Latest / Zero Friction / The Osteoporosis Care Gap: The Disease Nobody Claims | David Lee and Jared Torkelson

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The Osteoporosis Care Gap: The Disease Nobody Claims | David Lee and Jared Torkelson · Zero Friction

• speaker-0: Now you can have a steady stream of patients that you're probably seeing every three to six months. And it might act it takes this, you know, the ebb and the flow out of your out of your practice a little bit and you're providing great health care. And then you're also sett setting yourself up if for anything does go wrong with those patients, who are they gonna go see? speaker-1: Only about 20% of people after a fracture get diagnosed, treated if they have the disease. We all have stories of patients that have had eight, nine, ten fractures over a decade or more. No one healthcare provider, a family member, anyone kind of connected the dots with the disease. So we've got all of these folks walking around at very high risk to have another fracture that aren't getting the diagnosis. speaker-0: Right, so we need AID leverage to help treat these patients and to take care of them long term. So AI either needs to help us be better predictors of these, so finding these patients before they fracture, or it's gonna help us treat these patients. We're gonna use the people that are already in the system. Can we use AI to leverage that technology that actually makes them provider to find these patients to treat them? Hey there, I'm Terry Kucheluchis, founder of RevRX AI. We remove friction and architect revenue for med tech. And consumer health practices. Welcome to the Zero Friction Podcast. This is Terry Kuchalucis, and I have two great phenomenal guests with me today. We're going to be focusing on bone health. So with me, I have David Lee and Jared Torkelson. David is the founder and chief collaboration officer of the Health Collaboration Partnership. Gerald Torkelson is the president of the American Society of Osteoporosis Providers. And he's also a clinician at the Mayo Clinic, I believe, as well. So great to have you guys both here today. We have a a super topic, one that is, I think we all agree is sometimes forgotten in America among the other major chronic diseases, and that is bone health. So why don't I let you guys take a couple minutes to introduce yourselves and then we'll kind of go into what you do, how you do it, and who you do it for. But let's start with Jared and then we'll move to Dered. To David on the introduction, please. Great. Yeah, thanks, Terry. My name is Jared Torkelson. I'm the president of the American Society of Osteoporosis Providers, and we focus on clinician education, create an environment around clinicians that are treating this disease that's often kind of left by the wayside and orphaned. I'm a physician associate with the Mayo Clinic and I work in the orthopedic surgery sports medicine department. I support lower knee and hip. Re recon surgeon also run an F L S bone optimization program, which I've done for the last ten years. Great. speaker-1: And I'm David Lee. I'm the founder and chief collaboration officer of Health Collaboration Partners, which is my consulting group that I've been running for five years. I've been in healthcare for 35 years. I've been at OSCD Process for 15 years, roles running a large public private partnership called the National Bone Health Alliance. worked at Amgen on the global marketing team focused on post fracture care coordination. have been consulting, as I said, for five years. working right now as executive director of the International Federation of Musculoskeletal Research Societies and have also been affected by osteoporosis personally in that my mother has osteoprosis, had four fractures before getting the diagnosis that she needed, the treatment that she needed, and luckily has knocked on wood, not had any more fractures. Thanks. speaker-0: Great. And it's so great to have you guys here today. Number one. Number two is I think the one thing we want the audience the best understand today is that this is a major problem in our healthcare system today. it's a drag on our our patients, it's a drag on the healthcare economy. and we've got to find out a better way. And it's one of those chronic disease states that doesn't always tend to find its way at the top of the page. And let's talk about this orphan kind of concept around. bone health and and what we can do differently to sort of elevate that up in the topic. Yeah. So I mean, if if if you had a heart problem, Terry, you'd go say, Hey, I need to see my cardiologist. Or if you had an issue with your lungs, you'd say your primary care, I need to see a pulmonologist. You have an issue with your bone, who who do you go see? Right. And I think a lot of times that falls to so I work on orthopedic surgery, but if you get an orthopedic surgeon that goes to residency for five years and then a fellowship, they're not gonna want to do an opera care of bone. They're gonna do really great work on the surgical side, and then we hope that somebody hands off to it who does not work. So You know, the fractures fixed and then we moved on. if you talk about if you have a heart attack, you're gonna come into the ER, you're gonna get an EKG, you're gonna get laps, they're gonna diagnose you, they're gonna start at antiplatelets, you're gonna get a primary care provider visit, you're gonna see a cardiologist, you're gonna get an EKG again, you're gonna do a stress test, yada, yada, yada. And that's expected care, especially in in North America, the United States, and that's you should get. If you have a hip fracture, you're gonna trip and fall, they're gonna break your hip, and they're gonna say, You should go see primary care about this, and then it's the end. Right. So Osteoporosis affects thousands and thousands of people, but the the treatment for a hip fracture sometimes ends with, you know, at that three-month follow-up saying, Yep, your hip's good, see you later, where we know that this is something that's probably been brewing for a long time and isn't now or isn't getting the the diagnosis and attention that it needs to. so we need to figure out a way that how can we have somebody own this disease? And it's probably gonna have to be a couple people, right? So it's probably gonna be more than just primary care and orthopedics and rheumatology and endocrinology where it's historically been. it needs to be all of us because a lot of things affect bone. If you ever look at a list of secondary causes of osteoporosis, it's you know 50 lines long, right? Your your bone is a reservoir. A lot of things sit there and it kind of uses