Concerns About The Increase In Spinal Fusion Surgery

MS. SUSAN PAGE

11:06:54
Thanks for joining us. I'm Susan Page of USA Today sitting in for Diane Rehm. The rate of spinal fusion surgery has risen six-fold in the United States over the past two decades. Some medical experts question whether the surgery is always necessary and if financial rewards to doctors are spurring the increase.

MS. SUSAN PAGE

11:07:14
With me in the studio to talk about spinal fusion surgery is Dan Keating, a reporter with The Washington Post, and Dr. Brian Subach, a spine surgeon and president of the Virginia Spine Institute. And joining us by phone from Portland, Ore. is Dr. Richard Deyo, a researcher at Oregon Health Science University. Welcome to you all.

MR. DAN KEATING

11:07:35
Good morning.

DR. BRIAN SUBACH

11:07:35
Morning.

DR. RICHARD DEYO

11:07:37
Thanks. Good morning.

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11:07:38
And good morning. We invite our listeners to join this conversation later in the hour. You can call our toll-free number. It's 1-800-433-8850. You can send us an email to drshow@wamu.org. Or you can find us on Facebook or Twitter. Well, Dan Keating, it was really an investigation by The Washington Post. You were the co-author of the story that prompted us to do this show today. You found that the rate of spinal fusion surgery in this country has really exploded in the last 20 years. What did you find?

KEATING

11:08:12
That the growth has outpaced the increase in things that people really consider to be very common these days, like knee replacements or hip replacements. And the -- one of the biggest issues we found is simply the question of whether the popularity of this surgery and using it has outpaced what has been proven in terms of the medical benefits.

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11:08:35
And what prompted you to explore this area?

KEATING

11:08:38
Well, we're working on a series of stories, Peter Whoriskey, my colleague and I, over the year. A lot of them pertain to financial incentives and how they play in the medical system.

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11:08:50
And this was one of the cases that you looked at for that. Well, Brian Subach, describe to us exactly what spinal fusion surgery is.

SUBACH

11:08:59
Well, as you know, as we age, every disc, every joint in the body suffers from an arthritic process which means that the joints begin to grind. And what fusion does -- fusion essentially hastens or speeds up that arthritic process in the sense that it halts movement. So prior to knee replacement surgery, it was very common to do knee fusion, which means that the knee would be fused in a straight position.

SUBACH

11:09:25
You'd eliminate bending but also eliminate pain. So what spinal fusion does is it takes joints that are clearly degenerative and stabilizes it so that there's no longer any grinding, wobbling, or pain.

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11:09:37
So the point is to eliminate the pain people are feeling in their backs as they age.

SUBACH

11:09:42
That is correct.

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11:09:42
And how much does it cost to have this surgery?

SUBACH

11:09:45
Well, the cost can be significant depending on how big the surgery is, meaning that -- the most common operations we do are mostly like spot welds where we're working on one degenerative area that's really the true cause of pain. And those can be a few thousand dollars in terms of cost. There are hospital costs. There are device costs, and there are surgeon fees. But in general it's -- large procedures could be six figures.

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11:10:09
And how many of these procedures have you done yourself?

SUBACH

11:10:13
I typically do about 250 to 300 spinal fusions per year. And I've been in practice for 13 years.

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11:10:19
And have you been -- has that been pretty constant over the past 13 years? Or has the number you've done gone up?

SUBACH

11:10:23
It has actually gone down slightly.

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11:10:25
And why is that?

SUBACH

11:10:27
We're getting a significant amount of pushback from the healthcare insurers, meaning that the insurance companies are actually resisting. We're getting quite a few more denials of service, meaning that they don't feel that it's indicated, or their policies don't allow it to occur.

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11:10:40
And do you think that they're pushing back because it costs so much...

SUBACH

11:10:43
Yes.

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11:10:44
...or because they think the evidence is not there that they work?

SUBACH

11:10:47
The evidence is absolutely there that it works. I think it's purely a cost.

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11:10:51
Richard Deyo, let me turn to you. I know that you've written that you feel there are more spinal fusion surgeries being performed than ought to be. But what is your view on that?

DEYO

11:11:01
Yeah. I think there really are. As you pointed out, this has increased six-fold over the last 20 years. And certainly there's no reason to think that we have six times more unstable spines, if you will. But we're doing twice as much spine surgery as most countries in the world. That's Australia, New Zealand, Europe, Canada, and about five times more surgery than the United Kingdom, England, and Scotland.

DEYO

11:11:29
And the results actually for some indications of spinal fusion are very good. I'd agree with that. On the other hand, for the patient who just has a worn out disc, the sort of arthritis that Dr. Subach refers to, I would argue that the evidence is far less clear. We have several randomized trials, mostly done in Europe, that suggest that in fact spinal fusion surgery is no more effective than a highly-structured rehabilitation program. And that being the case, we have to ask whether this is really offering a major advantage or value for the cost.

