More than 200,000 Medicare patients with back pain underwent $2 billion worth of unnecessary surgeries, including spinal fusion and/or laminectomy or vertebroplasty, over a recent 3-year period, according to an of Medicare claims data from the Lown Institute.
If unnecessary, such procedures put patients at risk of blood clots, pneumonia, heart and lung issues, infections, paralysis, and death. After surgery, 10% to 40% of patients experience "failed back surgery syndrome," in which the vertebrae do not fuse back together, the report said.
"The times in which spinal fusion and laminectomy work for spinal stenosis is when the stenosis is causing neurogenic claudication, or radicular symptoms, meaning you're getting pain shooting down the leg; the nerve is pinched," Vikas Saini, MD, president of the Lown Institute, told 鶹ý. "But if you don't have that ... and you just have spinal stenosis without that pain, then those surgeries have not been shown to be effective."
Spinal fusion is recommended for patients with low back pain caused by traumatic injury, sciatica, slipped spinal bone, or spinal deformity. The report excluded spinal fusion/laminectomy surgeries from those considered unnecessary if the claim documented radicular symptoms, trauma, herniated disc, discitis, spondylosis, myelopathy, radiculopathy, radicular pain, scoliosis, neural claudication, or spondylolisthesis.
"For patients who have low back pain caused by aging, there is not sufficient evidence of a benefit from these procedures compared to non-surgical alternatives," the report noted.
Vertebroplasty procedures were defined as overused for patients with spinal fracture caused by osteoporosis. Patients with bone cancer, myeloma, or hemangioma were excluded from those considered to have undergone unnecessary procedures.
When the Lown Institute removed claims for which there was good reason for the surgery, "we are still left with a lot of cases that were unnecessary," Saini said.
When Saini was asked if surgeons or the people who submitted claims on their behalf could have made mistakes, were lazy, or didn't check the right ICD-10 diagnosis codes, he noted that there could be some of that, but not nearly in the numbers that the institute found.
Saini was also asked why Medicare would pay for procedures without diagnostic justification.
"The answer about why Medicare pays is because Medicare doesn't really use appropriateness criteria to decide whether to pay," he replied. "Maybe that's the real big story here. Why does the Lown have to do this? Because nobody else does."
The Lown report does not name the surgeons performing these potentially unnecessary procedures, but it does draw an association between large sums of money paid by the spine surgery industry to surgeons "with measurable spinal fusion/laminectomy or vertebroplasty overuse." For example, NuVasive and Medtronic paid physicians $8 million and $7.5 million, respectively, from 2020 through 2022.
Charles Rosen, MD, of the University of California Irvine and a specialist in spine surgery who was not involved in producing the report, found its conclusions credible.
It captures "the practice of operating on low back pain without any of the qualifiers that indicate a legitimate need for surgery -- neurogenic compression or compression of the nerve, scoliosis, spondylolisthesis, tumor, [or] fracture," he told 鶹ý.
"It's really not terribly accepted in academic circles to operate on just back pain or discogenic disease when you have no real etiology for the pain," he said.
Rosen also echoed Saini's comment that Medicare just pays for everything. "It's called pay and chase. They approve everything and that's where the huge amount of abuse for Medicare comes in."
He noted that there's been a number of studies that showed that losing weight, stopping smoking, and engaging in healthier activities is a better treatment for back pain when you don't have a specific diagnosis, like nerve compression or deformity.
Rosen also pointed to the heavy influence that the spine surgery equipment industry has on hospitals and surgeons. "I mean, spinal hardware is $1,000 a screw and you put in three or four levels, you can get $20,000, $30,000 of equipment put in."
In the report, the hospitals with the highest rates of unnecessary spinal fusions/laminectomies included:
- Mount Nittany Medical Center in State College, Pennsylvania: 62.8%
- Medical Center of Aurora in Colorado: 42.1%
- Jefferson Abington Hospital in Abington, Pennsylvania: 40.6%
- Concord Hospital in New Hampshire: 40.6%
- Heritage Valley Sewickley in Pennsylvania: 40.1%
Hospitals with high rates of unnecessary vertebroplasty included:
- Shannon Medical Center in San Angelo, Texas: 55.5%
- Chi St. Vincent Infirmary in Little Rock, Arkansas: 50.5%
- St. Elizabeth Florence Hospital in Florence, Kentucky: 48.7%
- Lutheran Hospital in Fort Wayne, Indiana: 44.6%
- Ascension Providence Hospital in Southfield, Michigan: 42.3%
The report also named hospitals with low rates of unnecessary spinal fusion/laminectomy procedures, which included Avala Hospital in Covington, Louisiana (0.1%); Northwest Specialty Hospital in Post Falls, Idaho (1.2%); Fresno Surgical Hospital in California (1.2%); Baylor Surgical Hospital at Las Colinas in Irving, Texas (1.3%); and Christus Mother Frances Hospital in Tyler, Texas (1.7%).
Several hospitals had no claims for unnecessary vertebroplasty procedures, including MetroHealth Medical Center in Cleveland; Essentia Health - St. Joseph's Medical Center in Brainerd, Minnesota; Marshall Hospital in Placerville, California; and Denver Health Main Campus in Colorado.
There was also wide variation in unnecessary procedures from state to state. For example, hospitals in New Hampshire, Iowa, Massachusetts, Pennsylvania, Alabama, and Hawaii had the highest average rates of unnecessary spinal fusion/laminectomy procedures, while Arkansas, Kansas, Oklahoma, Nevada, Nebraska, and Indiana had the highest average rates of unnecessary vertebroplasty procedures.
For the report, overuse was measured using Medicare fee-for-service claims data from 2020 to 2022 and Medicare Advantage claims data from 2019 to 2021. The cost of unnecessary back surgeries was calculated using Medicare's procedure price lookup tool for outpatient procedures, using the most frequent Current Procedural Terminology code for the procedure. The cost of inpatient procedures was calculated using the average Medicare cost of the most frequent Diagnosis Related Group code for the procedure, using Medicare fee-for-service claims data.
None of the hospitals contacted for comment responded as of press time.
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