FORT MYERS, Fla. — In the past decade, the rate of back surgery among Medicare patients has increased by more than half, driven by factors including new technology to fuse damaged vertebrae, more advanced imaging to diagnose injury, generous federal reimbursements and greater demand.
Yet even as the numbers swell, there is no clear-cut science for treating back pain. Some doctors favor surgery, while others recommend exercise, rehabilitation and other conservative approaches.
The result is a jigsaw pattern of medical care in which the patient's chance of having surgery often is decided by where he or she happens to live.
In Fort Myers, Medicare patients are twice as likely to have back surgery as those in Miami.
Had Fort Myers's surgeons operated at the more conservative Miami rate, there would have been 4,800 fewer back surgeries from 1992 to 2001 and Medicare would have saved millions of dollars, according to an estimate by James N. Weinstein, chairman of the Department of Orthopaedic Surgery at Dartmouth Medical School. Weinstein has tracked variations in the number of spine surgeries in South Florida for a decade.
Medicare patients in Fort Myers underwent spine surgery at a rate of 6.9 per 1,000 in 2001 — the latest year for which figures were available. In Miami, the rate was 3.2. Nationally, it was 4.5.
Back surgery is a growing cost to Medicare. In 2003, the government paid about $1.6 billion to hospitals for more than 167,353 spine procedures, not including doctors' fees. The average charge per surgery was $40,000.
Dartmouth researchers estimate that as much as one in three dollars spent by Medicare goes to unnecessary care. In that sense, variations in back surgery in South Florida provide a glimpse of Medicare's inefficiencies.
"It's highly improbable that Medicare retirees living in Fort Myers prefer back surgery two times as often as residents of Miami," Weinstein said. "So if it's not the patients, what is it?"
Weinstein points to what he calls the "surgical signature" of doctors — idiosyncratic patterns in the likelihood of a doctor choosing to operate. The greater the scientific uncertainty in treatment options, Weinstein said, the more variations appear.
Less clear is the role of hospitals. For hospitals that offer spine surgery, the financial rewards can be substantial. In 2001, spine surgery accounted for more than half of all profits from orthopedic procedures in hospitals but only 21 percent of the volume, according to a study done for the American Academy of Orthopaedic Surgeons.
"It can be very profitable, especially at centers with big volumes," said James H. Herndon, past president of the group and a Harvard Medical School professor. One new, aggressive surgeon can increase the rates in a community "if he comes into an area where surgeons are conservative," Herndon said.
In Fort Myers last year, surgeons at the three hospitals that are part of the Lee Memorial Health System performed 447 spine procedures on Medicare patients, generating nearly $2.8 million, according to data provided by the system. Medicare reimbursements to the three hospitals for spine operations have grown by nearly 50 percent in the past five years.
Chuck Krivenko, the system's chief medical officer, said he is hard-pressed to explain the high rates of back surgery. At first, he suggested it must be because of the annual winter influx of elderly visitors. But the Dartmouth researchers account for seasonal visitors by counting their surgeries as though they occurred at their place of year-round residence.
"I can't explain it," Krivenko said. The neurosurgeons who perform spine surgeries at Lee Memorial "are not what I'd call aggressive neurosurgeons. We have a very good group of what I consider conservative neurosurgeons . . . and we have some of the best outcomes," he said.
Nevertheless, Krivenko said, because treatment for back pain remains discretionary, many doctors are going to opt for surgery. "If the only tool you have is a hammer, everything looks like a nail," he said.
Not necessarily, Weinstein contends. At his hospital, Dartmouth-Hitchcock Medical Center in New Hampshire, patients with back pain are given educational materials and allowed to choose. They often opt not to have surgery.
"What we have found," Weinstein said, "is that patients tend to make good decisions when presented with good information."
Medicare data appear to back up Weinstein. In 2001, the rate of back surgery among Medicare patients in his area was 2.3 per 1,000, among the lowest in the nation.
source: http://www.washingtonpost.com/wp-dyn/content/article/2005/07/23/AR2005072301040.html 24jul2005
In many ways, Medicare is one of the federal government's enduring successes. Without it, many of the 42 million elderly and disabled Americans it insures would have no health coverage.
"Medicare changed the whole idea of being old," said Rosemary A. Stevens, a retired University of Pennsylvania historian. "People lived longer. They had major surgeries. They could access care without going broke."
But when Medicare became law on July 30, 1965, as part of President Lyndon B. Johnson's Great Society program, it also reflected a series of political compromises that were decades in the making and continue to define and shape the giant government insurer.
For half a century, social reformers had pushed for national health insurance. They faced heated opposition from the American Medical Association and other groups, which feared government-run insurance as an attack on doctors' autonomy and incomes. Robert M. Ball, Social Security commissioner under Presidents Kennedy, Johnson and Nixon, has called Medicare a "fallback position."
Ball and other proponents designed Medicare so it would face the least possible opposition. In contrast to the Medicaid program, which was passed at the same time as a way to provide health coverage to the poor, Medicare was available to all people 65 and older, regardless of income. It resembled private health plans such as Blue Cross and Blue Shield, which allowed patients unlimited choice and paid what doctors and hospitals charged, so long as they weren't dramatically out of line with their peers.
"It was all about greasing the wheels to make the program successful," said Judith M. Feder, a Georgetown University professor who wrote a history of Medicare.
Congress required Medicare to set minimum standards of care in hospitals, referred to as "conditions of participation." Early on, those standards were widely credited with improving the quality of care. Over time, however, Medicare's standards have lagged behind changes in medicine. Efforts to update them have often become bogged down in politics and bureaucracy.
Standards for kidney dialysis care, for example, remained in place for a quarter-century until Medicare proposed revising them this year; standards for hospice care languished for 22 years.
But Medicare was changing American medicine in other ways, Stevens said. The torrent of federal tax dollars stimulated growth and led to an unprecedented expansion of the health care system.
There were few brakes on that system. By law, Medicare was prohibited from explicitly considering cost when deciding whether to pay for a new treatment or machine, an edict that remains in place today.
"Essentially, they were paying claims," Feder said. "They were simply turning over the keys to the Treasury to the providers."
Since its inception, Medicare spending has grown more than 14 times the rate of inflation to about $300 billion. It spends more than $800 million a day. In a decade, analysts estimate, spending will top half a trillion dollars and account for nearly a fourth of the federal budget.
John E. Wennberg of Dartmouth Medical School recently wrote that Medicare is speeding toward "a trillion-dollar train wreck." An advisory panel of trustees overseeing Medicare's long-term finances wrote in a report last year that the combination of rising costs and a sharp upturn in the number of beneficiaries -- from 42 million today to 71 million two decades from now -- threatens to bankrupt the hospital program.
To prevent that, Congress would have to increase the current payroll tax used to finance the hospital portion of Medicare by about fourfold. Or dramatically slash benefits, the trustees said.
source: http://www.washingtonpost.com/wp-dyn/content/article/2005/07/23/AR2005072300383_pf.html 24jul2005
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