it to hold things. But as we age, we know aging is a loss of reserve. That reserve comes out of your bone. So any chronic disease is pulling from your bone to help keep things going and moving along. So we need to appreciate that as practitioners that a lot of things affect the bone. A lot of these patients fracture for a lot of different reasons. speaker-1: Yeah. And I'd add just you know, we have a major care gap still. So just a couple of statistics. So only about 20% of people after a fracture get diagnosed, treated if they have the disease. you know, we all have stories of patients that have had eight, nine, 10 fractures over a decade or more that, you know, no no one healthcare profile prof provider, family member, anyone kind of connected the dots with the disease. So we've got you know, all of all of these folks walking around at very high risk to have another fracture that aren't getting the diagnosis. Of course, they're getting, you that fracture fixed if it's at the ED by an orthopedic surgeon. And then I think some of the other challenges of this disease is you know, the the endos and rooms are the primary kind of bone health specialists, but we have a shortage of them, especially the ones that specialize in bone health. So there may be six to twelve months before you can see that physician. In some places as well, there's some you know some delays in getting ADEXA, which is, you know, the bone density test that you need as is part of the diagnosis. So if you're walking around at high fro at high fracture risk and it's gonna take you a year to even get a diagnosis, let alone you know, maybe having to fight your insurance company to get on the the therapy that your physician, healthcare professional thinks that you should go on. you kind of see why we have this gap, but even though as you said it's an orphan disease, it's what's maddening, I think, for us as a field is that it is such a prevalent disease, but it is treated like an orphan disease. speaker-0: And where do you think like I I think I heard a couple things in that last comment where the caregiving escapes somewhere. So, you know, you you have an incident, you have a repair, so it's a break and it's a fix. And then it's a three to six month sort of window of rip rehab and going back to your doctor and making sure that things are healing appropriately. And then After that is kind of where things sort of get lost. Is that where? speaker-1: Yeah. speaker-0: Yeah. I mean fix it. And then we kind of just do this and then we just hope something happens that, you know, somebody's monitoring their bone health again or they're coming back in, or they actually do they actually know if they have a bone health problem or like what what typically is the situation? It I think there's a lot of pieces to that. One, you know, if you have a hip fracture, you have the diagnosis of osteoporosis period, and that's not always recognized. So you can if you look at ICD 10 codes, you can code for a hip fracture, you can code for an osteoportic fracture. Nobody's really going to code for the osteoporotic fracture, think about doing that typically. with most of our data mining that we do it, it's it's off of I C D 10 code. So it's if it's never coded from the beginning, then it's tough finding these fractures. If if you have, I mean, we're in the the time now of disjointed care, you know, if you have an orthopedic service that is maybe a private practice line connected to the hospital or they're on one side of the hospital, primary care is on the other side, and they're not talking to each other and they're looking at notes saying hip fracture, great done, then what? There's not really a plan of of con of continuing that care, treating that patient from there. So and primary care is inundated with, you know, 50 things that they have to do. we don't we can't make enough endocrinologists nor do we have any. I mean to see an endocrinologist is six months, to see a rheumatologist is six plus months. so sometimes just forgotten about, right? And if that patient that first six to twelve weeks, they're very focused on fracture prevention and not falling and you know, because that's a it's a real thing. But if it's six, nine months out till they're seeing somebody, one, they may forget why they're seeing them. And two, they're gonna be like, I think I'm good now. You know, my my hips moving okay. I may I must be fine. I must be okay. you know, when I talk to patients, I say I have two ways to know that you have osteoporosis. Either we get a DEXA scan or you break something. outside that you can't see it or you can't feel your bones, right? It's not like if you're having harder lung issues, you start, you know, I have dyspnea, it's tough to get around, you get really tired, you can feel those things. If I have really thin bone, you don't know, you know, unless something happens. speaker-1: Yeah, yeah. And I'll speaker-0: May I speaker-1: bring in a a personal story about my mother. So you know, she had two fractures. She broke both of her elbows, fall from standing height. She did see a endocrinologist, but because she had so so, you know, the the T score is what we use to kind of see, you know, based on that DEXA, where you are in terms of your of, you know, your bone health. So a negative one to negative two point four nine is considered a low bone mass or osteopenia. Anything negative 2.5 or worse is osteoporosis. She had a negative 2.4. So he put her on a bisphosphonate, which is, you know, the the oldest medication we have, not the right medication for you know her other risk factors in addition to the two fractures and being so close to the edge of osteoprotic bone. know, she had some GI issues, she went off that medication. Two years later, she broke her toe. And then because she was in a boot, she fell in the bathroom and broke her shoulder. And I happened to be with colleagues luckily as this was happening and found her a physician in, you know, in her area in Charlotte, North Carolina, that she got a diagnosis. She got put on, you know, one of the newer medications. She now four of her six sites has normal bone mass. So, you know, the lucky thing is, of course, she didn't have that hip fracture because the statistic is. 20 to 25% of hip fracture patients within a year are dead. so, you know, great that your your mom is okay, Terry, because it is a scary statistic. And then about 50% of those folks that live go from independent living to some kind of, you know, nursing home situation. So, you know, it really is a very challenging thing. And now, you know, for me, it's not just professional and 15 years in osteoporos, but now also personal. And I'm just