Splurging on Surgeries

It’s difficult to pinpoint the exact amount of wasteful healthcare spending that occurs each year in the United States, but estimates put it at 25% to 30% of the total healthcare spending. A 2019 JAMA Network study estimated that annual dollar amount at $760 billion to $935 billion.

This unnecessary spending is due to myriad factors, including fraud and abuse, administrative complexity, and failure to coordinate care. But another important factor is overtreatment or low-value care, which the JAMA study authors estimated to cost as much as $101 billion annually.

There are several low-value services that are consistently offered to patients. The Task Force on Low-Value Care provided a top offender list of procedures that could relatively easily be cut from the system. This includes things like vitamin D testing, unnecessary testing before surgeries, and PSA testing for men over the age of 70. These are small services that, when overused, can make a dent in healthcare dollars spent.

But there are also several higher-cost, higher-risk procedures that healthcare watchdog groups find to be frequently overused. Two of these are stents given to people with stable cardiac disease and spinal fusion for people with lower-back pain. Aside from costing the system hundreds of millions of dollars, these procedures, when used unnecessarily, may even worsen the health of patients.

There are many cogs in the system that can account for the overuse of these procedures, from physicians who don’t follow best practices to insurance companies that incentive the treatments. But this overuse is preventable, and a range of organizations and healthcare vendors are working to steer patients toward lower-cost, and sometimes more effective, treatments.

Treating Stable Patients

The Lown Institute, a healthcare think tank, recently identified 106,474 unnecessary procedures performed between March and December 2020. (Lown analyzed data from a Medicare claims database for procedures performed at hospitals nationwide.) At the top of the list were stents given to people with stable coronary artery disease. According to the organization, about three quarters of stents implanted are potentially unnecessary.

The issue with stents is not that they should never be used. But when patients have stable cardiovascular disease and reduced blood flow to the heart (ischemia), they are not necessarily candidates for a stent.

“We have known for the last 10 to 15 years that people who have no symptoms of angina [chest pain], no chest pressure or shortage of breath don’t do better with stents or bypass surgery,” says Dr. Jeff Levin-Scherz, population health leader of health and benefits at WTW North America. “They should be treated with medications, get their blood pressure under control and stop smoking.”

Levin-Scherz says the problem with the way stents are being used is a disconnect between patients’ anatomy and symptoms. If someone has a heart blockage, stents don’t necessarily fix it. Levin-Scherz says stents should be used to save heart tissue when someone is presenting with a heart attack. A 60-year-old man who exercises regularly and feels but discovers he has a heart blockage should be conservatively, he says.

In 2020, a large study was done that confirmed this approach. More than 5,000 patients from 320 locations in 37 countries took part in the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (Ischemia) trial. Most of these patients had stable cardiovascular disease, and about 35% had no chest pain prior to enrollment. The patients were randomly assigned to receive either conservative therapy or testing and surgery.

The researchers found that outcomes for both groups were generally the same. Using stents did not reduce the number of cardiac events or deaths over a three-year period. The one thing that did change was quality-of-life measures. For people who originally had angina, they reported better quality of life after receiving a stent.

“The implications for lowering costs are profound,” says Dr. John Spertus, director of health outcomes research at Saint Luke’s Mid America Heart Institute and co-principal investigator for the Ischemia trial. “We used to use stress tests to diagnose and decide who needed to go to the cath lab. But it turns out it did not help differentiate who would benefit from surgery.”

So the researchers found not only that surgery is not required for all stable cardiac patients with some blood flow blockage but also that stress tests, which are widely performed and can cost anywhere from $500 to $4,500, may also be unnecessary. Instead, Spertus says, a simple questionnaire, asking whether patients have symptoms of chest pain and tightness, is just as effective to determine treatment protocol.

Spertus says he was “flabbergasted” with the results of the study. Taking part in the research has changed the way he manages his patients. He refers patients for a stent only if they have symptoms of angina. And even then, he suggests they take medication for a few months and make some lifestyle changes. If these conservative treatments don’t work, then he considers offering more invasive care.

“It has given me more confidence to take the time to explain more clearly the importance of lifestyle changes,” he says. “I can talk with patients with evidence from the Ischemia trial to inform them of their treatment options and benefits.”

Spertus says it’s best for many patients to concentrate on controlling their blood pressure and cholesterol, getting exercise and eating a healthier diet. For patients without angina, there really are no symptoms to improve. The goal of treatment for this group should be preventing further disease progression.

