One of the putative factors in the growth in health spending is excessive physician use of certain procedures, possibly to enhance their incomes. There are a number of medical areas where solid clinical evidence on specific treatment paths does not exist, giving doctors room to use discretion and to, consciously or unconsciously, guide patients to accept the physician’s recommendation for treatment. Back problems is such an area of medical care and concerns have been raised for a number of years about whether surgery was being used excessively. Research published in the Journal of the American Medical Association fortifies this concern by examining use of one form of back surgery for Medicare patients. (JAMA Article).
The article examined treatment of spinal stenosis in Medicare patients in 2007. There are three principal treatments–decompression, simple fusion and complex fusion. Overall from 2002 to 2007, the rate of surgical procedures stayed steady, but the number of decompression and simple fusions declined while complex fusions increased by 15 times, which is simply astounding in the absence of some clear medical finding which made its use almost mandatory for good care. On the contrary, however, studies suggest that complex fusion has no better outcomes and has much higher rates of complication, over twice that of decompression, and twice the risk of dying following the procedure.
In addition, the costs for the complex fusion are much higher, so that even though rates of surgery overall were steady, the spending on back surgeries by Medicare increased sharply. Patients spend almost two days longer in the hospital and were more likely to spend time in a skilled nursing facility following discharge. While the authors half-heartedly posit some other causes, it is apparent that this increase is likely driven by economics. Surgeons and hospitals make more on complex fusions. A good job has been done identifying certain areas of health cost where there are high rates of inappropriate utilization and then controlling those areas, such as prescription drugs and imaging. Back surgery is an area that apparently sorely needs some attention to end the abuses that are contributing to excessive spending.