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11:12:07
And why do you think the number of surgeries has gone up so much when you're saying that the studies that have been done don't show that they're appropriate in all these cases?

DEYO

11:12:17
Well, I think the financial incentives are important. But I wouldn't put the blame necessarily on surgeons or physicians. I think there's a lot of aggressive marketing going on by the companies that manufacture the devices, the screws and the plates that are often inserted in the course of spinal fusion surgery. And it's got a high profit margin for hospitals as well, so there's often a good deal of pressure on surgeons to be performing as much spine surgery as possible.

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11:12:45
Do you -- what do you think about that, Brian Subach? Is the -- I mean, we're all very accustomed to seeing a lot of medical advertising on TV now for devices, for surgeries, for drugs. Is that playing a role in this?

SUBACH

11:13:01
I don't believe the advertising is playing a role whatsoever. What I would tell -- I'll give you an example. If you look at people who have a cervical spinal fusion, meaning a disc is removed and bone is inserted to take away pain or compression of the spinal cord, the traditional treatment was to place a bone graft in that disc space and then stabilize it with a hard collar, one of those hard plastic collars that someone wears, for three months.

SUBACH

11:13:27
If you decide to put a $1,000 plate on the front of the spine, you completely eliminate the need for that rigid collar. So ask someone in Virginia or in D.C. in the summer if they're going to wear a collar 24 hours a day for three months or they'd rather pay a thousand dollars for a plate that will do the same thing on the inside. There's no decision. As far as I'm concerned, that investment in the instrumentation of the plate dramatically improves outcome and comfort for the patient.

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11:13:56
So, Dan, what did you find in your reporting on the reasons behind this big increase?

KEATING

11:14:01
Well, the central thing we found is that while the surgery -- I mean, I think the surgeons are getting really good at it. And when you're good at something and you see a benefit of it, there is a temptation to use it in a lot of circumstances. But what we found is even the professional associations in the field that are kind of responsible for standards and what is the best practices are saying that, you know, optimism and enthusiasm for this practice is outrunning proven medical benefit.

KEATING

11:14:30
So they're not saying it doesn't work for anybody, but they're saying that for some diagnoses, there has not yet been a proven benefit to doing spinal fusion as compared to other less invasive things so that -- but they think that people are just -- you know, there's a lot of enthusiasm to do it because they're good at it now.

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11:14:48
So the doctors are enthusiastic about doing it. And I wonder to what degree it also reflects changing attitudes about aging and expectation that there should be a fix for some of the things that happen when we age.

KEATING

11:15:03
I think that's absolutely true. I think people are excited when a doctor can tell them, this procedure is going to help you. And some of the people we interviewed for the story were told by doctors, this is going to really make you better. And in fact what it turned out with is the diagnoses they had didn't really justify the surgery, and, unfortunately for them, the surgery worked out badly. So, yes, people love it when a doctor can say, I can fix this problem you have.

KEATING

11:15:27
But when the doctor's saying that about something which there isn't proven medical evidence that in fact spinal fusion does solve the problem they have, then, you know, that's where the enthusiasm is running away from medical evidence.

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11:15:41
What do you find when you deal with patients who come in with back pain? And do they say to you, please, surgery, fix this for me so I don't have to deal with it?

SUBACH

11:15:50
Well, in my practice, I'm essentially a tertiary referral practice. I have people who have done physical therapy. They've seen their primary care doctor. They've come in with X-rays and MRI scans, and they're frustrated. They don't want to be given Percocet to deal with their pain. They want their quality of life back. One of the people in the WAMU blog wrote that it wasn't just about playing tennis. I would just say it's about tying your shoes. It's about working. It's about being part of your family.

SUBACH

11:16:14
And so the reason why we do what we do is that -- I disagree with Dan respectfully -- saying that I don't do anything that is unproven. We do investigate. We do try to do our outcomes research because we need to prove the validity of what we're doing. We need to show other people that our interventions do make a difference, and it impacts people's lives.

SUBACH

11:16:33
So we try not to do a whole lot of things that are on the fringe. We do reasonable medical practice. But people are certainly excited when you can show them on the MRI scan that this is the problem, I believe that I have a cure for you and that we can get you back to your life.

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11:16:49
Richard Deyo, what do you think?

DEYO

11:16:51
Well, I worry that patients are given unrealistic expectations. The reality is that most people are not pain-free after they have spine surgery. And all of the clinical trials that we have suggest that that's true. There may be improvements in pain, but very few of these patients are actually pain-free. Also, the concern is that patients don't want to be taking pain medications or painkillers for the rest of their lives.

DEYO

11:17:17
They want to stop their Percocet. The reality is, in trials that have been done for FDA approval of new surgical devices, that when patients undergo spine fusion, the vast majority are still taking painkillers, even two years following their surgery. So it's often not an either-or. It's often surgery and opioids for many patients.

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11:17:39
And what about other practices, less invasive procedures or other courses that patients with back pain can take? How do they compare with the success of spinal fusion surgery?