The Mysteries of Back Pain

The fourth most common surgery on Lown’s unnecessary procedure list is spinal fusion for back pain. Not only do surgeons perform this often unnecessary procedure, but the X-rays and MRIs that typically lead to it cost the system mightily.

There are a few reasons to receive a spinal fusion, including trauma to the spine, broken bones, tumors and cases of multilevel spinal stenosis and instability where conservative treatments don’t work, says Dr. Steven Atlas, director of practice-based research and quality improvement at Massachusetts General Hospital and associate professor of medicine at Harvard Medical School.

But for people who do not have pinched nerves yet still experience chronic back pain that isn’t getting better, Atlas says, there is little evidence to support fusion.

“There have been some studies done that show there is either little benefit or no benefit to spinal fusion for these patients, but patients who are desperate for something turn to providers willing to do it,” he says. “It’s 50:50, like flipping a coin. And for major surgery, flipping a coin doesn’t sound like such a great deal.”

In a 2021 study from BMC Health Services Research in New South Wales, Australia, researchers examined more than 9,000 claims of people who had either spinal fusion or decompression. The average cost for a spinal fusion was nearly $30,000 U.S. dollars. After two years, only 19% of patients who had received spinal fusion were working again at full capacity. And 19% of all the patients had undergone additional spinal surgery within two years of the original one.

A 2021 study from The Spine Journal, “COVID-19 pandemic and elective spinal surgery cancellations,” highlighted the opportunity of not jumping right into surgery for back pain. Researchers looked at the records of 133 patients who were supposed to receive elective spinal surgery at NYU Langone Health but had to put it off because of COVID-19 restrictions. As of January 2021, 8% were waiting for updated exams, 6% canceled because of symptom improvements, and another 8% had follow-up recommendations for conservative treatment.

Christine Goertz, chair for implementation of spine health innovations in the department of orthopaedic surgery at Duke University School of Medicine, says back pain is so challenging to treat because it’s often difficult to pinpoint the underlying cause.

“It’s tempting to look at an X-ray or MRI and say, ‘I see degeneration or bulging around a disc, so that must be what is causing pain,’” she says. “But what we have learned over time is people with those imaging findings may or may not have pain. As a result, we often end up with a diagnosis of nonspecific lower-back pain, meaning we don’t understand why the patient is suffering at the moment.”

And spinal fusion is not a benign procedure. Not only may it not resolve symptoms, Atlas says, but it can make them worse. This treatment is often performed in people from 30 to 50 years old—still in their prime working years. But preventing motion in one part of the back can lead to abnormally increased movement above and below the surgical site, causing pain in those areas. Even those who reap benefits, he says, are at increased risk for additional surgeries down the road.

Recovery from fusion also isn’t inconsequential. There are typically six weeks to three months where the bone is healing and a person can’t work. Only after that can a patient start physical therapy.

Though back pain may be difficult to diagnose, there are some guidelines for treatment. A 2018 report from The Lancet summarized current guidelines from various medical associations. For acute back pain that has lasted less than six weeks, doctors should suggest physical activity and educate patients on their condition. If that doesn’t relieve symptoms, recommendations are to try exercise therapy, cognitive behavioral therapy, chiropractic, massage, acupuncture and yoga. Medications should either not be prescribed or used sparingly, according to the report. They also found no evidence for surgery for these patients, and there is little evidence that surgery should be recommended for patients whose pain has lasted longer than 12 weeks.

Perpetuating the Problem

It seems clear which procedures and tests are frequently overused, and there are relatively clear recommendations on when not to perform them. But the issue persists.

“Although guidelines exist, they are not well implemented. There are a number of reasons for this,” Goertz says. “Many people are frightened when their back hurts, because they start to think of a cousin who has been addicted to opioids for decades due to low-back pain or a person they know whose back pain was caused by cancer. As a result, they want an MRI or a surgical consult even when this is not what is recommended by experts.”

Among the physicians surveyed in a PLoS One study, 84% said the most common reason for overtreatment is fear of malpractice lawsuits. Three in five doctors said they order unnecessary treatments because of patient pressure or requests. In a 2014 Choosing Wisely survey, 10% of physicians said patients request tests or procedures daily that the doctors do not think are necessary. Another 37% said it happens at least weekly. But when doctors do talk with patients about the treatments, 70% said their patients always or often follow their advice not to have the treatment.

“I don’t think patients who are undergoing these surgeries feel they are low value,” says Dr. Vikas Saini, president of the Lown Institute. “I think they are desperate for something that can relieve their pain and give them back their life.”

