Where There’s Back Pain There’s Sure to be Profit

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Back pain is endemic: It affects 8 out of every 10 people at one point in their lives. Americans spent some $86 billion in 2005 on doctor’s visits, surgery, imaging, and drugs to treat back and neck pain—and costs continue to rise each year. Despite being ubiquitous—and an enormous drain on medical resources—back pain continues to be poorly treated as well as over-treated. Recent research has shown that doctors consistently fail to follow accepted guidelines in treating their patients; ordering X-rays and MRIs when they aren’t useful, prescribing expensive prescription drugs when over-the-counter pain relievers would work just as well and resorting to surgery without evidence that it will actually relieve pain and disability.

The trend, unfortunately, is continuing. A new study published in this week’s issue of the Journal of the American Medical Association found that although the rate of lower-back surgery among older Americans had declined slightly between 2002 and 2007, the rate of the most complex, medically risky and most expensive type of lower back surgery increased 15-fold (from under 1% of operations to 14.6%) during this same time period. There is little upside to this increase in intervention: Besides driving up health care costs, the authors found that overuse of the expensive, risky technologies put patients at increased risk of death and life-threatening complications without providing a corresponding increase in pain relief or mobility.



First some background: The growth in spine surgery has been fueled in large part by its increased use to treat Medicare patients for a condition called spinal stenosis—a leading cause of pain and disability in this group. What happens is that as we age, degeneration of the vertebrae and associated ligaments can causes the spinal canal to narrow, putting pressure on nerves that then leads to serious back and leg pain and numbness. Over the last two decades, a surgical technique that alleviates this pressure on the nerves—called lumbar decompression—has improved so much that many older adults who undergo it have relatively good outcomes. The average hospital costs for simple decompression surgery is $23,724.

But the JAMA study found that increasingly, doctors are using far more complex procedures that involve spinal fusion and the use of expensive—and still experimental—bone grafts and implants to treat stenosis in their older patients. In a small minority of cases the severity of spinal degeneration and other anatomical problems makes it necessary to use such invasive procedures. But the researchers in the JAMA paper found that 50% of the new complex fusion operations were performed on people who did not have these problems. They would have had good outcomes from the simple decompression procedure. A companion editorial written by Eugene Carragee, director of the Orthopaedic Spine Center at Stanford University School of Medicine finds :

“Newer and more complex technologies are being used for patients with little specific indication for the approaches and for whom there is good evidence that simpler methods are highly effective.”

Why are doctors choosing to perform complex surgeries for patients who would likely fare better with simple decompression procedures? Carragee chalks it up to “conflicting economic incentives:”

“[S]imple decompression operations rarely have well-funded advertising campaigns or well orchestrated promotions at professional meetings.

“The fact that lumbar decompression is well studied and highly effective in spinal stenosis does not mean that it is well-compensated. In the Medicare population studied by Deyo et al, surgeon reimbursement for a simple decompression for spinal stenosis is approximately US $600 to $800, whereas the reimbursement for a complex fusion may be 10-fold greater.”

Carragee also points out that in the simple decompression surgery there are no profits to be made from implants, devices or proprietary biological materials. In the complex surgeries, charges for implants alone can exceed $50,000. With Medicare footing the bill, doctors get paid more for the complex procedure, hospitals get paid more and medical device companies eagerly watch their profits grow. But there is another, more serious downside from the patient’s point of view:  According to the JAMA paper, the complex spinal surgeries carry greater risk of death, serious complications and long-term problems and so far have not proven to be more beneficial than simple decompression.

An article last year in the Journal of the American Board of Family Medicine documented enormous growth in tests and treatments targeting back pain including “a 629% increase in Medicare expenditures for epidural steroid injections; a 423% increase in expenditures for opioids for back pain; a 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries; and a 220% increase in spinal fusion surgery rates.” Despite the dramatic increase in interventions, there is little evidence that patients are reaping the benefits: the rate of disability from back pain was even higher in 2005 than in 1997.

In 2007, spinal surgery was number one on Consumer Reports’ list of the top 10 overused medical tests and treatments. “In 90 percent of cases, the pain goes away on its own within six weeks,” wrote the authors of the report.

Richard Deyo,  Kaiser Permanente professor of evidence-based family medicine at Oregon Health & Science University and lead author of both the new JAMA paper and the Family Medicine article told Newsweek last year:

"We seem to be doing more and more"… “[But] there's no evidence that people are getting more pain relief." He continues, "This suggests to me that we're overtreating a lot of people, and we're providing a lot of services that may not be very beneficial."

As the nation begins to implement health care reform it is imperative that we focus early on eliminating treatments and procedures that are not only costly but also ineffective and potentially dangerous. Action is clearly pending on the overuse of MRI for lower back pain—especially in the context of Medicare reform. This latest JAMA report raises important issues about spinal surgery and ultimately, money-driven medicine in general. It also highlights the unhealthy relationship that has developed between the medical device industry, doctors, and hospitals that ultimately drives over-treatment. It’s time to remove the financial incentives and market forces that favor more surgeries and more interventions at the expense of good patient care.