DEYO

11:17:54
Well, we have, again, some clinical trials comparing rigorous rehabilitation programs with spinal fusion surgery for patients who have just degenerative discs. So I'm not talking about patients with severe deformities but just patients that have worn-out discs. And in those trials, it appears that in fact a rigorous well-structured rehab program that comprises mostly exercise and so-called cognitive behavioral therapy is just about equally effective as spinal fusion surgery with far fewer complications.

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11:18:31
We're going to take a short break. And when we come back, we'll go to the phones and take some of your calls. Our toll-free number, 1-800-433-8850. You can send us an email to drshow@wamu.org. Or find us on Facebook or Twitter. Stay with us.

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11:18:59
Welcome back. I'm Susan Page sitting in for Diane Rehm. With me in the studio, Dan Keating, a reporter at The Washington Post, and Brian Subach. He's a spine surgeon and president of the Virginia Spine Institute. And joining us by phone in Portland, Ore. is Richard Deyo. He's a professor, a physician and researcher at Oregon Health and Science University. He is the author of "Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises."

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11:19:25
I know we have several people waiting on the phones for us. Let's talk first to Lori from Jacksonville, Fla. who's giving us a call. Hi, Lori.

LORI

11:19:33
Hi.

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11:19:34
Thank you so much for calling us.

LORI

11:19:36
Oh, you're welcome. Thanks for having me. This is a subject that's near and dear to my heart. I had spinal fusion in July of this year, cervical spinal fusion. And I had a lumbar discectomy in March of this year. And I can't say enough about the benefits of the surgery.

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11:19:56
So it worked for you?

LORI

11:19:58
It worked for me. And to give you some background, I'm an attorney who handles disability claims, so I've represented hundreds if not thousands of individuals who have had spinal surgery. And I only see those who have failed surgeries, because they wouldn't be coming to me for help with disability claims if they had a successful surgery. So I (unintelligible) surgery for at least 10 years, I've suffered in pain.

LORI

11:20:22
If I have surgery - it finally got to the point I couldn't deal with the pain anymore. So...

PAGE

11:20:28
Okay, Lori, thank you very much for your call. I'm afraid you're breaking up, but I take your point that the surgery was a success for you, but you've represented people in the past who had had unsuccessful outcomes. She was calling us from Jacksonville. And I know that, Dan, you looked at kind of a case study in Florida about patient records in Florida. Tell us what you found in looking at that state.

KEATING

11:20:51
Yeah, we looked at about 125,000 surgeries spread over from 1992 to 2012. And specifically what we did we looked at particularly lumbar surgery which is lower back. She had cervical which is up higher. But we looked particularly at lumbar because there are pretty clear standards announced by the professional societies with regard to which diagnoses routinely justify spinal fusion and which ones it's probably better to do other things.

KEATING

11:21:21
And so in looking at that, we saw, you know, the growth in lumbar spinal fusions there from less than a thousand in 1992 to more than 15,000 in 2012. And the dollar cost adjusted for inflation went from $47,000 to $2 billion. And what we saw was all that growth...

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11:21:39
Dan, say those numbers again. In that time it went from...

KEATING

11:21:42
It went from $47 million -- sorry, did I say thousand -- $47 million to $2 billion. And that was just the hospital fee, not the doctor fee, just the hospital. And what we saw is that about half of those in that huge growth did not have diagnoses that would be considered to have justified use of the -- so now, looking at the data is not the same as diagnosing an individual patient and we don't pretend that it is.

KEATING

11:22:07
But when you see such a broad pattern, it is indicative of the likelihood that these surgeries are being used in cases where there's not a proven recommendation. And that matches up with some other studies that have been done that find about half of them might not be called for.

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11:22:23
So half of the surgeries don't seem to have been indicated. How did you get access to these records, I was curious?

KEATING

11:22:28
That data is actually the kind of data that is becoming more and more available. It doesn't have patient's names in it. And in fact, we have to sign an agreement when we get the data that we would never try use the data to find or contact or identify a person and we would never do that. But it is the kind of data that's being made more and more available for researchers to look at outcomes and price and all kinds of issues in medical science.

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11:22:51
So, Brian Subach, what do you make of these findings?

SUBACH

11:22:54
Well, part of the problem had to do with the ICD-9 coding. Meaning, how you describe a specific patient is a generalization. So it's very difficult to describe Dan Keating's back with an ICD-9 code, in general. All of the spinal fusion surgeries done in our practice and that I am a part of have a definitive diagnosis and the research is there for degenerative disc disease, for spondylolisthesis, for post-laminectomy syndrome.

SUBACH

11:23:21
There are definitive diagnoses that make these indications which are suspect not an option in my practice. So what I say to Dan and what I say to the other, Peter who's not here, I say to the other reporter. I say in the specifics of Florida, I can't really speak to that. But the research that has been done and the studies that have been showing outcomes that are solid with spinal fusion for known indications, there's no real way to combat those things.

SUBACH

11:23:51
Those are proven. They work, and that's what we incorporate into our practice.

