Five ways to reduce back surgery overuse

By Noelle Serino | November 19, 2024

The Lown Institute released new data on unnecessary back surgeries in Medicare, identifying 200,000 low-value procedures and $2 billion in Medicare dollars wasted over three years. Back surgery overuse varies widely among states, hospitals, and even doctors in the same hospital.

We brought together Dr. Sohail Mirza, orthopedic surgeon and professor at Dartmouth College, and Claire Brockbank, Director of Policy and Strategy for the 32BJ Health Fund, along with Lown President Dr. Vikas Saini to discuss the results, what’s causing back surgery overuse, and how we can stop it. Watch the video recording below for the full conversation!

How to reduce back surgery overuse

From our “more is better” medical culture, to fee-for-service payments, to patient expectations, there are many reasons why physicians continue to perform procedures not backed by evidence. How do we tackle such a complex problem?

Here are some potential solutions the panelists discussed for reducing low-value spine surgeries:

1. Get a second opinion

The 32BJ Health Fund is launching a new “Centers of Excellence” program for spine surgeries, which designates certain covered providers for procedures based on quality metrics. However, there could be a benefit to reducing overuse as well. Ms. Brockbank explained that a key aspect to the program is having a second opinion before undergoing surgery. They have found that in 30% of cases, a second opinion found that spinal surgery was not necessary or was unlikely to benefit the patient.

When asked about one piece of advice for patients with back pain, Dr. Mirza said, “The first thing is that you need more opinions. I see so many patients who wish they had sought additional opinions before signing up for an invasive treatment.”

2. Improve oversight within the specialty

Dr. Mirza suggested that boards (such as the American Board of Orthopedic Surgery) could be helpful in identifying overuse during case reviews. “If there was better scrutiny of what kinds of cases a surgeon is doing, that should be the first kind of quality metric,” he said.

3. Reward physicians for the right things

The panelists pointed out that the way we pay physicians incentivizes doing more procedures, rather than spending more time talking with patients about the best path forward. Dr. Mirza estimated that the average amount of time an orthopedic surgeon spends with a patient before assigning them for their surgery is just 16 minutes.

“I think you need a lot more surgeons and have them do a lot less in terms of clinic volumes and spend more time with each patient,” he said.

4. Get payers on board

It would make sense that Medicare and other insurers would want to reduce the billions in wasted money from unnecessary back surgeries. But the panelists pointed out that Medicare still covers vertebroplasty for osteoporotic fracture despite lack of evidence that it benefits patients. And while private insurance companies require pre-authorization for these kinds of procedures, this process doesn’t always prevent overuse.

“If you’re committed to getting something authorized, you can find the language to get it approved,” said Dr. Mirza. “If you pick healthy patients who are not going to have complications, you can kind of go under the radar for any scrutiny, for something that may not be supported by the literature at all.”

Even payers that assess quality of care may not have the data they need to be able to find overuse. “We get more data than most payers out there but it doesn’t tend to have this diagnosis information that would allow you to identify overuse,” said Ms. Brockbank. When assessing quality, the 32BJ Health Fund looked mostly at what doctors were doing well. “Maybe we should be looking at the negative quality measures, both the A and B side,” she said.

5. Disrupt the norm of conflicts of interest

The Lown Institute worked with Conflixis, a data startup, to analyze Open Payments data for physicians with back surgery overuse, and found that doctors were paid $64 million over three years by industry.

This was not surprising to Dr. Mirza, who said that in orthopedics the relationship between doctors and industry goes both ways. “Certainly sales people and industry representatives are looking to recruit surgeons into their product line,” but also “physicians and residents will ask [industry] for consulting payments for using their product,” he said.

Clearly, receiving payments from industry is not only accepted in orthopedics; to a certain extent, it’s expected.

For more on our back surgery overuse findings, check out our latest report on the Lown Hospitals Index!

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