15 thoughts on “Where There’s Back Pain There’s Sure to be Profit”

  1. Surely this isn’t news – what would be is finding centers where decisions are based on a combination of effectiveness and cost-effectiveness.

  2. I’d love to see data comparing salaried surgeons with fee-for-service ones. For example, does anybody know of any data from the VA system about this issue?

  3. Shouldn’t there be a law against this sort of over treatment that is endangering patients?

  4. Excellent article Maggie. While this may not be for everyone, I would like to mention that often chiropractic care is even better. Often it’s more effective, plus it’s not invasive and it’s less costly. I would like to see some standards set where as much as possible patients would be referred to alternative medical providers such as chiropractors, acupuncturists, and naturopaths. A lot of people get lousy care from their doctors. I heard of cases of people who go to their doctors and say that they have pain or they’re upset about something and their doctors load them up with all kinds of meds, like Norcos, Somas, Larazapam etc. Often we hear on the news about terrible automobile accidents caused by medicated drivers. At best this is not making people well and at worst, we’re making people sicker. I don’t want a universal health plan to pay for this. Our purpose must be to help people be well. Under a universal health plan a panel consisting of the regular traditional doctors and the alternative providers could be set up to write standards on the medical care that people get. One thing that I would really like to see would be for the government to encourage the growth of medical facilities like Kaiser, except that we would have traditional doctors, and the alternative providers like chiropractors, acupuncturists, and naturopaths working together under one roof. When a patient would visit their primary doctor at such a facility, often he or she would be referred to one of those alternative providers. Of course if treatment by any of those alternative providers would not be beneficial to the patient, the patient’s care would be provided by the traditional doctors. I am very pleased that health insurance reform was finally signed into law, although what I really favor is extending Medicare to everyone that includes the alternative treatments that I mentioned plus dental and vision care. However whether we’re talking about this new law or extending Medicare to everyone, what we’re really talking about here is just HEALTH INSURANCE reform. Encouraging the alternative treatments and encouraging health living, would be true health care reform.

  5. Walter–
    Thank you — but this piece was written by Naomi Freundlich who is HealthBea’s associate ediotr. .
    I agee that this is an excellent post. Thank you from both of us
    But I’ll leave it to Naomi to respond to your comment

  7. Walter,
    Thanks for the response to my piece. I agree that we need to explore other promising options for treating back pain—including some alternative or complementary techniques. In the UK, the National Health Service recently adopted a new policy for patients who have suffered from back pain for more than 6 weeks. They will be offered a course of either acupuncture, exercise sessions or manual manipulation (chiropractic, massage, etc.) as well as painkillers and more traditional advice. If one approach doesn’t work, patients can try another or choose an intensive treatment program combining exercise and psychological therapy. This approach, which is based on evidence from clinical studies and is ultimately geared toward saving money, recognizes that back pain is a multi-cause problem that is often resistant to traditional therapies, including high-intervention ones like spine surgery. We would do well to take a look at what is happening in the UK when drafting treatment recommendations in this country.
    Naomi

  8. Ed,
    I don’t think the law will be effective in preventing over-treatment but financial incentives—and disincentives—will surely do the trick. Step one would be to have Medicare set clear treatment parameters for coverage that follow recommendations from comparative-effectiveness studies. Another step in reducing over-treatment would be to crack down on financial incentives paid to doctors by medical device manufacturers who encourage use of expensive—but still experimental—devices in these complex surgeries. The sad fact is that some 1200 studies have been published on back treatments and clinical guidelines are readily available—for a variety of reasons, many doctors still do not follow them.
    Naomi

  9. Naomi, When I commented on your piece I accidentally addressed my comments to Maggie, not noticing your name at the bottom. 11 years ago when I was on workers comp, I had arthroscopic surgery on my shoulder which was supposed to relieve pressure in my upper back. It hardly did me any good. Unfortunately the workers comp insurance would have given me a very difficult time, had I gone to a chiropractor then. Periodically during the year, I see a chiropractor and it serves much better plus the exercises I do. However in talking about the alternative treatments that I mentioned in my comments, I’m not only talking about those treatments for back problems but other ailments also.

  11. Excellent topics, I really like this topics. After long searching I found this online that the best chiropractic clinic helps people in Buford GA with back pain, neck pain, headaches. Call their office and speak to any one of their friendly staff to make an appointment for a FREE consultation.

  14. A recent report by the Agency For Healthcare Research followed a group of1,450 patients either had back surgery or not for similar types of herniated discs. only 26 percent of those that had surgery were able to return to work while 67 percent of those with no surgery were able to be productive again.
    At least I was able to heal myself of back pain, all with natural methods.

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