14 August 2010
Pushing back on back surgery: Insurers, and some physicians, are questioning the need for aggressive spinal surgery
August 9th, 10 - Star Tribune
Three years ago, Amy Leyden took her 10-year-old son, Luke, on a vacation to Oregon. Her back hasn't been the same since.
In a furious game of touch football, Leyden made a spectacular catch but landed flat on her back. That night, she slept on a friend's couch, and the next day, the fearless duo went on an ill-advised dune buggy ride on the Oregon coast.
Within a month, the "40-something" marketing manager at the University of Minnesota was diagnosed with a herniated disk, a condition so painful she had to conduct meetings lying flat on her belly in her office. "It was excruciating," she said.
Leyden's story is an increasingly familiar one in American medicine. Four out of five Americans will suffer from disabling back pain during their lifetimes, according to the National Institutes of Health. Spending on back care soared between 1997 and 2005, reaching $86 billion -- just shy of what Americans spent battling cancer.
As those numbers have multiplied, so have questions about the more aggressive forms of back treatment. A 2008 study in the Journal of the American Medical Association, for example, noted that the increase in back-care spending occurred "without evidence of corresponding improvement" in patients' health. "Intense pain is not necessarily an indication for surgery," said Dr. Richard Deyo, a professor of family medicine at Oregon Health and Science University and one author of the study. "You can't fix everything with a knife."
Perhaps the biggest controversy involves an invasive surgery called spine fusion, which attempts to relieve back pain by permanently connecting (or fusing) several levels of bone in the spine. While the overall number of back operations has flattened out in recent years, complex fusion surgeries, which can cost upward of $80,000, continue to proliferate. American surgeons now perform twice as many of these operations as their counterparts in most European countries, Australia and New Zealand, and five times more than the United Kingdom, despite similar patient populations.
This debate is likely to intensify under the sweeping new federal health legislation that President Obama signed in March, which will gradually require doctors and hospitals to demonstrate that their services are cost-effective. In that vein, the New England HealthCare Institute estimates the United States could save roughly $1 billion a year by eliminating unnecessary back surgeries.
Minnesota is likely to be a crucible in this debate. The state is home to Medtronic Inc., the world's largest maker of devices used in spine surgery, as well as Abbott Northwestern Hospital, which performs more spine fusion surgeries on Medicare patients than any other hospital in the country, according to the industry publication Orthopedic Network News.
Fusion surgery has historically been used to correct deformities, fractures, complications related to tumors and other rare conditions. The surgical results have been good, and largely noncontroversial.
But in recent years, more and more of these procedures have been used to treat back pain related to aging, prompting several studies to question whether the expensive intervention is worth it.
Fusion involves a surgical toolkit consisting of screws, rods, cages and plates, and sometimes a biologic product made by Medtronic called Infuse, which grows bone between the vertebrae in an effort to stabilize the spine.
Cost varies widely
In 2006, American doctors performed approximately 343,000 spine fusion operations, up 82 percent from 1999, according to the National Center for Health Statistics, which tracks Medicare data, omitting perhaps thousands more paid by other sources. Since then, the number has continued to rise, though not as explosively. The Millennium Research Group estimates 445,300 spine fusion surgeries were done last year.
The cost of fusion surgery varies widely, according to data compiled by UnitedHealth Group, the Minnetonka-based insurer. For a complex lumbar fusion surgery, the cost can vary from $25,000 to almost $80,000 in a "typical" major metropolitan market.
Deyo has argued that the rising costs, high rates of complications and second surgeries and wide variations in the number of procedures performed from one state to another "generate concern that the procedure may be overused."
Others claim the increase in fusion surgery may be related to improvements in technology and the simple fact that baby boomers are aging. "Americans think longevity is a right and death is optional," said Dr. Sam Ho, chief medical officer for UnitedHealth Group, the nation's largest insurer. "We all want to be as active as we can -- and for as long as possible."
The surge in fusion surgery has meant big money for Fridley-based Medtronic, whose spine business reported some $3.5 billion in sales last year.
