Back surgery is one of the best documented examples of expensive medical treatments that drive up health care costs while not always helping patients, and sometimes even hurting them. The latest Medicare data show that hospitals frequently order MRI back scans for patients who haven’t even tried recommended treatments such as physical therapy. An MRI often prompts surgery.
In 2009, 32.2 percent of Medicare patients with lower back pain who received a spine MRI at a hospital outpatient imaging center hadn’t tried a more conservative — and cheaper – treatment than surgery, according to data published on Medicare’s Hospital Compare website this month.
Among 2,088 hospitals where Medicare had enough data to evaluate, Regions Hospital in St. Paul, Minn. had the highest rate: 63.5 percent of the 329 patients that got scans in 2009 handn’t received prior treatments first.
According to Hospital Compare, the hospitals with the next highest rates in 2009 were:
- Monroe County Hospital in Monroeville, Al. (60.7 percent)
- Muhlenberg Community Hosptial in Greenville, Ky. (60 percent)
- University Medical Center in Layfayette, La. (59.6 percent)
- Santa Clara Valley Medical Center in San Jose, Ca. (58.7 percent)
- Weeks Medical Center in Lancaster, N.H. (58.3 percent)
- Providence Mount Carmel Hospital in Colville, Wash. (57.8 percent)
To be sure, high MRI rates aren’t proof that any of these hospitals are jumping the gun (or the scan) on patients. It’s possible that doctors who referred to these places tended to have more patients who warranted prompt scans on clinical grounds. And hospitals like to note that they don’t control many of the doctors who order these tests.
Nonetheless, this is one of only two measures of potential imaging overuse that Medicare publishes and that has been endorsed as valid by the National Quality Forum, which does rigorous screenings of health care quality measures with the participation of medical providers. (The other NQF-endorsed measure of potential imaging overuse that Medicare publishes is double chest CT scans.)
And there’s evidence that patients receiving back scans are more likely to end up getting spinal surgery. Spine surgeries are a rapidly growing cost to Medicare, and there are widespread concerns that some spine surgeons are too eager to perform these lucrative surgeries, egged on by financial conflicts-of-interest and aggressive sales of dubious devices and products by manufacturers.
The Medicare data show that at 9 out of 10 hospitals, at least 25 percent of the patients who received back MRIs hadn’t tried a more conservative treatment first. Some of the nation’s best regarded teaching hospitals were particularly circumspect: only 18.5 percent of patients at NYU Langone Medical Center in New York City and 19.1 percent of patients at UCSF Medical Center in San Francisco hadn’t attempted an alternative before getting scanned.
Among states, Minnesota had the highest average rate of MRI back scans without prior interventions, at 40.9 percent. Wyoming was second, followed by Arkansas, West Virginia, Utah and Montana. The state with the lowest rate was Delaware, at 25.9 percent, followed by Florida, New Jersey, California and New York.
These results are intriguing because many of the states with the highest rates of possibly premature MRIs, such as Minnesota and Utah, are frequently cited by folks at the Dartmouth Atlas and elsewhere for their cost-effective care. Some of the states with the lowest rankings, such as New Jersey and New York, are often cited as places where doctors and hospitals perform too many procedures.
If you want to look up your hospital’s back scan rate, go to Hospital Compare. Enter your city and state or zip code, select your hospital and then select the “Use of Medical Imaging” tab on the left. Note that many hospitals didn’t do a sufficient number of MRIs for Medicare to do a valid analysis.
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As an emergency physician with over 20 years of practice, I can tell you how some of this happens. It’s a combination of patient expectation and provider risk avoidance. When patients with back pain come to the emergency department, often they expect that we will do an X-ray. But the literature shows that unless you have some trauma, like a fall, the Xray is unlikely to demonstrate a problem. So, we do an X-ray, it shows nothing, and the patient is given pain medication, muscle relaxant, and told to see their primary care physician. They see the primary care physician and, because they are no better, and they’ve already had an Xray, the primary care physician sends them to MRI. Why not physical therapy? Three reasons – First, some physical therapists are reluctant to treat these patients until all the really serious problems have been ruled out. Second, physicians are scared that ultimately there will be a serious diagnosis and they will be sued for a “failure to diagnose.” Third, physical therapy takes time, and our society expects instant results. In addition, some insurance carriers have pretty strict limits on the amount of physical therapy care they will cover.
I’m not sure that back scan actually cause more back surgery. It’s still something of a process to get to MRI, so naturally those people who’ve gone through the funnel are more likely to end up going to surgery. Also, it may not be that the surgery itself is ineffective, but that the post-operative care that is required to make the surgery effective, the intense, long-term physical therapy, is not happening, for reasons mentioned above.
Until we start to develop practice guidelines and, more importantly, adhere to them, we will always have these issues.
I believe there is seldom a single answer as to why an event occurs. I suggest clinical drivers, budgetary concerns and defensive medicine are part of the mix. The real question is, is there political will to take on these variables?
My father, at age 54, and my best friend, at age 24, both experienced excruciating back pain. My friend could not walk more than 100 feet without stopping to sit. My father got to the point where he couldn’t walk at all, or sit in anything but a hard chair, or stand for more than a few seconds. Neither could sleep in a bed, they had to sleep on the floor. This was simply excruciating pain.
Both were required to have an MRI before a physical therapist would see them, and months of physical therapy didn’t help either of them. My friend couldn’t even take the muscle relaxers because she had no choice but to drive, and her insurance company refused to pay for the MRI for months because she was so young. The MRI showed 2 slipped discs, and the doctor told her the delay in approval for the MRI made both far worse.
They both had the surgery and did post-op physical therapy and are both perfectly fine now, 3 years later, and still do their prescribed stretches daily. I’m a huge supporter of the Affordable Care Act (it is the only reason my 23 year old sister, who has a serious health condition requiring thousands of dollars of drugs per month, has insurance right now) but I do worry that one of the ways we’re going to “cut costs” is by refusing needed tests to people like my friend who have a condition at the “wrong” age. Even my father, whose condition was at least age appropriate, went through months of simply agonizing pain with no help except drugs that did little to relieve the pain but left him unable to drive to do his job before the insurance company would approve his MRI. And my friend and my father both had great insurance: my dad’s through his job at a huge multinational corporation and my friend through her job at a university.
This article makes the huge mistake of equating having an MRI with having spinal surgery.
Every patient that has a spinal MRI does NOT have spinal surgery.
The MRI is used to make a diagnosis: why is this patient having pain?
Once a diagnosis is known, then treatment can be more specific and effective.
Up to 80% of the time patients with disc problems get better WITHOUT surgery.
But they have to have a diagnosis first.
Los analistas de costos de sistemas de salud intentan corregir constantemente los criterios de respuesta de los médicos a las necesidades de los pacientes para disminuir los costos; de esta manera restringen el numero de estudios autorizados y demoran su autorización a otros. Eligen los equipos mas baratos con peores imágenes y no dan elección a sus pacientes. No importa la inquietud del paciente , ni del médico, sino las cifras gastadas mensualmente. Hace tiempo leí que el 90% de la población mundial tendrá uno o varios episodios de lumbago a lo largo de su vida y el 90% se curarán con medidas sencillas. ¿Someter a todos a todos los estudios? ¿realizar estudios progresivamente según responda o no a los tratamientos realizados?¿dejar librado al criterio del médico y su experiencia la solicitud de los estudios mas complejos?