What deems a spine surgery as “unnecessary” goes beyond just coding data alone, and the definition of ‘low-value’ care needs to be assessed by physicians first, some spine surgeons say.
Five surgeons discuss their insights.
Note: Responses were lightly edited.
Question: Spine surgeries deemed “unnecessary” have cost Medicare almost $2B over three years, according to the Lown Institute. What’s needed from physicians, devicemakers and policymakers to address this?
George Cybulski, MD. Northwestern Medicine (Chicago): What is needed for all modalities of spine care are measures that would assist decision making, that is, matching patient diagnosis with most anticipated appropriate care for optimal outcome. This is where artificial intelligence will have a significant impact. The other more challenging aspect of optimization of outcomes is addressing the concept of moral hazard, that is, the denial of accountability for decisions that do not recognize the most cost-effective treatment due to payment by third parties.
Craig McMains, MD. OrthoIndy (Indianapolis): Reducing low-value care is essential, but the Lown Institute’s $1.9B figure is a claims-based screen, not a direct case physician review, and claims can often miss the bedside details that determine appropriateness (neurologic deficit, instability, failure of conservative care). Some spending flagged as ‘low‑value’ also arises upstream. Early imaging and serial injections driven outside the OR can shape what shows up in claims. The path forward is accountable surgeon autonomy. We can follow NASS appropriateness criteria, work within local Medicare rules, record the nonoperative path and second opinions, and be transparent about outcomes and revision rates. At the same time, we should protect access to high‑value operations — microdiscectomy for persistent radiculopathy and decompression (with or without fusion) for stenosis/spondylolisthesis. This is where evidence shows meaningful quality of life gains and good value. Prior‑authorization rules for Medicare Advantage programs should support this with timely (seven‑day/72‑hour) decisions targeted to outliers; not blanket barriers that impede access to care.
Vladimir Sinkov, MD. Sinkov Spine. (Las Vegas): The decision on whether a spine surgery should be done and how “necessary” it is should be made only by the patient and their spine surgeon. Both device makers and policymakers do not represent the best interest of the patient, do not understand the entire clinical picture, and are not bound by professional and ethical standards (such as Hippocratic oath). Therefore, they should not be involved in the decision of what is the best treatment for any patient.
In the Lown Institute report, the definition of “unnecessary” spine surgery was vague, and their study methodology was flawed. They only analyzed Medicare coding and billing data and did not review individual patients’ charts to properly understand why the spine surgery was offered or done in that particular case. The supporting studies they quoted (mostly literature review reports and meta-analyses) mention that in certain situations spine surgery gave the same outcomes as non-surgical care. It should be noted that typically spine surgeons offer spine surgery, and the patients request or accept the offer of spine surgery only after they have already exhausted all reasonable non-surgical treatments. In such cases, continuing non-surgical treatment (physical therapy, medications, injections, activity modification) will definitely not improve their symptoms, while the surgery has a reasonable chance of improving their symptoms, function, and quality of life. This is why such surgery is being offered to the patients and why the patients choose to undergo the surgery in hopes of improvement.
The Lown report makes a very broad statement regarding “unnecessary” spine surgery without properly analyzing why those surgeries were being offered and done. To me it looks more like a thinly-veiled attempt at justifying rationing of care for Medicare beneficiaries. It may also potentially create more distrust towards spine surgeons offering clinically appropriate treatments. This, in turn, can affect patients’ compliance with their recommended treatments, thereby worsening their clinical outcomes.
William Taylor, MD. UC San Diego: First it is clear that the current system is not effective in dealing with this problem. I think patients and patient expectations are an absolute critical piece of this. Often when I tell a patient, I don’t think I can help them and further surgery might be unnecessary, they return back from another physician who feels differently. The patient will come back to see me and say “they found something to do!”
I think it’s this expectation of action which is present both on the patient side and the referring physician is a significant contributor to the unnecessary surgery problem you discussed. The referral physician expects something to be done, and they’re clearly sending you for some reason, and the patient’s expectations remain that you will be able to fix them. Unless we deal with this expectation of individual patients and often their belief that our healthcare system is maybe working against them, I doubt we will be able to fix the unnecessary surgery problem.
Secondly, I would say that I often see people getting more surgery based on the idea that one larger surgery might be better than multiple smaller ones. Many patients of mine have gone elsewhere when I’ve told them that I would proceed with a smaller surgery and they returned or reported that they found another physician to fix their problem once and for all. Our understanding of the multiple surgery patient is flawed in that we consider a larger surgery to be less likely to keep people away from the operating again.
Unfortunately, looking at the literature, that is often not the case.
I’m also very encouraged by work that has been done recently in which we identify specific pain generators through spect and other scans. This often results in a more targeted surgical intervention. I think it’s the responsibility of us as a group to identify situations where less surgery might be more beneficial for the patient.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): According to the aforementioned article, what’s truly needed is a necessary and massive cultural shift from the decade’s old mentality of ‘Putting dollars ahead of patients.’ This is a shared character trait of hospitals and providers alike. Stating an excess of more than 200,000 spinal surgeries per year are completed unnecessarily would indeed underestimate this number and further corroborates the adverse incentives or speculation of the industry, especially in the physician owned, for-profit hospital realm. Degenerative spinal disease is ubiquitous, yet surgical intervention should be solely based on symptom terminus and further reserved for reticence to other treatments. Extrication of diagnostic criteria as a means to an end, is no longer tolerated. Pan-sectional spinal fusions are almost unforgivable in relevance, procedure and outcome.
