mead cohen berger shevtsova garfinkle michta grygiel blankenhorn
Spinal Fusion Surgery a Microcosm of Wider Crisis


What’s making US health care so expensive? Consider spinal fusion surgery. This expensive procedure, as the Washington Post reports, is now more common than hip replacement. Over the past 20 years the rate has increased sixfold, and not due to medical necessity, as new research suggests:

More than 465,000 spinal fusions were performed in the United States in 2011, according to government data, and some experts say that a portion of them — perhaps as many as half — were performed without good reason….

The Medicare agency every year audits a sample of the claims it has paid and determines how many of those have “medical necessity” errors. The agency estimated the amount of money spent improperly on spinal fusions was more than $200 million in 2011, for example, and most of that was because the treatment was deemed unnecessary, often because a more conservative course hadn’t been tried, officials said.

In Florida alone, according to the Post‘s own analysis, about half of the treatments were done “on patients with diagnoses that experts and professional societies say should not routinely be treated with spinal fusion.” This is just one example of the over-treatment that plagues US health care more generally.

Fortunately, over-treatment can be reversed, or at least restricted. Medical authorities can make definitions of disease more precise, and improve best practice guidelines for care providers. American cancer treatment has already taken steps in that direction. Aggregating data on how doctors and practices perform can improve treatment standards still further. As long as it’s conducted in conjunction with consumer-oriented reforms, big data could be a big help.

But health care reformers give far more attention to insurance policies, even though though reducing over-treatment hugely important. It doesn’t get wonks excited in the same way, as more abstruse issues like, say, the tax-exempt status of employer-based health care. But since it’s relatively less complex, there are plenty of “low hanging fruit” solutions that could significantly reduce health care costs—not to mention the suffering and stress Americans experience because of unnecessary treatments.

[Photo of stethoscope and money courtesy of Shutterstock.]

Features Icon
show comments
  • Jacksonian_Libertarian

    This type of medical abuse wouldn’t be possible if there wasn’t an insurance company paying for everything between the consumer and the medical provider. Consumers which have to pay for all or most of these procedures, are going to get 2nd and 3rd opinions and shop for the best value.

  • wigwag

    Wow; who would have thunk it? Professor Mead supports “medical authorities” making reference to “big data” to articulate “best practice guidelines” to eliminate “over treatment.”

    Does the Professor even realize that this is the very definition of the so-called “death panels” that caused so much consternation amongst opponents of Obama/Romney care?

    • Andrew Allison

      Stuff-and-nonsense. There’s an enormous difference between denying necessary and limiting unnecessary care. Both result in hardship for the patient, but the latter involves profit for the provider.

  • BS

    Wouldn’t the problem be that doctors have all the incentive to prescribe overtreatment and virtually no incentive to limit it? First, under the current malpractice liability regime, they will always err on the side of overtreatment, lest they incur even a small risk of colossal damages. Second, the media will immediately publicize all instances of undertreatment leading to any kind of tragedy (even if the medical decision was actually quite reasonable), leading to calls for overbroad reforms to prevent such accidents in the future.

    To give an example from my native Poland: until 1999, people could call an emergency ambulance even for trivial reasons (like common cold) with total impunity (thereby not only generating costs, but delaying response in true emergencies). In 1999, the government introduced a scheme under which people who unnecessarily called an ambulance could be charged with (rather small) fee to deter this kind of abuse. And for the following few years, national media publicized every actual or supposed instance of someone dying because the family was reluctant to call ambulance for the fear of paying the fee. The result? After a three years, a new government rolled back the reform, and the abuse of emergency medical services returned.

    • NCMountainGirl

      Doctors and hospitals don’t get sued for running too many tests or for recommending the most expensive high tech treatment. I had two noted orthopedist as clients. The malpractice insurance companies pretty much dictated a preference for overtesting and over treatment. The result is to make the most expensive procedures the only ones being offered.

  • jeburke

    I think VM ought to be a lot more skeptical of such findings by the agency which passes out the Medicare dough and, thus, has something of a conflict of interest, especially since the agency is on a search for justifications to cut Medicare spending.