thankful that you know, we got her the care and did not have that. horrible outcome that we could have had as someone who's now eighty three. so thanks. speaker-0: What's it's you know, it's really interesting. I think we all have our, you know, I got my own personal story with my family as well. But you know, you look at the the economics behind, you know, fixing fractures. and there's obviously a financial remuneration, there's an incentive to treat fractures, but tell us like why does there seem to be a gap in preventing them and and and creating a I guess a motivational aspect of why aren't we doing a better job of preventative medicine, proactive medicine, proactive health, maybe not even medicine, but just, you know, we talked a little earlier in our conversation with core strength, muscle strength falls in line with balance. All these things can sort of help a patient who is aging and losing bone mass and losing muscle mass. Those are really bad combinations 'cause they lose their balance, right? And that opens up and exposes them to, you know, falling and breaking and Yeah. I I mean I think with prevention, it's it's the same story, right? We're all invincible until we're not, you know. So if you don't you have that inciting incident where you trip and fall and then things come happen, yeah. and and like as I said before, the only way that you know that you have poor bone quality if you get a DEXA scan or if you break something, right? And currently in the United States, we should be getting screened DEXA scans in women at 65 and men at 70, and those rates are bad. I mean, the DEXA scanning rates are less than 20 percent in CMS population, it's actually probably less than that. So most time they're not getting it. If they are getting it, a lot of providers like like imaging and this is just my soapbox here being an an orthopedic clinician, but you need to look at the image and a lot of times they don't. They look at the read and they say, they see osteopenia. they don't they're fine, but the osteopenia could be like with with David's situation at two point four nine. And if anything else that pushes them up a little bit or higher risk, they should be treated with something, but they were at osteopenia on the on the little reed out there for the DEXA scans, then nothing happens. So that's that's kind of the biggest one up front for patients too. I think preventative medicine's a great thing, but again, you can't see or feel bone, right? We can understand bone mass. And I think preventative medicine's having a moment right now, which is fantastic. And we're starting to understand the relationship between bone mass and muscle mass. And we're understanding more about you know your glute strength and your core strength prevents falls, which can prolong your life. We're understanding more about what sarcopenia and bones and muscles con. Talk to each other and they contact each other and do different things. So I think we're hopefully getting there. And that might just be being hopeful. But a lot of us has to do with just, you know, the mantra forever was you old, you fall, you break things, the end. And that's kind of what happened. And I think we're getting to a point now realizing it doesn't have to be that way. You know, I tell patients that are 85, 90 years old, you don't get to 85 or 90 years old being a wimp and not being a little stubborn, you know. So we kind of have to put a little bit of work into it too. So I think patients are willing to do that. I think. Us as clinicians, we have to say at 60, hey, have you thought about your phone? Are we exercising? What's your diet looking like? and kind of pushing those on their patients and just kind of reiterating that conversation about doing it. But I'm having more patients that are asking those questions, which is great too. So I I'm hopeful we'll be in a better position, but we still need, you know, to talk about it prior to age sixty five. We probably need to talk about in our fifties. And I think we need to shift the paradigm of secondary fracture prevention to primary fracture prevention. me being in orthopedics, you know, we get a lot of patients that are getting their elective hip and knee and shoulder surgeries at a younger age. That's a great time to start just talking about your bone, right? Maybe you get a DEX scanner, at least you you look at their medical history and saying, You're at a higher risk based on these things. Do you need to go talk to a bone health specialist where you start talking about those things at that time so it doesn't become a problem. speaker-1: Yeah. And just to add, there's a couple of models of care. so there's one called a fracture liaison service that ensures if you have it in your hospital, no matter where that fracture occurred, you know, you're gonna have NPPARN is gonna, you know, reach out to you and say, Hey, I see that you came in the emergency department and we fixed your wrist last night. We now need to get you in for ADEXA to diagnose you to see if you might have osteoporosis. the challenge in the US is that There aren't nearly enough of these programs. Like in other countries, I mean the UK is probably 60, 70% of the hospitals have these programs. and a lot of it is, I think, a challenge in understanding how reimbursement works. And I mean, I've been on calls with physicians that have been trying to pitch this within their C suite. And the C suite goes, All right, so you know, we don't want to hurt patients, but tell me how this works. You know, we're gonna hire someone for $100, $120,000 a year to be the coordinator. And you're telling me there's gonna be 30 less fractures coming through our system. I don't wanna harm patients, but you know, that's a lot of lost revenue. How are we gonna make up that revenue and you know pay for this program? and then there's another model that I know Jared also runs called bone health optimization, which on the orthopedic side, if it's spine or you know, an orthopedic surgeon, you do that DEXA or get that bone density measurement. Pre-surgery. And of course, if you have underlying if it's, you know, something that can wait and you have the underlying disease, we get you on a on an anabolic therapy to build your bones so that you have a better chance of having a good outcome. and there are some, you know, CMS has some new bundle payment programs, team access that is starting to incentivize for some of this post-fracture care work. And I think at the end of the day, especially in the US health system, it's gonna come down to dollars and either, you know, penalties if you're not doing the right thing or some incentives if you are, because at the end of the day, you