Spine surgeries deemed “unnecessary” have come at a cost to Medicare over the past years, and different stakeholders can prevent the prominence of these cases, Vijay Yanamadala, MD, said.
Dr. Yanamadala, of Hartford (Conn.) Healthcare, discussed how different stakeholders should address the problem.
Question: “Unnecessary” spine surgeries have cost Medicare almost $2B over three years, according to the Lown Institute. What’s needed from physicians, devicemakers and policymakers to address this?
Dr. Vijay Yanamadala: The Lown Institute found that over 200,000 unnecessary spine surgeries were performed on Medicare beneficiaries over three years, costing approximately $2 billion. These procedures included spinal fusions, laminectomies and vertebroplasties that were performed on patients who clinical trials have shown receive little to no benefit.
Here’s what’s needed from each stakeholder group:
From physicians: Physicians need to fundamentally change their approach to spine surgery decision-making. Currently, the average orthopedic surgeon spends just 16 minutes with a patient before recommending surgery — far too little time to thoroughly evaluate alternatives and ensure the procedure is truly necessary.
Key actions physicians should take include:
1. Mandate second opinions: Actively encourage and facilitate patients getting second opinions before proceeding with surgery. Research shows that in 30% of cases, a second opinion found spinal surgery was unnecessary or unlikely to benefit the patient. This should become standard practice rather than an exception.
2. Increase consultation time: Surgeons need to spend significantly more time with each patient, discussing conservative treatment options, realistic expectations, and the evidence (or lack thereof) supporting surgery for their specific condition. This means reducing clinic volumes to allow for more meaningful patient interactions.
3. Strengthen peer review and oversight: Medical boards like the American Board of Neurological Surgery and American Board of Orthopedic Surgery should implement more rigorous case reviews to identify patterns of overuse among individual surgeons. When one physician is responsible for the vast majority of unnecessary procedures at a hospital (as the Lown Institute found in some cases), this should trigger immediate intervention.
4. Embrace evidence-based guidelines: Physicians must stop performing procedures that clinical trials have repeatedly shown to be ineffective for certain patient populations, particularly vertebroplasties for simple osteoporotic fractures and spinal fusions for non-specific low back pain without neurological symptoms.
5. Cultural shift within the specialty: The neurosurgery and orthopedic community needs to move away from the “more is better” mentality and recognize that recommending against surgery can be just as valuable as performing one when it’s not indicated.
From devicemakers: Device manufacturers must address serious conflicts of interest. Physicians performing unnecessary procedures received $64 million from device and drug companies over three years for consulting fees, speaking engagements, and travel expenses. This creates perverse incentives that can influence clinical decision-making.
Companies should establish stricter ethical guidelines around financial relationships with surgeons, increase transparency about payments, and focus on supporting evidence-based medicine rather than product promotion regardless of clinical appropriateness.
From policymakers: Policymakers need to implement systemic reforms that address the root causes of overuse.
1. Reform payment structures: Move away from fee-for-service models that reward performing more procedures toward value-based payment systems that incentivize quality outcomes and appropriate care.
2. Update coverage policies: Medicare should stop covering procedures that lack evidence of benefit, such as vertebroplasty for simple osteoporotic fractures, despite the procedure continuing to be covered currently.
3. Expand oversight programs: Scale up initiatives like CMS’s Wasteful and Inappropriate Service Reduction Model and prior authorization pilots that specifically target overused procedures.
4. Improve data transparency: Provide payers with better diagnostic information in claims data so they can identify patterns of overuse. Currently, even sophisticated payers lack the detailed diagnosis codes needed to spot inappropriate procedures effectively.
5. Strengthen pre-authorization processes: While pre-authorization exists, it’s often too easy to game the system using specific language to get approval. The process needs more rigorous clinical review based on evidence-based criteria.
