Osteoporosis Care Gaps: Who Owns Follow-Up?

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0:00 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 practice a little bit and you're providing great healthcare and then you're also setting yourself up if for anything does go wrong. With those patients, who are they going to go see? Only about 20% of people after a fracture get diagnosed treated if they have the disease. We all have stories of patients that had eight, nine, ten fractures over a decade or more. No one, health care provider, 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. Hey there, I'm Terry Coutsolioutsos, founder of RevRx AI. We remove friction and architect revenue for medtech and consumer health practices. Welcome to the Zero Friction Podcast. This is Terry Coutsolioutsos 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 Partners. Jared Torkelson is the president of the American Society of Osteoporosis Providers. 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 super topic. One that is, I think we all agree, 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 David on the introduction. 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, creating an environment around clinicians that are treating this disease that's often left by the wayside in orphan. I'm a physician associate with Mayo Clinic, and I work in the orthopedic surgery sports medicine department. I support lower knee and hip recon surgeon. I also run an FLS bone optimization program, which I've done for the last 10 years. 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.

2:48 I've been in healthcare for 35 years. I've been in osteoporosis 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, and that my mother has osteoporosis, had four fractures before getting the diagnosis that she needed, the treatment that she needed, and luckily has kind of would not had any more fractures.

Thanks. Well, 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 to best understand today is that this is a major problem in our health care system today. It's a drag on our patients. It's a drag on the health care economies. 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 what we can do differently to sort of elevate that up in the topic.

Yeah. So, I mean, 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, you're a primary caregiver. I need to see a pulmonologist. You have an issue with your bone. Who do you go see? Right? And I think a lot of times that falls to, so I work in orthopedic surgery. But if you get an orthopedic surgeon that goes to residency for five years and then a fellowship, They're not going to want to do a nonoperative care bone.

They're going to do really great work on the surgical side, and then we hope that somebody hands off to it and who does that work. So, you know, the fracture is fixed, and then we moved on. If you talk about, if you have a heart attack, you're going to come into the ER, you're going to get an EKG, you're going to get labs, we're going to diagnose you, you're going to start anti-platelets, you're going to get a primary care provider visit, you're going to see a cardiologist, you're going to get an EKG again, you're going to do a stress test, yada, yada, yada, and that's expected care, especially in North America, the United States, and that's what you should get. If you have a hip fracture, you're going to trip and fall, they're going to break your hip, and they're going to say, you should go see primary care about this, and then it's the end.

Osteoporosis affects thousands and thousands of people, but the treatment for a hip fracture sometimes ends with at that three month fall, 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 getting the diagnosing 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 going to have to be a couple of people, right? So it's probably going to have to be more than just primary care and orthopedics and rheumatology and endocrinology where it's historically been.

5:34 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 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. Chronic disease is pulling from your bone to help keep things going and moving along so you can appreciate that.

Practitioners that allow things to affect the bone allow these patients fracture for a lot of different reasons. 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 8, 9, 10 fractures over a decade or more that's, you know, no one healthcare provider, family member, anyone kind of connected the dots with the disease. So we've got, you know, 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 know, that fracture fix 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 12 months before you can see that physician in some places as well. There's some delays in getting DEXA, which is the bone density test that you need as part of the diagnosis.

If you're walking around at high fracture risk and it's going to take you a year to even get a diagnosis, let alone maybe having to fight your insurance company to get on the therapy that your physician healthcare professional thinks that you should go on, you see why we have this gap. But even though, as you said, it's an orphan disease, it'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. And where do you think like, I think I heard a couple of things in that last comment where the caregiving escapes somewhere.

So, you know, 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 months sort of window of Thank you so much. Yeah, yeah. 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 do they actually know if they have a bone health problem or like what, but typically is the situation. I think there's a lot of pieces to that.

8:38 One, if you have a hip fracture, you have the diagnosis of osteoporosis period, and that's not always recognized. If you look at ICD-10 codes, you can code for a hip fracture. You can code for an osteoporotic 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's off of ICD-10 code. If it's never coded from the beginning, then it's tough finding these fractures.