know, we still are it's the business of medicine. speaker-0: Right. And and I think you you bring up a good point there too. I think we've been so focused on like over reducing thirty percent of the fractures that's that's less cases, right? And I think we need to look at the bigger picture, right? Yes, reducing thirty fractures, but if you look at one fracture, they're in the hospital for three to five days, they're costing the hospital, you know, it's ten to fifteen thousand dollars a day with resources and time and people. If you save those those thirty fractures, that's thirty elective patients now you can put into those cases that generate way more revenue. Right. So I think a lot of time we've looked at it so siloed that if you look at the entire health system, your entire hospital, there's big savings here, right? And we need to get more creative and and and and look at the bigger picture saying, like at the end of the day, that hundred and twenty thousand dollars you're paying that clinician, that's pretty darn cheap to be saving, you know, three, four hundred thousand dollars. speaker-1: Yeah. And just to add my mother's case, you know, this the math was not tracked. So she had two, I think, 20 to 30 day stays in, you know, rehab institution each time. So to think of how much money we put into her care and, you know, bisphosonate that cost nothing, where, you know, we got her on an anabolic, which was, you know, more expensive therapy, but a heck of a lot cheaper than Another thirty day stay and you know, one of those stays was in the very beginning of COVID pre anything. So, you know, the fear of gee, she's gonna get coveted in the hospital because she had these two fractures, was very high. speaker-0: Yeah. And look at the system too, right? Like it and then you gotta think about you as a caregiver, right? So that if you gotta take take time off work, that's that's your your employer now is affected by it too. You're taking the time, that's energy on your family. Now do we have to move, you know, mom or dad or grandma or grandpa into a different facility, into a long term facility too. It's just it the the burden on the health system is so large with these patients. And we focus it down to did we fix the hip fracture, and then it's like, but then what? speaker-1: Yeah. speaker-0: Well, it's not even a burden, like there's I think you're Nailing the head on a lot of different things here. But at the end of the day, better care is better care. And that's hospitals are in the business of better care, not more revenue, right? So patient-first activity, higher quality care, number one. Number two is I think Jared was talking about this as well. And David, you both were the it's less expensive in the long run to the healthcare system, especially if you can have more elective beds versus more reactive, you know, like these patients are in the hospital, then they're in rehab and they're they're costing the entire healthcare system money. So it's we're not just talking about like, you get paid for it, but like at the end of the day, Medicare and CMS has X amount of dollars every year to spend. And so if we can create more efficiency out of a better quality care and a better outcome for our patients, which goes into the whole proactive and preventative medicine part of it too. Right. You know, like spend your money up front and and have those things. I think it was a great topic and I think, you know, we all have to figure out a better way in multiple ways, but bone health is what we're focused on today. And I think that's a I wanna pivot to a direction 'cause you guys are in this demographic where AI is everything around and I know you both are highly involved in AI and and I'd like to get your perspective on AI and bone health and How you see AI changing the dynamic and the landscape of of bone health today. Yeah, I I think the the the first button that was hit when AI came in was detection. And I think and and David, I'm sure you spoke you've spoken with a lot of these companies and I've been pitched all the time to say, Hey, I fixed your problem. Look, I have this AI algorithm that goes through CT scans and finds you all these patients. And then I tell them, that's not my problem. You know, I to to get in to see me right now, you won't see me until end of November. Right. So we need AI to be leverage to help treat these patients and to take care of them long term. So AI either needs to help us be better predictors of these. So finding these patients before they fracture, or it's going to help us treat these patients, whether that's to educate clinicians, whether that's to empower our primary care providers. If we're going to use the people that are already in the system, can we use AI to leverage that technology that actually makes them a provider to find these patients to treat them? And that is where this needs to go. speaker-1: Yeah, yeah. I would I would definitely agree. And then would also say that, you know, there are a lot of these AI companies that, you know, as you said, are are looking at, you know, kind of look at a previous C T or X-ray measure bone density. But I think one of the challenges, and until one of them are able to be a surrogate for DEXA, there's still the issue of, you know, you might have to get a confirmatory DEXA to even get started with anything. and, you know, as I said before, there's some, you know. Three to six month wait, I've heard in some institutions, even to get a dexabone density test. and then I think the other part is the implementation problem. To your point, Jared, you know, you don't, if you have a list of 100 patients that, you know, this algorithm says has osteoporosis, if you don't have the person power to deal with it, it's just a nice list. And I think there's also some ethical challenges in that, you know, if you're reaching out to a patient and go, Hey, I know you were in for you know an abdominal CT last year. We now see that you have osteoporosis, and the pr patients like, you missed my osteoporosis. Obviously, it wasn't there for that reason, but I think there's also some challenges as it relates to that. And you know, so still I think it does come back to this, you know, FLS bone health optimization, not having enough of these programs that can handle. The patient load, and I guess the other thing we haven't talked about is, you know, part of why this is all happening is the aging of the population. I mean, you look at a Japan and they're, you know, 15, 20 years advanced, and they've done a lot as it relates to these models because they were, you know, starting to really cripple their national budget because they were spending so much to fix fractures and not not, you know, preventing them. speaker-0: What what what is Japan doing differently then? 