miner Res, 2007.
Medicare Payment Cuts For Osteoporosis Testing Reduced Use. Health Affairs. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2011.0233
Choksi P, Nair SS, Lee JH, et al. Osteoporosis care during the COVID-19 pandemic at a large academic health system. Endocr Pract. 2021;27(5):476–481. doi:10.1016/j.eprac.2021.01.007
Solomon DH et al. "Osteoporosis treatment after fracture in Medicare beneficiaries." JAMA, 2014.
Huybrechts KF et al. "Medication adherence in osteoporosis." Osteoporos Int, 2006.
Brauer CA et al. "Incidence and mortality of hip fractures in the United States." JAMA, 2009.
Lewiecki EM et al. "Osteoporosis and healthcare policy: critical connections." JBMR, 2014. White Paper Initiative. "A Roadmap to Fracture Prevention: Reframing Osteoporosis as a Chronic Disease." American Society of Osteoporosis Providers (ASOP), 2024.
H.R.3517 - Increasing Access to Osteoporosis Testing for Medicare Beneficiaries Act [7] of 2021. Congress.gov. https://www.congress.gov/bill/117th-congress/house-bill/3517/text
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