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11:23:56
And, Richard Deyo, let me ask you what do you make of these findings of looking at these 125 thousand surgeries in Florida?

DEYO

11:24:05
Well, I think the real question is how valuable is spinal fusion for patients who just have degenerative discs. Excuse me. I'd agree with Dr. Subach that spinal fusion can be very effective for patients who have deformities like spondylolisthesis, which is the slip of one vertebrae on another. I think the real controversy comes with just degenerative discs. Again, if we look at FDA trials for new surgical devices, we have several trials that had spinal fusion as one arm of a clinical study.

DEYO

11:24:41
The FDA said, we'll call it a success if the patient has an improvement in their daily function, if the bones are actually fused successfully, if there's no nerve injury, if the screws are in the right place and if the patient has no surgery within two years, no repeat surgery. And by those criteria, only about 40 to 50 percent of patients actually had a successful outcome. So I think the actual success rate by those criteria is far less than we'd like to think.

SUBACH

11:25:15
May I? Interesting that you say that because just last month in the Spine Journal there was a publication from Mirza and Deyo which talked about surgery for degenerative lumbar disc disease. And so, my read on this is that if you compare a non-operative subset with those undergoing spinal fusion surgery, it looked like the spinal fusion surgery patients did twice as well. Actually, more than twice as well.

DEYO

11:25:39
Excuse me. They did better, but I have to point out that the success rate there was about one out of three.

SUBACH

11:25:47
Understood. So you set the criteria. And as we know, Mark Twain says, there are statistics, damn statistics and lies. So I know statistics are all open to interpretation. But for someone who has spent his career talking about degenerative lumbar disc disease, it is interesting that a study out of your institution actually shows value to surgery over non-operative management.

DEYO

11:26:06
Well, I have to point out that that's not a randomized trial. It's not the most rigorous research design. And furthermore, the patients who got non-surgical treatment weren't offered the sort of structured rehabilitation that's been shown effective in randomized trials. What they were offered in general was just more of the same that they've already had and wasn't working.

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11:26:26
You know, we have a caller who I think has a story that might relate. A personal story. That's Cindy, who's calling from Fort Myers. Cindy, you're on the air.

CINDY

11:26:34
Hi. I am a patient that was seen by a neurosurgeon, several neurosurgeons in my area to treat a problem I had, where I was not able to work because I had numbness in my hands. I'm a surgeon actually myself. I had vax-D therapy done as an alternative choice.

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11:26:59
Now, I'm sorry, what was the alternative choice that you had done?

CINDY

11:27:02
Vax-D therapy.

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11:27:04
And what is...

CINDY

11:27:04
It was not actually recommended by the neurosurgeon that I first saw. He recommended a five-disc fusion for my neck because I had three bulging discs related to an old injury. A car accident whiplash injury that 15 years later gave me numbness in my hands. And since I was using my hands for work, they recommended that I have this five-disc surgery done. And I absolutely said I have got to look into alternatives. I've got to see what I can do.

CINDY

11:27:30
This is going to ruin my career. And I had another neurosurgeon that I saw as a second opinion who, understanding my background, my family and me personally, said no way. You go get Vax-D therapy done. You're going to try cervical compression/decompression treatments and we'll see how you do over the course of a year. I got rid of three bulging discs and no pain, no tingling in my hand.

CINDY

11:27:58
I have no pain now at all. I do daily exercise to just make sure that my neck stays healthy and I am out of pain completely. And I think a lot of aren't aware of alternative medicines options, such as Vax-D therapy. I think it's huge. It's not very popular because the medical profession doesn't recognize it as a therapy that's worthwhile investigating. That's been my experience. And I think patients want to, you know, trust their doctor.

CINDY

11:28:28
They want to know when they're seeing a neurosurgeon that their doctor was recommending surgery because that is what is best for them. I don't always find that's the case as people are recommending surgery when there's alternative options out there that are not even discussed. So I have a, unfortunately, a negative view on the fact that sometimes patients might be taken advantage of when they're in pain and they need to get out of pain. And this is the kind of pain that interferes with daily life.

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11:28:54
And why do you think doctors, in your view, do not often enough recommend or explore these other possibilities?

CINDY

11:29:00
Because there is no place in medicine where Vax-D therapy can be done. You can't have it done in the hospital. You can't have it done in an orthopedics office. You can't have it done at a neurosurgeon's office or a neurologist office. It's done by a chiropractor. It's done in a different venue of medical care in our society. And a lot of chiropractic care is not really in the medical profession respected to the level that an orthopedic or neurologist referred to a chiropractor doing Vax-D therapy. It's just doesn't happen in the real world.

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11:29:34
And, Cindy, just one last question in your own -- are you back working as a doctor yourself?

CINDY

11:29:40
I am the doc. I actually do surgery myself with my hands. I'm working and I am in no pain at all.

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11:29:46
And has this experience changed your own practices as a surgeon in terms of recommending alternative medicine?