'Cause they they do have a longer lifespan and obviously, you know, w give us some some background on speaker-1: Yeah, I mean it was a a lot of additional reimbursement support for both on the orthopedic side and you know the in inpatient side, which we call ortho geriatric, as well as the outpatient, which you know, this fractural liaison service model doesn't kick in until a patient's been discharged, unless it's like a, you hip fracture patient that's still hospitalized. So a lot of additional reimbursement for the care coordination you know, apps that we're helping to track these patients, things like that that you know, the the you know, Ministry of Health and and other federal funders put into the program. speaker-0: Got it. Yeah, they've they've they've had a lot of more support, I think, on the the infrastructure side, which is is where we need it too, right? So you need that incentive. you know, money talks. We live in a capitalist society. So if there's money there to be had, a hospital's gonna find say how can we utilize this? I think that's helpful. That's that's part of the problem too. But I think they've also leveraged technology in a way that they they also say, Hey, we have a certain amount of providers, they have a certain type of health system. So How can we be more efficient to treat this aging population? Because they understood that was going to cripple their health system. Yeah. And do we all like line up that that screening is the first pathway to all of this? So is that is that a limiting factor? Is that a friction point in bone health today? It's just the ability or inability to screen in mass. I think it's more, I would do more identification. Right. Because we can you can make a a thing in your EMR that says get a DEXA scan and then the clinician hits the button and they get the DEXA scan. And then if you don't do anything with the DEXA scan, what was the point? So then identifying that DEXA scan happened and that this patient's at high risk or as osteoporosis is that next piece too. So screening, yeah, but identifying that patient that when how we're gonna do something with it, I think is probably where it needs to go. Well, speaker-1: Think the challenge too is that I'm hearing sorry, go ahead. speaker-0: I was just gonna say that sounds like a phenomenal AI opportunity. where AI could go through and identify patients that have had the DEXA scan, help facilities sort of build their own awareness systems around what patients should be further evaluated for, you know, therapy or preventative therapy or whatever it might be. But that's that sounds like a great AI tool that would sit on top of an EMR system that would just literally Sit there and monitor these patients and then pull them out when the data says, Hey, these are this is a group of patients we should be following, right? Yeah. Th those exists. The pr the problem is it's not, you know, the again they see the list and they see that they have a a T score and the T score's osteopenic. They say, Well, they're not osteoprotic. Well, there's there's other diagnosis of osteoporosis. Have they had a fracture, they smoked those types of things. So You know, we can do that piece, which is great, but then we also don't have the people that treat it, right? So if you are a primary care clinician, maybe you're really comfortable with oral dysfost matrix is great, but if it's a a fracture patient, we know that those patients need to be on anabolics. Now they have to go, okay, now I gotta find them in a fusion center, and now I have to do the prior off, and the prior auth gets denied. So now I have to do the appeal, and that takes a long time. And it's the medication's a big scary name, and I've never done it before. And there's this thing on the internet about this thing with the jaw that's really scary. We're just gonna try laundronate and if it fails, then somebody else will figure it out. Right. So the the the identifying piece is first, but the the the the the bottleneck here is clinicians that are comfortable treating these patients and we do not have near near as many as we need. So it's an education opportunity then too, right? So it's it's getting it's getting competence created around a patient pathway so that you can actually, you know, not just identify, but then you can pass these patients through some sort of algorithm where they actually have a competent physician who can treat them the right way. speaker-1: Yep. Yep. The other thing I would add is that, you know, I'm hearing from clinicians that, you know, they're seeing osteoporosis with patients in their 50s, early sixties. So I think one of the other challenges is literally getting the authorization to even have that DEXA if you're not 65 for women, 70 for men. even with risk factors, it's it's a big pushback. And then as we talked about before, some access issues. there was a big change in the reimbursement in the office setting versus the hospital setting probably eight, nine years ago. So it used to be that you could go see your endo and room, walk down the hall, get your DEXA, come back, get your diagnosis. Now you might see your endo a room, which is going to take six to twelve months, as we said, and then you're gonna have to go to the hospital to get a DEXA, you're gonna have to come back to get that diagnosis. So I think the big thing is the tail of the diagnosis now can be nine months to a year. And if you've got a patient that is at a high risk. walking around with osteoporosis, the likelihood that they're gonna break another bone is high. I mean the statistic is after you break a bone without intervention, there's an eighty six percent chance that you will break another bone within one year. speaker-0: Mm-hmm. And it stays high for two years, you know. And if you think about the delay in care, if you're not getting seen for nine months, that nine months yeah, I mean that you're likely gonna fracture again, especially in that older population. speaker-1: Yeah. Yeah. And I would say too, to your point, you know, we've always talked about wanting to do primary prevention, having primary care, own this. But, you know, if you've got three chronic diseases and you've got a 20-minute visit with your PCP, unless you have a cast on your arm, osteoporosis is not going to be one of them. It's going to be my arthritis that, you know, affects me on the daily, you know, obesity, diabetes, you know, these other things that really are, you know, gonna affect you where the challenge in a way In osteoprosis being a silent disease is you don't feel that your