Everyone agrees we can’t sustain the trajectory of rising health care costs in the United States, which spends more per capita than any other nation, with far from the best results.
But when talk turns to cutbacks, critics warn of “rationing,” or worse, “death panels.”
Dr. Richard Deyo, an Oregon physician who spoke in Charlotte recently, said doctors should be taking the lead in this discussion – because they know where to make cuts without hurting anyone.
“It’s not about rationing anything useful,” he told me after his talk. “It’s about rationing stuff that isn’t useful. We’re simply doing a lot of stuff that isn’t useful.”
Deyo spoke at the annual Oscar Miller Day symposium, sponsored by OrthoCarolina, on the topic: “Back to Basics: An Evidence-Based Approach to Spine Care.”
Deyo described research about treatments for back pain – drugs, surgery, spinal injections – and said many are used aggressively without much evidence that they’re working.
For example, 2 percent of the U.S. population take prescription painkillers, also known as opioids, for chronic back pain, Deyo said. The drugs include hydrocodone and oxycodone.
Over the past 10 years, he said, there’s been a 600 percent increase in spending on opioids for back pain, but the effectiveness over the long term “remains uncertain.”
Media messages imply that “everyone should be pain-free, and if you’re not, your doctor has failed you,” Deyo said. But with the increase in prescriptions, there has been an increase in deaths related to opioid overdoses, he said.
Doctors should get control of this, he said. “Physicians ultimately do have the prescription pad.”
Surgery rates have also gone up, partly due to unnecessary MRI scans, Deyo said.
He cited a study that compared back pain patients who got X-rays versus MRI scans. Those who got MRIs were twice as likely to have surgery. But follow-up showed both groups had identical results.
Despite a 600 percent increase in spinal fusion surgeries since the early 1990s, Deyo said there’s no good consensus about when to operate.
For example, the most common reason for lumbar disc fusion is degenerative disc disease. But studies have shown that fusion for that diagnosis “didn’t really have any conclusive advantage over non-surgical therapy,” Deyo said.
Doctors in different parts of the country – even different parts of a state – operate at widely varying rates.
A study in Maine showed patient satisfaction was higher in the parts of the state with lower surgical rates and lower where surgical rates were higher – the opposite of what you’d expect, Deyo said.
Nationally, he said, spinal fusion is the most expensive surgery, with 500,000 procedures per year at a cost of $43 billion.
“You have to ask: Is the increasing rate really resulting in better outcomes?”
Finally, Deyo talked about epidural steroid injections, which have recently led to fungal infections in patients who received tainted drugs. Injections have also increased dramatically in recent years, but patients still end up having surgery. There’s “insufficient evidence” that injections are effective for back pain, Deyo said.
“Overall it looks as if the more intensive interventions we’ve been doing over the past decade have not been improving outcomes of patients with back pain,” he said.
If doctors don’t do something besides complain, “we’re just begging to be regulated,” said Dr. Craig Brigham, the orthopedic surgeon who invited Deyo to Charlotte.
“We’ve got to fix this,” Brigham said. “We cannot afford in this country to continue to do what we’re doing.”