CINDY

11:29:52
It has. I bought a laser to do surgery so I could do more conservative surgery than what I currently was doing, because I think sometimes people don't realize that surgery creates its own issues. And that's why a lot of people aren't out of pain after having it done because you create scar tissue, you create immobility, which in turn really causes muscle atrophy, which causes its own set of issues.

CINDY

11:30:15
And a lot of these problems, they're problems that are chronic that don't happen maybe right after the surgery is done but happen over time.

PAGE

11:30:23
Yes.

CINDY

11:30:23
And so being conservative, I think our whole medical profession is going in that direction, being less surgically oriented to get rid of pain and more toward preventive, proactive approaches that are more conservative. I think the whole medical arena should be heading in that direction. I don't think the neurosurgeons have work to do when it heads in that direction. And that's what the problem really is.

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11:30:46
All right, Cindy, thank you so much.

CINDY

11:30:46
That's why you're not getting a recommendation, you know, from the neurosurgeons to have Vax-D therapy done, probably half their patient population would be cured by doing something more conservative.

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11:30:55
Cindy, thanks so much for your call. We're glad that you're problem with your back has been relieved.

CINDY

11:31:00
My neck, thank you.

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11:31:00
You know, Brian Subach, I'm not saying that anyone in your practice would do this. But I wonder if you think this is a problem generally that doctors are too reluctant to recommend some alternative approaches.

SUBACH

11:31:12
Oh, I don't think that they're reluctant that a good physician will recommend all of the conservative management strategies possible prior to surgery. So the way I look at it is that everyone certainly does not benefit from surgery. And of the people who needs surgery, a very small percentage need spinal fusion. So I'm glad Cindy is doing well. As far as pain management or physical therapy or chiropractic manipulation or even acupuncture, these are things that we very routinely recommend in our practice.

SUBACH

11:31:40
And so I think the outdated philosophy that a surgeon is a hammer and the patient is a nail, where there's only one option, I think that is antiquated and, honestly, not the way it's done anymore.

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11:31:52
I'm Susan Page, and you're listening to "The Diane Rehm Show." We're taking your calls at 1-800-433-8850. Dan, what do you think?

KEATING

11:32:01
I think, unfortunately, the issue that Brian just brought up is exactly what people are concerned about, which is that doctors not have this -- surgeons have this issue where once they get good at spinal fusion, it seems like an alternative to use for things that haven't yet been proven to work. But then there are the additional incentives in the situation. There are incentives from the hospital.

KEATING

11:32:24
There are incentives from just the fees themselves. And then there is this growing of physician-owned distributorships, PODs, where the doctors are also getting the money for the hardware that's used in the surgery. So the hardware is a significant cost in this. It's very profitable. They sold about $5.1 billion worth of spinal fusion hardware in the U.S. per year. That is more than double the entire rest of the world combined.

KEATING

11:32:54
That's a lot of money. So when you talk about heavy marketing and everything, this stuff is a very big issue. And now it's not something where the patient is going to say, okay, let me go pick which screws and rods are going to be inserted in my back. That's totally going to be the physician's decision. And now you've got this growing situation of PODs, physician-owned distributorships, where the physicians are the ones selling the hardware that they are then putting in people's backs.

KEATING

11:33:21
And the I.G., the inspector general for the Department of Health and Human Services recently came out with a report that it suspects that these physician-owned distributorships are a significant part of why spinal fusion is growing so much. They looked at whether the pods actually reduce cost, which was the premise that they would and found that, A, they didn't reduce cost in the I.G. study. And, B, the places that had them had an increase in spinal surgeries and fusions.

KEATING

11:33:50
And, C, there is almost no disclosure, even sometimes to the hospitals but almost never to the patients that, oh, by the way, I'm going to be making money off the hardware I'm putting in your back as well as doing the surgery and sometimes, like the case we wrote about, being paid incentive money by the hospital to do more and more surgeries. So with all of those things combined, you know, it's a case where you -- I have never met a doctor who I personally thought was, you know, doing this just for the money.

KEATING

11:34:19
But overall in the whole system, it's hard to believe that this influence of all these incentives to be made and really big dollars are not influencing people.

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11:34:30
You know, we have gotten a lot of emails like this one from Vicky in Haymarket, VA. She writes: I'm a patient at the Virginia Spine Institute and suffered from back and leg pain for almost a decade. I was in constant pain with little or no disk left between and my insurance did not want to approve the procedure for me of spinal fusion surgery, calling it not medically necessary.

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11:34:52
I was so angry, but in the end I was approved after a long and painful fight. I'm happy to say that eight days ago I awoke from surgery with no pain at all other than the incision and fusion spot, which is to be expected. I'm now pain free a week after surgery. So that's very good news, Vicky. Thanks so much for writing us. But we also have this email from Scott. He writes us: I am a neurospine surgeon in California.