bones are weak before they break. once they heal for most patients, it's kind of out of sight, out of mind. They're of course thinking about their other chronic diseases and not osteoprosis. So that's I think part of the reason why it does feel like an orphan disease, even though it's very prevalent. You know, 54 million people have low bone mass or osteoporosis over age 50. two to three million fractures a year caused by osteoporosis. So it is a huge problem that just is not getting the the attention that it warrants. Although I would say it has it is changing a bit with the menopause conversation. I think there's a lot of influencers that are talking much more about osteoporosis. So I'm hopeful that that will continue and as we connect kind of the menopause and you know osteoprosis piece. And given that it is mostly a female disease, because you do lose up to twenty percent of your bone density as you go through menopause. So you might be okay premenopause, but by the time you're through menopause, you may have bone health issues. speaker-0: Yeah. And I don't think primary prevention needs to be primary care, right? That is to me somebody that's meeting that there too. So if I put my my ASOP hat on for so the American Society of Osteopos providers, we're trying to educate those clinicians to have that workforce out there. And they could be anywhere. They could be primary care, they could be orthopedics, they could be rheumatology, they could be in some small clinic in Nebraska, right? As long as they are competent to do that and they are educated and certified. I mean, these they they can be anywhere, and that's the beauty. you know, and I think that's a good place too for advanced practice providers as well. You know, so within orthopedics, like I said, if you're an orthopedic surgeon, you're in five years of residency in a fellowship, you're not gonna be doing this. But if you have, you know, two or three advanced practice providers that are doing this, helping you out to offload some of that, that's new consult them to be seeing. And then you're you're capturing that population, they're getting the appropriate care that they need. So speaker-1: Yeah. speaker-0: what so what's the answer with the the capacity issue or the I don't want to say it's competency issue, but the specialty, like I understand this disease really well and I'm comfortable treating it, problem. Like, is that knowing that we, you know, is it is this a a a mid-level, you know, is this can this be fixed with a PA or nurse practitioner, you know, sort of supporting the physician? Is it like how do we how do we build that infrastructure to handle this orphan disease, it obviously needs more fingers and toes to health it out, right? Yeah. I I think it can be any provider, right? I don't think it has to be an advanced practice provider. I mean, physician, clinician, anywhere you want to be. I think it's having the the the people that are competent doing those things and are confident doing those things. So when I look back into my training, the osteoporosis day was was somebody telling me about an oral bisphosphonate and then 20 minutes tell me how they actually don't know how read adexas scan. And then that was it. So the education piece can be more. and then if you get an endocrinology component or you do rotation endocrinology, you know, you get a little bit more too, but it's it's such a broad topic and it's something that really could be its own disease state, right? So the the beauty of it is you can treat one disease with six drugs and that's kind of it, and you can be busy all day doing it. the problem is I think our problem is that we're trying to decide where to put it and it probably needs to be its own thing. You know, it's it's it's busy enough and probably generates enough. patient volume that it could be its own practice. So so does bone just need to be something? Do we need to actually take it out of endocrinology, taking out orthopedics and just make it its own thing to identify and to uplift it in a certain way that that we don't have to say, well, it goes here, it goes here, it goes here. Well, it goes everywhere, right? And so does the heart, so does the lung, but it just it might just need its own lane. And it might even that might even help the referring part make it easier too, because I'm sure part of the problem is I don't know where to even send the patient. Right. Yeah. So yeah, and it's different everywhere. It's just easier just to like, okay, we'll just let them fall back into the system again. And 'cause there's speaker-1: Yeah. speaker-0: no there's no easy button for a referral. There's no like bone health specialist out there in their community that says, okay, I'm the like for this situation, call me, call me, call me. That might be a really good opportunity, you know, when you think about it. And if if historically you go to an endocrinologist, if you're a smaller hospital, like in our region, we don't always have an endocrinologist here. Typically they're focusing on diabetes. So then you have to get referred on to our our larger center, tertiary center. Then it's six months to get in. It's likely a virtual visit. if it's a visit at all or an e-consult. So if it's an e-consult, you don't see the clinician anyway. They look at your your chart and your review and they say after your primary care and hope that they're gonna follow it. And then you again follow the problem that primary care sees this drug that's really scary looking. They've never done it before, and then they go, I don't know how to do that. You know? So it it probably needs its own lane. Well, and you know, just like anything else, it's it's And the unfortunate state of healthcare, there's there needs to be a carrot system, right? They and you gotta follow money and it's just it's unfortunately the way it is, but that's the way our health systems is set up and built. That you have codes, you have procedures, yeah, and that's how doctors and offices, you know, make sure they can take care of their staff and take care of the practice and pay their bills and all those other things too. So and that That might be the place for AI to go. Is how do you actually find value? How do you show value? Right. So much of developing strategies telling a story. And this is a really tough story to tell. You know, it touches so many areas, and these patients aren't going to. So you can use AI to find that data to tell that story to go to your C-suite and say, here, to the health system overall, our value is here and it looks like this, right? Because it's really convoluted if I tell you about it and do these things. And David knows the story a lot. But