Critics argue that influence by big medical device companies -- including lucrative royalty and consulting arrangements bestowed on top surgeons whose opinions hold sway among their colleagues -- is one reason why the number of spine fusion surgeries has skyrocketed. Earlier this year, Medtronic disclosed these payments to doctors for the first quarter; of the $16 million Medtronic paid in those three months, $14 million went to spine and orthopedic specialists, mostly for royalties.
Medtronic and others insist that collaboration with doctors is crucial for creating and perfecting innovative new tools to treat patients. But Dr. Charles Rosen, a California spine surgeon and the head of the Association for Ethics in Spine Surgery, says these financial incentives create demand for certain brands of product. "That's one reason why you're seeing so many fusion surgeries," he said.
Other specialists say the situation is more nuanced. Each patient is different, they say.
"Is there too much back surgery? Yes," said Dr. John Sherman, an orthopedic surgeon with Twin Cities Orthopedics, one of the nation's biggest practices of its kind. "But it's not as dark as [Dr.] Deyo portrays it, nor is surgery a panacea for curing all back pain."
With costs and doubts rising, many Twin Cities insurers are starting to push back.
UCare Minnesota, the state's fourth-biggest health plan by revenue, implemented a rule this year that requires doctors to prove that they offered their patients conservative treatments, such as physical therapy and pain-numbing injections, before the plan will pay for certain types of back surgery, including fusion. UCare's guidelines are based in part on those developed by the Institute for Clinical Systems Improvement, a nonprofit health reform organization based in Bloomington.
Dr. R. Craig Christianson, UCare's associate medical director, understands the rule might be unpopular among some doctors and patients. But he sees it as a way of encouraging patients to discuss their options with their physicians.
"It could result in therapy for maybe a week or two, and if bad things happen, then we can always go to the operating room," he said in an interview. "It may prevent some percentage of failed back operations because of that one little intervention."
Other large health plans and insurers, including UnitedHealth, Blue Cross and Blue Shield of Minnesota and HealthPartners, also require doctors to offer conservative treatments before they approve payment for some types of back surgery.
Such rules are, predictably, controversial.
If research has shown that surgery works on some patients with low back pain, "Why would you put someone through weeks or months of physical therapy?" said Dr. Daniel Resnick, vice chairman of the Neurosurgery Department at the University of Wisconsin. "It doesn't make sense."
Resnick argues that much of the data circulating about back surgery is incomplete, even misleading. "We don't know who exactly is getting back surgery," he said. "No one knows whether it's being done appropriately or not and what the appropriate rate is. My personal feeling is that we need to be doing more of the right kind of surgery and less of the wrong kind of surgery."
Part of the difficulty in assessing treatment options is that many Americans have an unyielding belief in medical technology. "Many people have a very mechanical view of how the body works and imagine it's like a car," Deyo said. "So if a tire wears out, you'll just put in a new one. It just doesn't work that way."
The truth is, up to 90 percent of people with acute low back pain will heal on their own, no matter what they do, according to several studies.
A different approach
Sorting out who would benefit from surgery, and at what cost, can be tricky. "If it comes to surgery, there are a lot of options depending on how extensive the patient's problem is and the nuance of what's causing the pain," said Dr. Daryll Dykes, a spine surgeon at Twin Cities Spine, one of the country's busiest practices, logging 3,000 surgeries a year. "There is no one-size-fits-all treatment."
Even so, some doctors have embraced doubts about surgery and are exploring non-surgical options.
For example, Physicians Neck & Back Pain, a Twin Cities chain of clinics, has gained national attention for its sports medicine approach to treating back pain.
Founded by three local doctors 20 years ago and now a subsidiary of HealthPartners, the clinic offers its patients an aggressive rehabilitation program aimed at strengthening the back.
It can be a painful journey, according to CEO Dave Carpenter. "Generally patients tend to get worse before they get better," he said.
Carpenter said the clinics' philosophy isn't necessarily anti-surgery. "We just tell people they might want to try us first," he said.
One satisfied patient is Amy Leyden, who turned down surgery "out of pure fear" and went to 24 rehab sessions at Physicians Neck & Back Pain instead.
"You're pushed," she said. "It's like having a personal trainer. But I would have never done it on my own. As soon as it got painful, I would have quit."
It worked. Today, Leyden keeps up with two kids, plays tennis and goes to the Y a couple of times a week.