Other issues include doctors who are not aware of alternative treatments or are skeptical of them. Many physicians are not well trained in the art of communicating about the different types of back pain and the recommended treatments.

“It takes 17 years for research to trickle down to clinical practice, and many guidelines came out just six or seven years ago,” Goertz says. “Studies show that people who start out with guideline-concordant care like chiropractic and acupuncture are less likely to progress to worse pain, while those that have early imaging, steroid injections, or opioids are more likely to end up with chronic pain. Our inability to follow the guidelines isn’t just a matter of system inefficiencies. We are potentially hurting people.”

Doctors’ training can also have an impact on whether they overuse services. Even with guidelines, Saini says, doctors’ judgment and practice patterns influence how they treat patients. So does where they were trained. A 2014 JAMA study of internal medicine graduates found that those who did a residency in more low-intensity areas scored much better on the Appropriately Conservative Management scale on their board certification exams than did those who did residencies in the higher-intensity practice regions.

There are also a lot more places to go for injections and surgeries and fewer alternative providers, Atlas says. “Even in Boston,” he says, “there are many places to get surgery and invasive procedures and a handful that focus on rehabilitation. Even when I refer to rehabilitation specialists, I know the patient will also get injections—but hopefully some other treatment as well.”

Not only do patients have difficulty finding alternative providers; they also often have to pay more for these services. Many of Atlas’s patients’ insurance covers injections and surgery, but patients end up paying higher out-of-pocket rates for acupuncture and chiropractic.

A 2018 article in JAMA Network Open found that, among 45 commercial, Medicaid and Medicare Advantage plans surveyed, almost all covered physical and occupational therapy. About 89% covered chiropractic care. Of eight commercial plans analyzed, three considered acupuncture medically necessary, two listed chiropractic care as medically necessary (another two did depending on the condition or type of pain), and none considered therapeutic massage medically necessary. Medical necessity was also found to be “inconsistently determined” for chiropractic care and acupuncture. The same study found that among 15 commercial plans, 13 covered chiropractic care, 3 covered acupuncture, and none covered therapeutic massage. There was also more likely to be annual visit limits placed on chiropractic care, physical therapy and acupuncture, when covered.

“There is a huge disconnect,” Goertz says, “between what insurers pay for and what is recommended by the guidelines.”

Addressing the Problem

Something few employers are willing to do, but that could have a major impact on reducing unnecessary care, is removing low-value, high-priced healthcare providers from their insurance networks, says Ryan Olmstead, director of member services for Catalyst for Payment Reform, a nonprofit with the goal of creating higher-value healthcare and a better healthcare marketplace.

Another tweak to insurance would be requiring prior authorization for surgeries that are invasive, expensive and high risk. “You can insert that step where justification has to be offered,” Levin-Scherz says. “Nobody really likes it—not doctors or patients—but if it can save you from getting a procedure you don’t need or that could do harm, it is a net good.”

Olmstead also recommends using a second-opinion program and either requiring or incentivizing people to use it prior to surgery.

Saini agrees that second opinions can be a very good tool for reducing unnecessary procedures, especially when patients go to a provider with a very different perspective. While he was training at Harvard under Dr. Bernard Lown (founder of the institute), Saini says, Lown was frequently sought for second opinions on cardiac surgery. According to Saini, for every 100 patients who came to him with recommendations for surgery from other physicians, Lown would recommend medication use for about 85. Among the rest, eight or so would need more testing, and the remaining patients actually needed a procedure.

Second opinions could also work to reduce overtreatment of back pain. In a 2017 article in Spine, a peer-reviewed periodical, 137 patients were seen over a 10-month period. Of those patients, 100 had previously seen another surgeon who recommended spinal fusion. When the patients were reviewed by a multi-specialty group, conservative treatment measures were recommended for 58 of the 100.

Working with centers of excellence is another, increasingly popular option employers can use to reduce unnecessary procedures. Catalyst for Payment Reform did a case study for Walmart after it began its spine program in 2013. The retail giant contracted for a bundled payment arrangement with several health systems across the country, including Mayo Clinic, Geisinger Medical Center, and Virginia Mason Medical Center.

Under the voluntary program, Walmart agreed to cover all costs for evaluation, surgery, travel and lodging for associates who used one of these providers for back pain care. The employees who chose to use other providers had to pay the standard cost sharing for their insurance plan. A few years later, Walmart made any provider that wasn’t a center of excellence for these procedures out of network, increasing employees’ costs dramatically. As a result of this program, about 50% of cases where people thought they needed surgery were deemed medically unnecessary when seen at a covered health system.

