January 2, 2003
Letters to the Editor
The New York Times
229 West 43rd Street
New York, NY 10036
letters@nytimes.com
On behalf of the Board of Directors and the nearly 4000 members of the North American Spine Society (NASS) -- both surgeons and nonsurgeons -- I want to thank Reed Abelson and Melody Peterson for their article, “An Operation to Ease Back Pain Bolsters the Bottom Line, Too”(December 31, 2003). Their report elucidates an issue spine doctors struggle with every day – deciding which treatments will work best for which patients.
Treatment of the patient with spine problems is an art based in science. It is vital to note that back pain can have a wide variety of causes. So first the cause must be determined and then the experienced practitioner can discern the optimum treatment for that condition. A survey of our members indicates that 90% of the care they provide is nonoperative. Surgery is usually the last resort (absent clear neurologic indications or acute incapacitating pain). Still, controversies do exist -- what one doctor thinks is appropriate treatment another doctor might think is inappropriate. Often what they disagree on is the timing of an intervention. Should the patient try one more injection, a different drug or another type of physical therapy before surgery? Then, what surgical procedure (laminectomy, discectomy, fusion, instrumentation) is the best option for the patient?
We constantly debate these issues at our conferences and in our publications where we review a growing body of literature on outcomes. Numerous studies demonstrate the efficacy of fusions in general and even fusion versus laminectomy. A groundbreaking 1991 study, for example, clearly showed the benefits of fusion over decompression alone, specifically for the diagnosis of degenerative lumbar spondylolisthesis. (Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991 Jul;73(6):802-8.)
Laminectomy and fusions are very different procedures that are done for different reasons. It is not appropriate to compare their use for something as broadly defined as “back pain.” Certainly, when appropriate, a laminectomy is a simpler operation, but normally that is done when someone presents with leg pain. The difficulty is determining which patients will do well with a simple laminectomy and which patients require fusion for a longer lasting result. In a 1997 study of this very issue, researchers found that almost 50% of patients treated with laminectomy alone experienced a return of leg pain within five years. ( Jonsson B, Annertz M, Sjoberg C, Stromqvist B. A prospective and
consecutive study of surgically treated lumbar spinal stenosis. Part II: Five-year followup by an independent observer. Spine. 1997;22(24):2938-44. PMID: 9431630)
The award-winning Swiss study mentioned by Dr. Eric Woodard in your article showed better results for fusion versus nonsurgical treatment for chronic low back pain. (Fritzell P, Hagg O, Wessberg P, Nordwall A. Swedish Lumbar Spine Study Group. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine. 2001;;26 23):2521-32; discussion 2532-4. PMID: 11725230.)
We appreciate Dr. Ghogawala’s interest in this topic, but must point out to readers that he has only one peer-reviewed published work relating to spine. We would suggest that readers seek findings from spine specialists with well-established research track records. (Ghogawala Z, Mansfield FL, Borges LF. Spinal radiation before surgical decompression adversely affects outcomes of surgery for symptomatic metastatic spinal cord compression. Spine. 2001;26(7):818-24. PMID: 11295906.)
There is little doubt that finances play a role in the delivery of health care. Fifteen years ago, the NASS Board focused almost solely on clinical issues -- not business matters. These days, because of poor overall reimbursement for the vast majority of procedures, increasing regulations and huge increases in professional liability insurance premiums, NASS tries to assist members with practice management matters in addition to providing education on clinical issues. The article quotes Dr. Ed Benzel (who serves on our Board of Directors) as saying that the reimbursement system is “perverted.” Essentially his point is that doctors have little control over what is reimbursed and/or how much it is reimbursed. Reimbursement is driven by the Medicare system which is grossly underfunded given the expanding number of beneficiaries and their needs. Insurance companies key off of the Medicare fee schedule so overall reimbursement in the field is inadequate. Furthermore, physicians and hospitals are not allowed to balance bill patients to cover their total costs.
Contrary to the figures reported by Ms. Abelson and Ms. Peterson, based on 2002 data the average Medicare payment for lumbar laminectomy is $1037 (a decrease of 26% since 1997, by the way) compared to $1449 for lumbar fusion (a decrease of 20% since 1997). The average payment for lumbar instrumentation, one level, is only $776, (a decrease of 8% since 1997). It is also worth pointing out that these are the payments for a primary procedure. When combined (as is usually the case) with second and third procedures, they are reimbursed at only 50%. Furthermore, if Medicare reimburses only $1037 for a laminectomy and a doctor does 200 a year, he generates $207,400 -- but his insurance premium might be $200,000 per year or more. When you add the other practice expenses, he or she is not even covering basic costs.
The article implies that hospitals benefit from the use of instrumentation in fusion surgeries but the reality is that the hospital receives the same payment for the fusion operation whether or not instrumentation is used. The hospital carries the clear financial burden when instrumentation is necessary for a Medicare patient. With extraordinarily few exceptions, doctors have always held themselves to high standards taking the patient’s interests into account first and foremost. Patients today have become more involved in decisions about their care than ever before -- and this is a great development. We encourage it. The spine doctor of today has to be familiar with the range of options available and discuss with the patient risks, benefits and alternatives -- it is common practice and required as a matter of informed consent law. Spine providers are at the forefront of patient safety efforts as well as patient education efforts. (See www.spine.org for more information.)
Patients today expect and demand increasingly more benefit from their treatments than in previous years and fortunately, modern technology provides it, albeit at an increased cost. A new technology on the horizon -- artificial discs --may provide the same pain relief as a fusion for chronic low back pain and also offer motion preservation. In addition, bone morphogenic proteins, minimally invasive procedures, new drugs and physical therapies are part of the vast array of new and emerging technologies available for use in patient care. Grappling with the increasing costs of these increasing benefits is a true challenge to our generation.
The medical device industry on its own has recently adopted new guidelines on appropriate relationships between physicians and industry. These new guidelines (AdvaMed guidelines) provide excellent guiding principles to govern these relationships and serendipitously went into effect January 1, 2004. These guidelines embrace formal consulting agreements for education and research of new devices, technologies and treatments for the benefit of patients. In addition, all peer-reviewed professional organizations and publications require thorough disclosure from researchers regarding financial relationships they may have with any company or entity related to their research.
If an individual physician abuses the system in any manner, the legal system and professional societies (such as NASS) are well equipped to discipline them. The NASS Board recently adopted new ethical guidelines and implemented a professional conduct committee to review allegations of professional malfeasance. Fraud and abuse laws, antikickback statutes, Stark laws (prohibiting referrals for lab services or designated health services to an entity in which physician or an immediate family member of the physician has a direct or indirect financial interest ), civil lawsuits, quitam actions (government contractor fraud whistleblower cases) and other regulations dominate the health care system these days and doctors are very familiar with the repercussions of violating any of these rules.
Thomas J. Errico, MD
Associate Professor of Orthopedic and Neurosurgery
NYU School of Medicine
Chief of the Spine Service NYU/ Hospital for Joint Diseases
President
North American Spine Society