If you have, I mean, we're in the time now of disjointed care, you know, if you have an orthopedic service that is maybe a private practice and you're 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 there's not really a plan of continuing that care, treating that patient from there. So in primary care is inundated with 50 things that they have to do. We can't make enough endocrinologists in order to have any.

I mean, to see an endocrinologist is six months. To see a rheumatologist is six plus months. So something's just forgotten about, right? And if that patient, that first six to 12 weeks, they're very focused on fracture prevention and not falling. And, you know, because 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 going to be like, I think I'm good now. You know, my hip's 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 the Osteoporosis. Either we get a DEXA scan or you break something. Outside of that, you can't see it or you can't feel your bones, right? It's not like if you were having hard or long issues, you start, you know, 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. Yeah. Yeah, and maybe I'll bring in a personal story about my mother.

She had two fractures. She broke both of her elbows, fall from Stanley height. She did see an endocrinologist, but because she had so the T score is what we use to kind of see based on that DEXA, where you are in terms of your bone health. A negative one to negative 2.49 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 the The oldest medication we have, not the right medication for her other risk factors in addition to the two fractures and being so close to the edge of osteoporotic bone.

11:09 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 her area in Charlotte, North Carolina that she got a diagnosis. She got put on one of the newer medications, she now four of her six. SICE has normal bone mass, so the lucky thing is, of course, you didn't have that hip fracture because the statistic is 20 to 25% of hip fracture patients within a year are dead. So great that 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 nursing home situation. So, you know, it really is a very challenging thing. And now, you know, for me, it's not just professional in 15 years in osteoporosis, 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 83. So thanks. Well, it's, you know, it's really interesting. And 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 renumeration. There's an incentive to treat fractures. But why does there seem to be a gap in preventing them and creating, 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 because they lose their balance, right? And that opens up and exposes them to, you know, falling and breaking and that type of thing. Yeah. I mean, I think with prevention, it's the same story, right? We're all invincible till we're not, you know? So if you don't, you have that in setting, incident re-trip and fall, and then things come happen. Yeah.

13:40 And like I said before, the only way that you know that you have poor bone quality, if you get a DEXA scanner, if you break something, right? And currently in the United States, we should be getting screened DEXA scans in women at 65 and then at 70. And those rates are bad. I mean, the DEXA scanning rates are less than 20% in CMS population. It's actually probably less than that. So most times they're not getting it. If they are getting it, a lot of providers, like imaging, and this is just my soapbox here being 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, oh, they see osteopenia. Oh, they're fine, but the osteopenia could be with David's situation at 2.49. If anything else that pushes him up a little bit or higher risk, they should be treated with something, but they read osteopenia on the little read out there for the DEXA scans, then nothing happens.

So that's kind of the biggest one up front for patients too. I think preventative medicine is a great thing, but again, you can't see or feel bone, right? We can understand bone mass. And I think preventative medicine is 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 your glute strength and your core strength prevents falls, which can prolong your life. We're understanding more about our sarcopenia. Dr. David Lee, I tell patients that are 85, 90 years old, you don't get to 85 or 90 years old not being a little stubborn.

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, 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'm hopeful being a better position, but we still need to talk about it prior to age 65. We probably need to talk about it in our 50s.

And I think we need to shift the paradigm of secondary fracture prevention to primary fracture prevention. Me being in orthopedics, 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 DEXA scanner, at least 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 when you start talking about those things at that time?

So it doesn't become a problem. 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 going to have an NPPARN is going to, you know, reach out to you and say, hey, I see that you came into the emergency department and we fixed your wrist last night. We now need to get you in for a DEXA to diagnose you to see if you might have osteoporosis. The challenge in the U.S.

16:35 Is that there aren't nearly enough of these programs. Like in other countries, I mean, in the U.K., it's probably 60, 70 percent 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. We're going to hire someone for $120,000 a year to be the coordinator and you're telling me there's going to be 30 less fractures coming through our system.

