Analysis turned up 200,000 unneeded procedures that cost Medicare $2 billion over 3 years
https://www.medpagetoday.com/surgery/orthopedics/117856
The Lown Institute called out dozens of hospitals for performing unnecessary surgeries on Medicare beneficiaries with low back pain, putting patients at risk of serious complications with no evidence of clinical benefit.
Its analysis focused on high-volume hospitals that performed at least 500 spinal fusion/laminectomy or vertebroplasty procedures over a 3-year period — finding more than 200,000 unnecessary procedures amounting to about $1.9 billion in wasted Medicare spending during that time.
“We’re not doing this just to draw attention to the fact that there is unnecessary surgery,” Lown president Vikas Saini, MD, told MedPage Today. “We’re doing it to track how much, so people who want to do something about it have a guideline.”
As for the doctors who are performing these unnecessary procedures, Saini said there are “true believer” surgeons who insist that the procedure can benefit their patients despite a lack of evidence, “and there are those who are more skeptical. … But let’s be magnanimous and say that all of this comes from a place of wanting to help, and hope that it will help.”
“But if we’re really going to have a reliable, effective, and affordable healthcare system, we can’t just base it all on hope and a prayer,” he said. “It has to be based on evidence. Hope is easy to have, but in the end, it doesn’t solve the problem.”
The report also noted the high rate of complications from these procedures. Some 18% of spinal fusion procedures result in infection, blood clots, stroke, pneumonia, heart and lung problems, and in some cases, death.
The Lown Institute’s list was taken from Medicare data. The hospitals with the highest rates of spinal fusion/laminectomy overuse are Mount Nittany Medical Center in Pennsylvania (57.2% of 505 procedures), Concord Hospital in New Hampshire (39.5% of 517 procedures), and Lutheran Hospital of Indiana (38.6% of 1,232 procedures).
The hospitals with the highest rates of vertebroplasty overuse included Kettering Health Miamisburg in Ohio (56.1% of 578 procedures), Shannon Medical Center in Texas (54.6% of 694 procedures), and St. Elizabeth Florence Hospital in Kentucky (50.1% of 668 procedures).
The report also applauded hospitals with the lowest rates of these procedures. Avala Hospital in Louisiana, Northwest Specialty Hospital in Idaho, and Baylor Surgical Hospital at Las Colinas in Texas all had spinal fusion/laminectomy overuse rates of 1.2% or lower. Metrohealth Medical Center in Ohio, Harborview Medical Center in Washington, and the Mayo Clinic Health System-La Crosse were among 11 hospitals with no vertebroplasty overuse.
The hospitals with high rates of overuse have not returned a request for comment from MedPage Today.
The report also highlighted enormous state variation in rates of overuse of these procedures. California, Florida, Texas, and Pennsylvania had the highest amount of overuse of spinal fusion procedures, with at least 5,000 unnecessary procedures in each state. Texas, Florida, and Ohio had the highest volume of vertebroplasty overuse with at least 6,000 unnecessary procedures in each of those states.
Spinal fusion/laminectomy procedures were considered overused when performed for low back pain, but excluded patients with radicular symptoms, trauma, herniated disc, discitis, spondylosis, myelopathy, radiculopathy, radicular pain, or scoliosis.
Spinal fusion-only procedures were not considered overused when performed for stenosis with neural claudication and spondylolisthesis. Laminectomy-only interventions were not considered overused when performed in patients with stenosis who had neural claudication.
Vertebroplasty procedures were considered overused when performed in patients with spinal fractures caused by osteoporosis, but the list excluded patients with bone cancer, myeloma, or hemangioma.
The Medicare data included fee-for-service patients’ procedures from 2021 to 2023 and Medicare Advantage patients’ procedures from 2020 to 2022. Procedures performed on Medicare beneficiaries under age 65 were not included.
Saini said the report concentrated just on those hospitals that performed at least 500 of these procedures. For the spinal fusion/laminectomy analysis, 466 hospitals were evaluated, and for vertebroplasty, 625 hospitals were included.
He said these procedures are extremely expensive, costing $14,500 for spinal fusion and $4,200 for vertebroplasty.
Asked what efforts he thinks will reduce the number of these unnecessary back pain procedures, Saini suggested federal oversight, such as the WISeR (Wasteful and Inappropriate Service Reduction) model, could have a larger role, perhaps with more targeted prior authorization requirements or guidelines. Yet he acknowledged that pathway is extremely controversial.
“There’s no way we can replace clinical judgment of the physician in the exam room,” Saini said. “We can’t have the federal government practicing medicine.”
But a lot of clinicians “just aren’t with the program and some of them will argue with you until they’re blue in the face that the data just doesn’t refute the way they practice,” he said, noting the saying, “It’s hard to get somebody to understand something when their salary depends on them not understanding.”
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