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11:35:14
I'm a board member of the Association of Medical Ethics. Last year, I wrote an article about the ills of spine surgery in this country, largely due to the proliferation of physician-owned distributors of medical products. There is far too much spine surgery being done solely for the profit involved. So two very different points of view. We're going to take another short break.

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11:35:34
And when we come back, we'll come back to your phone calls and your questions for Dan Keating, a reporter at the Washington Post and Brian Subach who's a spine surgeon and president of the Virginia Spine Institute. And we're being joined by phone from Oregon with Richard Deyo, a professor, a physician and researcher at Oregon Health and Science University. We'll take your calls and questions. Stay with us.

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11:37:26
Welcome back. I'm Susan Page of USA Today, sitting in for Diane Rehm. Diane is visiting WUNC in North Carolina today. She'll be back on Monday. We've been talking, Dan Keating, about on the show prompted by an investigation you helped do in the Washington Post. And in it, you wrote a lot about a Dr. Vinas and a lawsuit filed at Halifax Health Hospital. Tell us about that story.

KEATING

11:37:51
Well, we used that as an example because the currently pending lawsuit gave us a window into some of the practices that normally the public isn't able to see. So specifically Dr. Vinas was a very successful -- is a very successful spinal fusion, spinal doctor at Halifax Health in Daytona Beach, FL. And he was doing so many surgeries that the compliance officer at that hospital became skeptical about whether they were all justified.

KEATING

11:38:22
And she pushed the hospital to do a study. And eventually they did do a study. They hired an outside consultant of neurosurgeons and reviewed 10 of his cases and they concluded that 9 out of the 10 were not medically justified. So even after that the hospital said they did their own review and they stuck by the doctor. They said they don't see any evidence that he's ever done any unwarranted surgeries.

KEATING

11:38:48
And so, the compliance officer herself filed a lawsuit for unjustified compensation. The Department of Justice in 2001 enjoined that lawsuit, meaning that they feel that -- they're arguing that money has been paid by the federal government when it was not justified. So that lawsuit is still pending. And I have to say, you know, Dr. Vinas' attorney said he would never ever do such a thing.

KEATING

11:39:11
He put us in touch with a patient who is very -- Dr. Vinas did repeated fusion surgeries on and said he did a great job. And the hospital's attorney said, you know, they would never ever do that. But part of what the lawsuit showed was that the hospital paid incentive pay to the neurosurgeons based on how many surgeries they did, which was seen as, you know, increase in the rate of surgeries.

KEATING

11:39:34
And that Dr. Vinas is very, very close with the salesman from the company whose hardware use and they even traveled to Thailand together. So it just -- it was a case -- and we also talked to some of the patients who had had really bad outcomes and questionable basis for having the surgery. And so, it was just a look inside when, you know, when I said before, I've met all these doctors and they're all very nice.

KEATING

11:40:00
And it's hard to wonder if there are really cases where people are influenced. And this is a case where we're saying the evidence for somebody being influenced seems to be pretty strong.

KEATING

11:40:00
You know, we have a lot of callers who have had good experiences with this kind of surgery. And then we've got callers who have had unfortunate and bad experiences with it. So let's try to take maybe one of each. Let's go first to Ashburn, N.C. and talk to Yvonne. Yvonne, thank you so much for giving us a call.

YVONNE

11:40:28
I just wanted to call in and tell you that my daughter had a ruptured disc and a bulging disc and had surgery two years ago right before Christmas. And it was a Christmas blessing for us. She woke up without pain and has done well ever since. And I just wanted to call in and tell our blessing that was for my family.

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11:40:50
Well, I'm so glad that things worked out for her. Thank you very much for giving us a call. Now let's go to a caller who has had perhaps a different experience to Indianapolis. We'll talk to Ellen. Ellen, hi.

ELLEN

11:41:01
Hello. How are you?

PAGE

11:41:03
Good.

ELLEN

11:41:05
Well, back in '91, I had a back surgery that went really bad. What happened was the doctor cut my spinal sheath and part of my spinal cord. So I have little feeling in my legs, but I'm able to walk. When I went into surgery, I'd been in a wheelchair and then on crutches. And afterwards, after the recovery room, I had a grand mal seizure, a stroke, and I lost part of my eyesight, the lower part, so I can't fly a plane anymore. And I lost my memory of most the things that happened before surgery.

ELLEN

11:41:58
So the first words that the surgeon said to me when I woke up was, you can't blame me. You can't sue me. Well, I never sued him because I, you know, I believe that it's a medical practice. It's not a medical perfection. But the funniest thing happened was that my identical twin sister said I had the stroke on purpose so I wouldn't have to take responsibility for anything that happened before the stroke.

PAGE

11:42:27
Well, Ellen, it's good that you've kept a sense of humor. We're so sorry to hear about the various problems that you had with your surgery. I mean, perhaps -- I wonder if there's any lesson to be drawn from the fact that we have any number of people on both sides waiting on the phones who have had very good experiences -- it's been life changing in a good way -- others who say their experience has been pretty sorry.