I don't want to harm patients, but that's a lot of lost revenue. How are we going to make up that revenue and 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 an orthopedic surgeon, you do that DEXA or get that bone density measurement pre-surgery. And of course, if it's something that can wait and you have the underlying disease, we get you 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, that 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 going to 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. Right. And I think you bring up a good point there too.

I think we've been so focused on like reducing 30% of the fractures that's less cases, right? And I think we need to look at the bigger picture, right? Yes, we're reducing 30 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 10 to $15,000 a day with resources and time and people. If you save those 30 fractures, that's 30 elective patients. Now you can put into those cases that generate way more revenue.

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 look at the bigger picture saying like, at the end of the day, that $120,000 you're paying that clinician, that's pretty darn cheap to be saving, you know, three, four hundred thousand dollars. Yeah. And just to add one mother's case, the math was not tracked. So she had two, I think, 20 to 30 day stays in rehab institution each time. So to think of how much money we put into her care, and a bisphosphonate that costs 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 30-day stay.

19:24 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 going to get COVID in the hospital because she had these two fractures was very high. Yeah, and you look at the system, too, right? Like, you got to think about you as a caregiver, right? So that if you got to take time off work, that's your employer now is affected by it, too. You're taking the time, that's energy on your family. Now do you have to move your mom or dad or grandma, grandpa into a different facility, into a longer facility, too?

It's just the burden on the health system is so large with these patients. And we focus it down to a duty-fixed-to- hip fracture, and then it's like, but then what? Well, it's not even a burden. 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. Hospitals are in the business of better care, not more revenue. Patient first activity, higher quality care, number one. Number two is, I think Jared was talking about this as well.

David, you both were there. Less expensive in the long run to the health care 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 costing the entire health care system. So we're not just talking about like, oh, 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, where, you know, like, spend your money up front 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, I want to pivot to a direction because you guys are in this Demographic where AI is everything around, and you know you both are highly involved in AI, and I'd like to get your perspective on AI and bone health and how you see AI changing the dynamic in the landscape of bone health today. Yeah, I think the first button that was hit when AI came in was detection.

And I think, and David, I'm sure you've spoken to a lot of these companies and I've been pitched up with 10 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, to get in to see me right now, you won't see me until end of November. Right? So we need AI to be leveraged 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.

22:10 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 provider. So 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 provider to find these patients to treat them? And that's where this needs to go. Yeah, I would definitely agree and then would also say that there are a lot of these AI companies that, as you said, are looking at, kind of look at a previous CT 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 might have to get a confirmatory DEXA I think it's important 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 DEXA bone density test. 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 occasion ago. Hey, I know you were in for an abdominal CT last year.

We now see that you have osteoporosis and the 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. 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 Thank you. What is Japan doing differently then?

Because they do have a longer lifespan, and obviously give us some background. Yeah, I mean, it was a lot of additional reimbursement support for both on the orthopedic side and the inpatient side, which we call ortho geriatric, as well as the outpatient, which this fracture liaison service model doesn't kick in until A patient's been discharged unless it's a hip fracture patient that's still hospitalized. So a lot of additional reimbursement for the care coordination, apps that were helping to track these patients, things like that, that the Ministry of Health and other federal funders put into the program.

25:02 Got it. Yeah, they've had a lot more support, I think, on the infrastructure side, which is where we needed to, 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 going to find, say, how can we utilize this? I think that's helpful. And that's part of the problem, too. But I think they've also leveraged technology in a way that they also say, hey, we have a certain amount of providers that 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. And do we all like line up that screening is the first pathway to all of this? So is that a limiting factor? Is that a friction point in bone health today? Is just the ability or inability to screen in mass? I think it's more, I would do more identification, right? Because you can make 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 the DEXA scan happen and that this patient's at high risk or osteoporosis is that next piece too. So screening, yeah, but identifying that patient that went, how are we going to do something with it? I think is probably where it needs to go. I think the challenge too is that I'm hearing, oh sorry, go ahead. I was just going to 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 preventive 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, those exist. The problem is it's not, you know, again, they see the list and they see that they have a T-score and the T-score is osteopenic. They say, well, they're not osteoporotic. Well, there's other diagnosis of osteoporosis.