if you go to a C-suite executive to tell him, like, I'm reducing my surgery, so this doesn't make sense in our surgical practice. Like, yeah, but look at the bigger picture here. You are the CEO of a health system. Look at the health system. This offloads a lot of different places, and it's relatively cheap to do that. So I think that's might be a better place right now for AI to do that is tell that story. Well, and it's gonna as you and you roll into value-based care systems too, we're all going that direction. So you know, we're all gonna be the system's gonna need to operate from a profitability perspective where They're gonna get X amount of dollars of every patient they're gonna manage and and then it's it's really not a revenue system anymore. It's an expense system. So right now our healthcare system is built upon a revenue system where if you have capitation, they get paid X amount of dollars and they're managing, you know, five hundred thousand patients or whatever it is, then it becomes an expense system. And then maybe that those efficiencies become a little more easy to find, you know. along the way. But I th I think that's a great conversation where AI can help build the strategy, build the story, and show the C suite the economics from all angles, by the way. And that's the one thing that AI does really well is it it can take a 360 degree view where and make it very simple to understand too. Right. speaker-1: Yeah, I think that's been the big challenge because, you know, many of the clinicians that I worked with that are trying to set these programs up, you know, they don't have MBAs. They don't feel like they can make a business case or that they might be able to do it with kind of, you know, national data or published data, but not the data from their individual hospital. So like when I was running the National Bone Health Alliance, we did develop a return on investment calculator. Which you know, you kind of put in, all right, we've got you know, we've got our coordinator at this much time. This is the kind of, you know, revenue streams that we think we're going to capture, you know, in addition to fixing the fracture. And then it would spit out a two, three, and four year estimate of the profit loss. And I think as you said, in you know, where we are in AI, we probably need an AI version of that because I feel like the reimbursement piece is the biggest reason why we don't have thousands of these. Fractual liaison service programs. And I mean, some sites have figured it out. I mean, there's some orthopedic practices that have a large volume that have two, three, four MPs, PAs that are these coordinators, and then others that cannot make the case to even hire someone part-time because of some of the issues we talked about before in terms of you know, not seeing enough revenue and just seeing an expense of, hey, we're gonna have to hire this person, you know, create this infrastructure and buy software tools, et cetera. they don't see the the the upside, but also it's hard to articulate the the up kind of truly what this is gonna look like. speaker-0: You know, I would think orthopedic practices might be a really interesting angle on this. And I'll just throw this out there from my business perspective is that typically these guys are fixing things and letting patients, you know, they're they have a three month or a six month sort of recovery and then they never see the patient again. And that was kind of how we opened up the conversation, right? Where now if you open up a bone health program, Now you can have a steady stream of patients that you're probably seeing every three to six months. And it might actually take this, you know, the ebb and the flow out of your out of your practice a little bit. And you're providing great health care, preventative, proactive health care. and then you're also set setting yourself up if for anything does go wrong with those patients, who are they gonna go see? They're gonna go see the guy, the the doctor who's been taking care of them. So It seems to me like there there there might be a solution here where it's an orthopaedic solution that that kind of ties into maybe they have a bone health practice that sort of lands next to one another where, you know, frankly, that's probably a really interesting pathway for them to go where because I know a lot of orthopedic practices it they're all on heavy churn on surgery, surgery, surgery, because that's that's how they that's how they do it, right? And now if you add a different service level in which is a little more, it's not the reimbursement you're gonna get on a surgery, but you have a steady stream of patients that are coming to your office over and over and over again, you know, twice a year, three times a year, four times a year. and maybe you're helping them do proactive things, maybe you help them with peptides and supplements and all sorts of things that enhance bone health and physical lean, you know, muscle mass and all these other things that are that help, you know, make the proactive health of that patient better as well. Yeah. Yep. And and I think the the the change in reimbursement too. So it if you're in tune with orthopedics around the big talk is CMS reduction in, you know, total total knee next year about 20% is huge. Yeah. So I think bone health, we've thought a lot about it for the health system standpoint and there's significant value. And I think there's probably going to be more in the private practice and even the ones that employing their own ASC, right? Because now with ASC, the biggest thing that they're going to have to deal with is patient selection. who's approved for the ASC and is not. And that's what bone health does. So if you are finding these patients and understanding that this patient has a higher risk, maybe needs to go to a health, maybe needs to go to your local hospital versus does someone actually need to optimize for six to nine months that they become that good patient. Plus then you're capturing that time, you're doing some pre-optive things, you're optimizing them, you know, both for their sarcopenia, their muscle loss, their bone quality is that they become a good ASC patient is there. The patients now capture within your system. They now built a relationship. So they're probably going to come back to you. Those are all great things to do. so I I think that's where a lot of that that beat can be. And I think there's a a fallacy built into the system. And I don't have data to publish which I would like to sometime, but my guess is that these patients, if you I just gotta back up here, but a lot of concern from orthopedic surgeons is right, is that if