Employers are also increasingly looking online to reduce costs with platforms like Hinge Health, which provides physical therapy and other treatments for people with joint pain.

“A lot of our clients are large, self-funded employers who are looking at ways to create healthy, happier employees while also controlling their healthcare spend,” says Jim Pursley, Hinge’s president. “Musculoskeletal and oncology are two areas where employers are getting crushed right now. There’s a big opportunity for us to bend the cost curve.”

Pursley says about 75% of patients who are seen through Hinge opt for conservative care—including physical therapy, weight loss and behavioral changes—rather than surgery. And members experience about a 68% reduction in pain. Overall, that creates cost savings for employers of about $2,400 per patient in additional doctor’s visits, in-person physical therapy, imaging and surgery.

For people who might need surgery to improve their condition, Hinge has curated a small network of high-quality, low-cost providers so members can receive the best care at the best price.

Part of Hinge’s success, Pursley says, is because it connects with patients early in the care process. Through its technology, Hinge Connect, it is able to analyze claims and recognize people at high risk for surgery. He says his team can look at data like opioid prescriptions and MRI orders in real time—received in 15-minute increments. This allows them to catch people before it’s too late.

“When you have already met with an orthopaedic surgeon and had a consultation or an MRI, the ability to steer that care plan is pretty minimal,” he says.

The final tool that doctors recommend for reducing unnecessary care of any kind is shared decision-making with patients  and insurers alike. “Health plans could use an individual patient approach, asking why a particular patient should get a lumbar discectomy,” Levin-Scherz says. “Insurers could also provide reports to doctors who seem to be doing things that are off guidelines, and, over time, they may change their habits if they are confronted with data.”

Increasing the use of bundled payment approaches would be an incentive for healthcare providers to take the time to discuss the risks and benefits of surgeries, Spertus says. “I get paid thousands of dollars for a half hour to put in a stent,” he says. “If I spend time talking with a patient about a procedure, I get paid about $20. That is not the right way to move to a more value-based, patient-centered health system.”

One tool that providers can use to help with shared decision-making for heart procedures is the website myhealthoutcomes.org. The tool is from Saint Luke’s and uses data from the Ischemia trial. A provider can enter a patient’s variables and receive a one-page information sheet to share with the patient to discuss treatment options. The tool estimates the person’s risk of dying in four years with or without surgery and what their quality of life and symptoms will be for the next year if they choose surgery.

“It can give patients the confidence to try medication first and go to the cath lab if they have unacceptable chest pain,” he says. “This can reduce the cost of care by limiting stress testing. Helping patients decide on a care plan by determining their goals and values is extraordinary.”

Atlas says when he talks with patients about chronic back pain with disabling symptoms, one of the first things he does is tell them his job isn’t to cure their pain completely but help them manage it so they can live the life they want and do the things they enjoy.

Atlas says he tells patients with chronic lower-back pain, without symptoms of nerve impingement involving the legs, that surgical interventions won’t eliminate the pain—at best it will decrease it. On average, there is a 50% improvement, he says, and 10% to 20% have recurrent pain over time. He prefers to focus on patients’ long-term goals and what they want out of treatment.

“For many providers,” Atlas says, “patients come with the expectation of being ‘cured.’ One of my jobs is to offer some humble pie. I would love to say I can get them pain-free, but for many patients it isn’t possible. It’s a different mentality, and for some patients it is a hard pill to swallow. Some patients can’t buy into that, and they go elsewhere. But if I were a betting person, I wouldn’t bet on that outcome.”

Goertz thinks patient education is so important that she’s writing a book on the subject. Employers, she says, could be on the forefront of this education movement. They could start by giving out information on back pain and best practices to their workforce in general. Let people know not to panic if they have back pain but to try ice and stretching. If they are in a lot of pain or the pain persists, see a chiropractor, acupuncturist or massage therapist or try yoga. If people know what to do before they ever have back pain, she says, they will be armed to treat it better when it does occur.

“If it were up to me, I would line up kindergartners in gym class and tell them that they will probably all have low-back pain at some point in their lives and they won’t need an MRI,” Goertz says. “MRIs are expensive and send people down rabbit holes because often they identify normal degenerative changes that may or may not be related to low-back pain. I really dislike the term “degenerative disc disease.” If my hair is thinning as I age, I don’t get diagnosed with degenerative hair follicles. We are overmedicalizing something that is a common condition—one that we need to learn how to handle in a way that doesn’t disrupt lives.”