Have they had a fracture or 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 and maybe you're really comfortable with oral dysphilis, which is great, but if it's a fracture patient, we know that those patients need to be on anabolic. Now we have to go, okay, now I've got to find them in a fusion center. And now I have to do the prior off and the prior gets denied.

27:42 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 going to try a londonate. And if it fails, then somebody also figured out, right? So the identifying piece is first, but the bottleneck here is clinicians that are comfortable treating these patients. And we do not have near as many as we need.

So it's an education opportunity then too, right? So 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. 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 60s. So I think one of the other challenges is literally getting the authorization to even have that DEXA if you're not 65 or women, 70 for men, even with risk factors.

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 in room, walk down the hall, get your DEXA, come back at your diagnosis. Now you might see your endo or room, which is going to take six to 12 months. As we said, and then you're going to have to go to the hospital to get a DEXA, you're going to 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 going to break another bone is high. Dr. Justin Marchegiani And I would say too, to your point, we've always talked about wanting to do primary prevention, having primary care, own this. But if you've got three chronic diseases and you've got a 20 minute visit with your PCP and the last you have a cast on your arm, osteoporosis is not going to be one of them. It's going to be my arthritis that affects me on the daily.

Obesity, diabetes, you know, these other things that really are, you know, going to affect you were the challenge in a way in osteoporosis 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 there, of course, thinking about their other chronic diseases and not osteoporosis. 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 a little bit of a mass osteoporosis over age 50.

30:36 Two to three million fractures a year caused by osteoporosis. So it is a huge problem that just is not getting the attention that it warrants. Although I would say 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 am hopeful that that will Continue, and as we connect around the menopause and osteoporosis piece, and given that it is mostly a female disease because you do lose up to 20% 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. And I don't think primary prevention needs to be primary care, right? That needs to be somebody that's meeting that there too.

So if I put my ASTOP hat on first, so the American Society of Osteoporosis Providers, we're trying to educate those clinicians that 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, they can be anywhere, and that's the beauty. And I think that's a good place too for advanced practice providers as well.

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 going to be doing this. But if you have two or three advanced practice providers that are doing this, helping you out to offload some of that, that's new consults for them to be seeing, and then you're capturing that population, they're getting the appropriate care that they need. So what's the answer with the capacity issue or the, I don't want to say it's a competency issue, but the specialty, like I understand this disease really well and I'm comfortable treating it problem, like is that No way in that we, you know, is this a mid-level, you know, can this be fixed with a PA or nurse practitioner, you know, sort of supporting the physician? Is it like, how do we build that infrastructure to handle this orphan disease that obviously needs more fingers and toes to help it out, right? Yeah, 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 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 somebody telling me about an oral bisphosphonate, and then 20 minutes tell me how they actually don't know how to read a DEXA 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 such a broad topic, and it's something that really could be its own disease state, right?

33:10 So 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. It's busy enough and probably generates enough patient volume that it could be its own practice. So, this bone just need to be something. Do we need to actually take it out of endocrinology, take it out of orthopedics and just make it its own thing?

It's identifying to uplift it in a certain way 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 might just need its own lane. 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. And it's different everywhere. It's just easier just to like, okay, we'll just let them fall back into the system again. There's no easy button for a referral.

There's no bone health specialist out there in their community that says, okay, for this situation, call me, call me, call me. That might be a really good opportunity when you think about it. And 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 larger center, tertiary center. And then it's six months again, 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 chart and your review and they start after your primary care and hope that they're going to follow it and then you can follow the problem. The 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. So it probably needs its own lane. Well, and just like anything else, it's And the unfortunate state of healthcare, there needs to be a carrot system, right? And you've got to follow money. And it's just, 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 yet, 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.

And 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 are 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 doing these things.

35:46 And David knows the story a lot. But if you go to a C-suite executive to tell him like, While I'm reducing my surgeries, this doesn't make sense in my 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 might be a better place right now for AI to do that, to tell that story. Well, it's good as any roll into value-based care systems, too.