ELLEN

11:42:48
Well, for me, life is a journey, and it's up and down. And, unfortunately, the back operation didn't turn out like I wanted it, but a lot of good things happened because of it. Afterwards, I took more interest in what was going on in my family.

PAGE

11:43:10
Mm hmm.

ELLEN

11:43:10
And everything that I was able to do, I was really thankful for.

PAGE

11:43:17
All right. Ellen, I mean, that's so good to hear. Thank you very much for your call. Richard Deyo, what lessons can we draw from the fact that we have such a mix of people?

DEYO

11:43:27
Well, you know, I think it really is true that there are some good outcomes from this type of surgery, and there are some good outcomes from nonsurgical treatment. We've heard a little bit about complications and talked very little about the complications. But that's an important feature here that one has to understand fusion surgery especially is a truly major operation.

DEYO

11:43:50
But I guess my wish would be that patients go into this very well informed and understanding not just that complications can happen but understanding how frequent the complications really are and even understand the fact that one out of five patients who has a fusion operation will have another back operation within the next 10 years, something that I think we talk about too infrequently.

PAGE

11:44:17
So if someone's having back pain and they're going to see a surgeon and they're recommending this surgery, what do you advise them to do?

DEYO

11:44:26
Well, I think it's important for patients to always consider a second opinion. I have an orthopedic colleague here in Portland who says, gosh, if you would get a second opinion about remodeling your bathroom, why wouldn't you do the same thing if you're considering back surgery? And I think that's an important thing for everyone to consider because sometimes you discover that there are important differences of opinion.

PAGE

11:44:51
What about, well, you, Brian Subach, what do you -- somebody is hearing this program. They're having back pain. They're thinking about, should they consider the surgery? How should they proceed in way that's smartest?

SUBACH

11:45:02
Dr. Deyo's point is very well taken. You should get a second or even a third opinion. I typically have people who have seen two or three other pain management physicians or surgeons prior to seeing me. So what my patients tell me is they tell me that no one has actually explained what is going on to them.

SUBACH

11:45:20
Many doctors keep their hand on the doorknob. They say, OK, we're going to give you this pill or this shot. And they don't actually treat the patient. So I think that people should get someone that they're comfortable with, whether it's a pain management physician, a primary care doctor, or a spine surgeon, someone who can explain the problem, have a conservative management approach, and hopefully be able to avoid surgery.

PAGE

11:45:41
Dan, you've been writing about financial incentives that may be affecting medical decisions. What other kind of examples have you found?

KEATING

11:45:50
Well, we wrote -- Peter Whoriskey and I wrote recently about medications for a really common form of blindness for -- as people age, called we macular degeneration. And there are a couple medications that are very effective in treating the condition. And one costs about $50 per treatment, and one costs about 2,000. And this is a treatment you have to get between every one and four months, so it repeats a lot over the course of the year.

KEATING

11:46:18
And they're both made by the same company. The one that's less expensive was originally designed as a cancer treatment. But doctors who are testing the newer drug and were familiar with both tested the older drug and found that it worked. And, because it's priced in the large doses needed for cancer treatment in the tiny little one-milligram dosage needed to inject into someone's eyeball, it's very inexpensive.

KEATING

11:46:41
So -- but the company Genentech has resisted efforts to have it be approved for eye treatment. So it packages and markets the expensive one -- and more than half of the doctors use the less expensive one -- but the cost difference, even with only being used a minority of the time, the more expensive drug is costing Medicare alone more than a billion dollars a year extra. And so we use examples like this as a way of saying how Medicare and the medical system in general has a really poor track record being able to control costs.

KEATING

11:47:16
With the spinal fusions, there have been times where Medicare has tried to apply some controls. And it's true that you don't want the government between you and your doctor making these decisions. So it becomes very hard to -- I mean, it's truly a system where all the kind of market-oriented approaches that we'd like to rely on in this country really applied badly to the medical system.

PAGE

11:47:40
And does the Affordable Care Act, which is changing and affecting so many aspects of healthcare in this country, does it try to address this particular problem?

KEATING

11:47:49
It does in a couple respects. One, it has more transparency in terms of some things like payments from medical suppliers and pharmaceuticals to doctors that maybe have some influence are now going to have to be disclosed, which currently are not.

KEATING

11:48:06
And, you know, there is the part of the ACA, which got called horrible names that I won't repeat, but was specifically oriented toward trying to say what are actual best practices with the best outcomes to be researched by other than the people whose interest is in selling perhaps the more expensive choice so that there would be more research applied to encourage use of affordable care.

KEATING

11:48:33
But that got a lot of pushback, and that has been tried repeatedly in the past and has always been defeated by pushback. So whether ACA is actually going to bring down the cost of care is one of the things that people are really not terribly optimistic about.

PAGE

11:48:47
Richard Deyo, how about you? Do you think the Affordable Care Act is going to have a big impact on this particular area?