you see a patient, you say they have poor bone quality. They're they're used to just turning and burning. It's about volume. It's getting the patient in to do surgery. They're like, I'm not going to delay surgery. Like, okay, I get it. To be honest, we don't have good data that says should we do treatment before, during, or after surgery? Where in that perisurgical period we treat them? We don't know that answer yet. I'm going to bet a lot of those patients that if you tell them they have poor bone quality, they will delay themselves till you say they have good bone quality to do their elective hyperney. And and I'm betting that's gonna be true for a good majority of those patients. So now you're optimizing that patient. They're self selecting. That brings in a different patient that's ready to go and to do surgery. And now when this patient's good to go, they're gonna have a better outcome down the road. You have to get more out of your bundle if you're part of a bundle payment system too. So I think I I think that's where a lot of us can fit. And I don't know if that's realized yet within the private practice AAC community yet. speaker-1: Yeah. speaker-0: Got it. speaker-1: Okay. And yeah, there's this model called team that I think what 300 or even more, I think 700 hospitals are part of it. And it was shocking last fall to talk to spine surgeons, orthopedic surgeons, and they didn't even know they were part of this bundle. So you know, hip hip fracture repair, spinal fusion, hip and knee replacement are among the procedures that are part of this bundle. It's a 30 day bundle. So of course, if you do, you know, to your point, Jared, that surgery on a patient that you haven't optimized their bone and it's an elective hip or knee, they come back with a revision, readmission. you know, the stats show that there's about a 20 or 30% increased chance of a revision or or readmission for people that have underlying osteoporosis compared to others that don't in spinal fusion. So I mean it's a big problem. So I think it it's gonna take a while, but I think this is gonna start to drive. The train and as we said before, you know, at the end of the day, the American system is built on on revenue and dollars. obviously also patient outcomes, but it does drive the train more than in many other countries. speaker-0: Well, good. Well, guys, I have one more question. Sure. Kind speaker-1: It will speaker-0: of wrap it up and and I'll give you a a choice. You can answer either one of them. So one question would be if he could change one thing and how this disease is handled, what would that be? Number one. Or if a founder or a clinician who's listening to this today, what is the one thing you want them to take from our conversation today? so I I talked to a lot of clinicians that are just starting out. I I I was able to give a lecture last week to Campbell Clinic, who's starting a practice and and I'm giving a talk in a few weeks at the the PN Orthopedic Society meeting. the normal thing is to start. Just do speaker-1: Just speaker-0: it. Just start, get into it. It's really scary to look at and it feels like a big thing. And you to for successful programs to happen, you have to be a little bit of an entrepreneur. And to be a good entrepreneur, you just gotta kind of Go into the dark and see what happens. So just just if you want to do it and you're seeing these patients start, if you're a primary care clinician and you have your handful of patients you're comfortable with, look for those patients. I guarantee that they're there and just start treating these patients and finding them. And on the business side, if you're an operations manager, you're in the C-suite, ask about this, right? This is something that can be beneficial to your patients and beneficial to your bottom line. So just start. speaker-1: Yep. And just to reinforce that, so one of the physicians that started the Kaiser Permanente Healthy Bones program, he talked about the early days. His name is Rick Dell, an orthopedic surgeon. He talks about literally, he said, My program was me over lunch, myself and my, you know, EA calling speaker-0: All the speaker-1: five patients. That was the start of our thing. So as you said, you gotta you gotta start somewhere. I think sometimes people come in and they're like, We need all these bells and whistles, all these tools, all these. Cool software. And it's, you know, it's you can really go old school as a start and then really build the evidence. And you're starting to see how bad this problem is. And as you start to intervene, and of course, as you have good stories of patients that had multiple fractures, that now, you know, their fracture risk is reduced. Not that we can reduce it to zero, but essentially the, you know, the drugs overall can reduce your future fracture risk by 50%. And the Anabolics are even much higher than that. So it, you know, I think that's the other thing is the misnomer of this. I'm gonna get this rare event, this one in many hundreds of thousands, as opposed to if I don't get treated and I'm walking around at high risk, I have a one in two chance of having a fracture. speaker-0: And I'll I'll follow in the entrepreneurial side and the business side. So I think that just like anything else in life, you just gotta make a first move and take your first step, right? And use your patient databases and, you know, figure out who's in your practice that can benefit from these conversations and these pathways. They're right in front of them. And if they do need help, there's there's all sorts of people that have programs and platforms that can help you do that extraction for patient activation campaigns, education. There's probably all sorts of educational components out there that they just need to use as a resource. Right. Probably a free resource that they could actually plug into their own practice that would actually help educate patients, help them understand there are options and what they can do. And that's just that's all part of that whole program is education competence and getting the movement. started. So yeah, I want to thank you guys both for being here today. Really informational, educational from my perspective. Hopefully the audience understands that this orphan disease definitely needs greater attention and more attention on the front end versus the back end side of things. Thank you. speaker-1: Thank you. speaker-0: Absolutely. Yeah. Thanks, Terry. Jason, thank you. Continued success to both of you. Appreciate it. speaker-1: Have a good day. speaker-0: Okay. So let's connect. Let's find where your revenue is getting stuck. Book a call at RevRXAI and build your revenue engine.