We're all going that direction. So we're all going to be The system's going to need to operate from a profitability perspective where they're going to get X amount of dollars of every patient they're going to manage. And then 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, 500,000 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 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. That's the one thing that AI does really well is it can take a 360 degree view and make it very simple to understand too. 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 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 fracture 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 core 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 Not seeing enough revenue and just seeing an expense of, hey, we're going to have to hire this person, create this infrastructure, buy software tools, et cetera. They don't see the upside, but also it's hard to articulate the kind of truly what this is going to look like.

38:40 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. Typically these guys are fixing things and letting patients, you know, 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 And you practice a little bit and you're providing great health care, preventative proactive health care.

And then you're also setting yourself up if for anything does go wrong. With those patients, who are they going to go see? They're going to go see the doctor who's been taking care of them. It seems to me like there might be a solution here where it's an orthopedic solution that kind of ties into maybe they have a bone health practice that sort of lands next to one another where Frankly, that's probably a really interesting pathway for them to go, because I know a lot of orthopedic practices, they're all on heavy churn on surgery, surgery, surgery, because 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, 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 muscle mass and all these other things that help You know, make the proactive health of that patient better as well.

Yep. And I think the change in reimbursement too. So if you're in tune with orthopedics around the big talk, a CMS reduction in, you know, total knee next year of 20% is huge. So I think bone health, we've thought a lot about it for the health system standpoint and their 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 and 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 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-optimized 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.

41:26 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 think that's where a lot of that beat can be. And I think there's a fallacy built into the system. And I don't have data that published, which I would like to at some time. But my guess is that these patients, if you I just got a backup here, but a lot of concern from orthopedic surgeons is that if you see a patient, you say they have poor bone quality, 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 this treatment before, during, or after surgery? Where in that peri-surgical predatory treatment? 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 hiperony. 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. 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 that's where a lot of us can fit. And I don't know if that's realized yet within the private practice ASC community yet. Yeah, John. Okay. Yeah, there's this model called TEAM that I think like 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. You know, 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 Re-admission, you know, the stats show that there's about a 20 or 30% increased chance of a revision or a 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's going to take a while, but I think this is going to 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 any other countries, right? Well, good. Well, guys, I have one more question. Sure. And we'll kind of wrap it up. And I'll give you a choice.

43:57 You can answer either one of them. So one question would be if you could change one thing and how this disease is handled, what would that be? Number one. Or if a founder or clinician who's listening to this today, what is the one thing you want them to take from our conversation today?

So I talked to a lot of clinicians that are just starting out. I was able to give a lecture last week to Campbell Clinic who's starting a practice and I'm giving a talk in a few weeks at the Peanorthopedic Society meeting. The normal thing is to start. Just do it. Just start, get into it. It's really scary to look at and it feels like a big thing. And you, for successful programs that happen, you have to be a little bit of an entrepreneur. And to be a good entrepreneur, you just got to kind of go into the dark and see what happens.

So just if you wanted 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 benefits your bottom line. So just start. 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 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 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 their fracture risk is reduced, not that we can reduce it to zero, but essentially the drugs overall can reduce your future fracture risk by 50%.

Anabolic's are even much higher than that. So, you know, we think that's the other thing is the misnomer of this, oh, I'm going to get this rare event that's 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.

Now, I'll follow in the entrepreneurial side and the business side. So I think that just like anything else in life, you just got to make a first move and take your first step, right? And Use your patient databases and figure out who's in your practice who can benefit from these conversations and these pathways. They're right in front of them and if they do need help, there's all sorts of people that have programs and platforms that can help you do that extraction for patient activation campaigns, education.

46:54 There's Probably all sorts of educational components out there that they just need to use as a resource, 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 all part of that whole program is education, competence, and getting the movement started. 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.

Thank you. Absolutely. Thanks, Terry. Thank you. Continue success to both of you. Appreciate it. Thanks. Have a good day. So let's connect. Let's find where your revenue is getting stuck, book a call at RevRx AI and build your revenue engine.