DEYO

11:48:52
I don't think we're likely to see an immediate impact. But I'd like to think that in the long run a variety of forces are going to begin to moderate some of the increases that we've seen. And I think that the combination of new and better research, altered financial incentives and so forth, are likely to bring a lot of the higher costs under control.

PAGE

11:49:18
But you expressed concern, Brian Subach, that the -- one of the pressures is insurance companies just wanted to hold down cost, not necessarily having the best treatment for their patients in mind.

SUBACH

11:49:29
Really. They are denying access to care. That's what it comes down to. And it's really based upon cost. So in my practice specifically, the number of denials for surgical procedures are up over 30 percent, which means that not a day goes by that I'm not speaking with a medical director from an insurance company, trying to convince that medical director that what I'm doing is appropriate.

SUBACH

11:49:50
And many times it comes down to policy. So the healthcare insurance policy states that this is not a covered benefit. So no matter how much I speak and try to convince, it quite simply won't work because it's the policy.

PAGE

11:50:04
I'm Susan Page, and you're listening to "The Diane Rehm Show." Let's go to the phones. We'll go back to North Carolina and talk to Alicia who's calling us from Cary, N.C. Alicia, you've been really patient. Thank you for holding on.

ALICIA

11:50:16
Yes. Thank you so much. Thank you for taking my call. I'm 31 now. But when I was in my mid-20s, I started having severe back pain, almost to the point where I wasn't able to sleep at night. I wasn't able to stand up. And so I started going to different doctors. And none of them knew what was wrong with certain discs in my back.

ALICIA

11:50:38
And so they suggested surgery. And being so young, I did not want to do that. So I -- my regular doctor suggested a chiropractor. And I started going to the chiropractor, and I started practicing yoga. And now I don't have any back pain at all. And so I'm really glad I did not go through with the surgery.

PAGE

11:50:57
Yeah. That -- well, I'm glad to hear that worked out. Thanks so much for your call.

ALICIA

11:51:02
Yes, thank you.

PAGE

11:51:03
Well, you know, we also have an email coming from Nancy, who writes, "I am almost 81." So kind of at a different age group than Alicia. She said, "What are the age restrictions on spinal fusion and rehabilitative exercises? I have a lot of spine problems, including and probably aggravated by lifelong scoliosis." Dr. Subach, is there age restrictions -- I mean, or age limitations? Someone 81 years old, would they be considered a good candidate for this surgery?

SUBACH

11:51:29
Well, as Dan has alluded, we've gotten so good at doing these procedures. They're less invasive. We call them minimally-invasive approaches. We use lasers and biologics to eliminate painful bone grafting and many of the things that used to cause people to be laid up in bed for quite a period of time. So I think with the minimally-invasive nature of what we do that there's really no age limit.

SUBACH

11:51:48
She does have to go under general anesthesia, and so that would be a concern. She needs to have a strong heart and strong lungs to go through anesthesia. But in general, the blood loss is minimal. The time that's spent in bed is really nonexistent. So I would say that the only restriction on surgery is your general health.

PAGE

11:52:05
Dr. Deyo, you've been a skeptic about how many of these surgeries are being done. What do you think ought to happen? Is there either a medical group or a government operation that ought to be looking at this to try to make sure the surgery is called for in the cases that takes place?

DEYO

11:52:24
Well, that's the sort of thing that Dr. Subach is describing with the insurance carriers and some cases and in some states are trying to do. You know, as a clinician, I hate calling insurance companies to get clearance for procedures or tests that I want to order as well. So I sure understand the frustration with that. On the other hand, I think we've seen and heard a fair bit of evidence that spinal fusion surgery is perhaps being done excessively. And physicians aren't, in a sense, policing themselves in this regard.

DEYO

11:52:57
So it's not surprising, I think, that we're seeing insurance carriers beginning to develop more restrictions. I'd love to see clinicians, physicians, surgeons really address the scientific literature as carefully as possible and as rigorously as possible. And I think that if we did that, we'd suddenly be considerably more cautious than we've been up to now.

DEYO

11:53:20
I'm not saying there is no indication for spine fusion. I think there certainly are patients that do benefit from it. We've heard from some of them. But I do think that there are too many. And even there's plenty of surgeons who would agree with that point of view.

PAGE

11:53:36
And, Dan Keating, do you have any final words on what you think ought to happen?

KEATING

11:53:40
I think, as Dr. Deyo said, the best thing is sufficient research so that people aren't doing it out of optimism that they hope this kind of treatment works, but that we have a clearer idea of what works and what really doesn't work.

PAGE

11:53:54
Dan Keating of The Washington Post, Brian Subach, a spine surgeon and president of Virginia Spine Institute, and Richard Deyo, a professor at Oregon Health and Science University, thanks so much for joining us this hour on "The Diane Rehm Show."

SUBACH

11:54:07
Thank you.

DEYO

11:54:08
Thank you.

PAGE

11:54:09
I'm Susan Page of USA Today sitting in for Diane Rehm. She's visiting WUNC in North Carolina and will be back on Monday. Thanks for listening.
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