“We are up against an enormous financial juggernaut”:  Experts discuss back surgery overuse at Lown event

The Lown Institute hosted a webinar on October 7 to discuss their latest report on back surgery overuse. The event featured Vikas Saini, M.D., President of the Lown Institute, David Auerbach, Ph.D., Senior Director for Research and Cost Trends at the Massachusetts Health Policy Commission, and Eugene Carragee, M.D., Professor Emeritus of Orthopaedic Surgery at Stanford University. 

Watch the video recording and see our key takeaways below to learn more about the prevalence of back surgery overuse, drivers, and potential solutions.

Consequences of back surgery overuse

A new Lown Institute report found that U.S. hospitals performed more than 200,000 unnecessary back surgeries on Medicare beneficiaries over three years, including low-value spinal fusions, laminectomies, and vertebroplasties. Spinal fusions and laminectomies are performed to treat back pain, either by fusing vertebrae together (spinal fusion) or removing part of a vertebra (laminectomy). Vertebroplasty is a procedure to treat compression spinal fractures in which medical-grade cement is injected into the fractured vertebra.

The estimated cost to Medicare was more than $1.9 billion. Although the price tag for taxpayers is significant, even more concerning is the risk of harm that patients face from these unnecessary and potentially dangerous surgeries. 

Complications of spinal fusion can include infections, blood clot, patient safety incidents, cardiac events, and even occasionally, death. With an estimated complication rate of 18%, that adds up to thousands of complications each year.

Vertebroplasties are less invasive, but still carry some risk. Between 5 and 10% of patients experience complications, which can include infection, hospitalization, pulmonary embolism, cardiovascular event, and bone cement leaking into the spinal canal.

Culture and money drive overuse

The Lown report shows that while some hospitals have done a fantastic job avoiding unnecessary back surgeries, others perform them at alarming rates. On average, 13% of spinal fusions at hospitals met criteria for overuse, but there were over a dozen hospitals with rates above 33%.

Some hospitals also had incredibly high overuse rates for vertebroplasty. “For the three hospitals with the highest rates of overuse, every other patient visit for spinal fracture resulted in an unnecessary vertebroplasty,” said Dr. Saini.

“For the hospitals with the highest rates of overuse, every other patient visit for spinal fracture resulted in an unnecessary vertebroplasty.”

Dr. Vikas Saini

Even within hospitals, physician overuse rates varied at times, and outliers were a big issue. The top 10% of physicians by spinal fusion overuse volume accounted for 60% of the total overuse.

The factors driving higher rates of overuse are linked to financial incentives and a fractured professional culture.

“I’ve been a visiting professor at dozens of places and the cultures can simply be different,” said Dr. Carragee. “It is very difficult to be in a place and do tons of very marginal surgery if the rest of the spine division is like, ‘What the hell’s going on?’ On the other hand, it’s pretty difficult to be the guy at the preop case conference saying, ‘What the hell’s going on?’ when everybody else says they need a fusion.”

“Financial interests bend true belief into opportunistic belief.”

Dr. Eugene Carragee

Dr. Auerbach agreed that practice patterns can be entrenched, especially in large institutions. “The inertia of processes in large health systems is very hard to work against. Even if a doctor might feel that this isn’t needed, it’s hard to get all of the different interests within a system… to do something for which there might not be an immediate payoff,” he said. 

Financial incentives, for both individual doctors and larger institutions, make it difficult to cull overuse as well. Dr. Carragee pointed out the ubiquity of medical device industry payments and other relationships with spine surgeons, including speakerships and consulting jobs. “There are millions, sometimes tens of millions that are funneled into certain groups,” he said. In this way,  “financial interests bend true belief into opportunistic belief.”

“When some services are more profitable than others, it’s hard to to fight against that when your organization is struggling.”

Dr. David Auerbach

Dr. Auerbach pointed out that the profitability of spinal surgeries for a hospital can make it harder for institutions to cut these services. “A lot of this problem is driven by financial incentives or at least the lack of a countervailing financial incentive,” he said. “And when some services are more profitable than others, it’s hard to to fight against that when your organization is struggling.”

For those working to reduce back surgery overuse, “we are up against an enormous financial juggernaut in the exact opposite direction,” said Carragee.

How to reduce unnecessary back surgeries

How do we fight against such an entrenched problem? Panelists explored the idea of value-based programs and other regulations, including prior authorizations, global budgets, and clinician conversations.  

“If we can reduce services that provide little or no clinical benefit without cutting coverage for people who really need it, for stuff they really need, that’s a win both for patients and for taxpayers,” said Dr. Saini.

Obstacles to WISeR

However, CMS’ latest effort to tackle waste through prior authorization through the Wasteful and Inappropriate Service Reduction model (WISeR) has received a lot of pushback from clinicians and advocates wary of excessive denials and administrative burden.

Dr. Carragee echoed concerns about profit-based incentives in the model. “We have very well-publicized prior authorization boondoggles by some insurance companies where it is simply deny, delay, defer,” he said. “If the authority to do the pre-authorization has an enormous financial incentive to make sure this is not done, there will be case after case emerging of someone who needed something that was obviously true.” 

Choosing services to target and how to define overuse is another key obstacle. “From CMS’s point of view, it’s difficult to figure out what I’m going to cover or not cover. It’s hard to draw those bright lines,” said Dr. Auerbach.

Ideally, policymakers would not have to get involved in regulating clinical care, said Dr. Saini. Unfortunately, doctors are unable to solve the problem of overuse on their own. “We have this problem of widespread variation in practice and real lack of understanding of the evidence,” he said.

Global budgets and physician conversations

Global budgets are one way to align the incentives of providers toward high-value care. Rather than paying doctors for each service they do, they are paid a set amount based on their patient population. Theoretically, this rewards doctors for keeping their patients healthy and out of the hospital, and for avoiding unnecessary procedures. However, Dr. Auerbach pointed out that the need to adjust budgets based on patient risks can lead to gaming. 

“Risk adjustment is kind of the Achilles heel for global budgets.”

Dr. David Auerbach

“[Risk adjustment is] kind of the Achilles heel,” said Dr. Auerbach. “There is no ironclad way to decide how sick a patient is; it just relies on the coding that providers put in, and that coding can be manipulated.”

For the Massachusetts Health Policy Commission, their annual reports on overuse provide data to start a conversation. Dr. Auerbach shared the story of one provider group that was standing out for high rates of spinal injection for lower back pain. “Because of our data, they looked into their rates. They found that there was one physician who was doing this procedure at a higher rate and they had a conversation and their numbers did come down,” he said. “So there can be these successes.”