    Whether and when to have a spinal fusion or a knee, hip or shoulder replacement is a very subjective business both for patients and for docs. (It’s not a binary choice in diagnosis, like whether you do or don’t have a melanoma). Sure, conservative therapies like drugs and physical therapy, as well as appropriate exercise, sleep and overall good health can help many patients manage chronic orthopedic pain. But VM should tread carefully in cheering on a government agency as it tells a patient to suck it up and spend the last 20 years of your life in daily pain because CMS decrees that you don’t pass their test.

    • Andrew Allison

      Perhaps you should be more skeptical of the medical “profession”:

      • jeburke

        Perhaps so, but I see no reason to endow some guys at CMS with the ability to decide that my surgery is not “deemed medical necessary.” Will some docs suggest surgery to patients to fill out their operating schedules. Maybe, but I don’t go to docs who might; mine are all filled up because they are good — and I know that because I take the trouble to find out.

        In any case, it is I, not the docs, who will decide what surgery I need, want and will undergo. There you have the difference between a system with patient choices and one run by bureaucrats.

        • Andrew Allison

          I fear that you miss the point. What “some guy at CMS” is deciding is not whether you should have surgery, but whether the taxpayers should pay for it.

          • jeburke

            I’m sorry but that is not so. The issue discussed here by VM and in the Post story linked is not about spinal fusion surgeries for patients under government plans but spinal fusion and other aggressive surgeries generally and the impact of supposedly “unnecessary” surgeries on total health care spending in the US, private and public.

            If should be abundantly clear,as the news of the day is about Obamacare obliging every private insurer to offer only policies that include X, Y and Z, that it’s a short step to the feds forbidding private insurers to cover A, B or C — on the grounds that they are “medically unnecessary.”

          • Andrew Allison

            You brought CMS, which deals only with government approved insurance, into the discussion.
            I beg to differ with your assertion that it’s a short step to the feds forbidding private insurers to do anything. The feds have no power to dictate to private insurers who don’t participate in government programs, and I suspect that you and I would be in a race to the barricades if they tried.

      • jeburke

        As for the USA piece, what I see there is more loose thinking. It throws together in the same category of “unnecessary surgeries” (1) a horror story about one Dr. Patel deliberately committing fraud, (2) allegations of malpractise by trial lawyers who know they can make a payday with sloppy charges because insurance companies will settle, and (3) the CMS-driven complaints about spinal fusions and whatnot which is the subject of VM’s post and my comment.

        Of course, there is the occasional crook like Dr. Patel, but I the rest of this is baloney.

        Anyway, I’d far prefer that some spinal fusions or knee replacements take place without the patients exhausting all the supposed benefits of physical therapy, steroid shots and pain medications (which are all very subjective, remember) than to have to beg Kathleen Sebelius for permission to have surgery.

        I personally know six people who have surgeries of this kind and none is a whiner. All spent years working at managing increasing pain and immobility.

  • charlesrwilliams

    Medicare is loaded with perverse incentives. It is a single-payer system with low administrative costs, poor cost management, rampant fraud and an irrational reimbursement structure that distorts the practice of medicine. This is the problem with Medicare. Medicare distorts all fee-for-service medicine because reimbursements for insurance are patterned after Medicare.

    All I can say about spinal fusion surgery is that it has been a blessing for my wife. We went through all of the conservative alternatives and they didn’t work. The surgery has kept my wife off of disability for the last ten years and spared her a painful and limited daily life.

    Kaiser-Permanente manages our health care. They have fewer incentives to overtreat. I am fine with this as long as we ultimately call the shots and can pull the plug on our HMO if necessary.

    What I don’t want is some bureaucrat calling the shots or long waiting lists for this kind of surgery.

  • Fat_Man

    “Stopping Overtreatment Sounds Easy, Until It’s Your Heart Attack”
    By Megan McArdle – Oct 25, 2013

    “Everyone agrees that we treat people too much. Unnecessary back surgery is almost always Exhibit A: Most studies show that you’re better off with physical therapy. I was very fond of castigating back surgeons about this (though not to their faces). And then one day, after a panel where I mentioned the epidemic of unnecessary back surgery, a nice middle-age fellow came up to me. Awkwardly, he turned out to be a back

    “Do you think we don’t read the studies?” he said. “We know physical therapy is better for you than most back surgery. What we don’t know is how to make sure that the patients go through with physical therapy.”


© The American Interest LLC 2005-2016 About Us Masthead Submissions Advertise Customer Service