When Back Surgeons Are Like Bad ContractorsApril 6, 2010 - 5:27 pmShare
Robert LangrethBio | Email
Robert Langreth is a senior editor at Forbes, in charge of health care coverage
If you wonder why medical costs are surging out of control, there are few better places to look than treatment for back pain. Costs have surged as doctors resort to ever more complex devices and operations despite little evidence that patients are feeling better.
The latest piece of evidence: A new study in the Journal of the American Medical Association finds that rates of complex back surgery surged 15-fold among elderly Medicare patients with pain from narrowed spinal canals between 2002 and 2007. The more complex operation cost three times as much as a simpler operation that could have produced just as good results in many patients. It had also had a far higher rate of life-threatening complications.
“This may be a good example of why health care costs are going up without much discernable improvement in overall patient health,” says lead author Richard Deyo, a back pain researcher at Oregon Health and Science University “The more complex and more expensive operations really took off with little evidence that they actually improved the results.”
Deyo in his colleagues looked at elderly Medicare patients who had pain due to a narrowing of the spinal canal, a condition called spinal stenosis. An old operation to called a laminectomy to widen the narrowed canal works well for this condition. But surgeons in recent years have increasingly turned to far more complex procedures that fuse together spinal vertebrae using cages, screws and other expensive gear. There is little proof that these “instrumented fusion” operations produce more pain relief for the typical patient, Deyo says. But they do cost a lot more.
In 2002, less than 1% of elderly spinal stenosis patients were getting the instrumented fusion operations. By 2007, 14.6% of patients were getting the operations. The complex fusion operation makes sense for spinal stenosis patients who also have deformities such as scoliosis, says Deyo. But he found that in 2007 over half the patients getting the complex fusion operation had no deformities that would justify the more expensive operation, according to Medicare claims data he analyzed.
Among patients who got the instrumented fusion, the rate of life threatening complication was a full 5.6%, versus just a 2.3% rate of life-threatening complications among those who got the simpler operation.
It all makes little sense until you look at the economics. Doctors, hospitals, and medical device makers reap far more revenue make from the fusion operations. Overall hospital charges were $81,000 for instrumented fusion, versus $24,000 for the simple operation, Deyo’s team found. Doctors may like to do the new operation because it makes them feel like they are on the cutting edge.
Another big beneficiary to the trend towards more complex back operations are device makers such as Medtronic and Johnson & Johnson who make gear that can be used during fusion operations. Gear implanted during a fusion surgery alone can be $50,000 or more, an editorial accompanying the study notes. Medical device companies have big incentives to convince doctors to do more of the fusion operations instead of the laminectomy operations, which do not involve implanting medical devices.
“The proliferation of risky and expensive practice beyond reasonable supporting evidence is…a fundamental failing of medical practice in the United States,” writes Stanford University surgeon Eugene Carragee in an editorial accompanying the study.
The Deyo study “demonstrates a definite human cost to this practice in terms of increased risk of surgical mortality, major complications, and prolonged morbidity associated with these more complex approaches,” Carragee writes. He adds: "These devices are aggressively marketed, so much so that their promotion may sometimes cross the line of professional conflict of interest among profession leaders and institutions."
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