After four back surgeries, Tiger Woods still is not back on the golf course. Steve Kerr, the coach of the Golden State Warriors, missed most of last season and even much of this year’s playoffs with headaches and recurrent pain after back surgery. These two high-profile patients, and their very public surgery results, should encourage us all to ask whether “more is always better” in health care.
The Institute of Medicine National Roundtable on Health Care Quality coined the term “overuse” to describe the provision of health care services for which potential harms outweigh potential benefits. Overuse in health care comes in many forms, including unnecessary or risky diagnostic and screening tests, use of therapeutic procedures that are not needed or introduce unnecessary risk, and the inappropriate use of medications. Unnecessary expenditures for health care overuse in the United States are estimated to range from 10 percent to 30 percent of total health care spending or, at a minimum, $300 billion a year. Although no medical specialty is immune from practices that lead to overuse, opportunities to improve quality of care for low back pain, while also reducing costs, are particularly apparent.
The management of low back pain accounts for more than $86 billion in health-related expenditures annually, rivaling cancer and heart disease as the most expensive diagnosis treated in the United States. Since the early 1990s, overuse of high-cost procedures for low back pain has contributed to a steady rise in these costs but has done little to improve outcomes. This overuse directly contradicts longstanding clinical practice guidelines that promote the use of non-opioid analgesics, avoidance of imaging tests, use of physical therapy-based exercises, and primary care for patients with low back pain. Early and aggressive exercise-based interventions during the acute phase of pain more effectively return patients to previous levels of activity than other treatments, and physical therapy early after an episode of acute pain lowers the risk of subsequent medical procedures more than therapy at later times. Nonetheless, during the 12-year period between 1999 and 2010, there was a 50.8 percent increase in use of narcotics, a 56.9 percent increase in the use of advanced imaging, and a 106.0 percent increase in the number of referrals to other physicians, some presumably for surgery.
Given the persistently low rate of guideline adherence (50 percent at best), complaints abound regarding the failure of the US health care system to effectively treat low back pain with too much money wasted on non-beneficial and non-proven treatments. Diagnostic imaging is an especially significant driver of back pain-related costs because it can lead to additional tests, follow up, and referrals that result in invasive procedures with limited to no benefit. In fact, the rise of outpatient surgeries for low back pain coincides with the rise in diagnostic imaging. While everyone agrees that, in certain instances, back surgery is absolutely necessary and can be lifesaving, rapidly rising rates of surgical back procedures, wide variations in their use, and high rates of reoperation and complications all point to its overuse. Not even the advent of new spine surgery technology, such as spinal fusion surgery or disc replacement surgery, has reduced rates of repeat surgery. Most recently, some of the largest increases in back pain-related expenditures have been for the newer prescription narcotics, despite their many potential side effects and ongoing controversy around their use for chronic pain.
Overuse is caused by both supply and demand. Many patients are dissatisfied with “wait and see” approaches; they want a clear diagnosis of the cause of their pain, information and instructions, and immediate pain relief. Some overtly avoid physical activity during an acute episode of back pain because they are afraid of aggravating their condition. These fears are only made worse when providers use diagnoses that “medicalize” the condition and further discourage patient activation (that is, a patient’s engagement in his or her own health care). In fact, certain changes in the spine, such as intervertebral disc degeneration, along with many other imaging findings, are common among aging patients and not necessarily correlated with low back pain symptoms.
Physician reimbursement methods and member insurance benefits can also incentivize overuse. For providers, retrospective payment for services may encourage the provision of more tests and procedures than is actually necessary to achieve better patient outcomes and upcoding for the maximum expected return per-patient visit, instead of adherence to evidence-based practices. In the physical therapy environment, interventions and procedures that have little or no support in the clinical literature typically have higher reimbursement rates than interventions that have been shown to be beneficial. Patients may also be incentivized to seek any medical service for their back pain, instead of considering those options that might be more effective or cost efficient. Many publicly insured patients are shielded from paying (cost sharing) for back pain treatment, and those who are privately insured have per-visit copayment responsibilities that fail to support interest and engagement in optimal physical therapy treatment.
Should the experience of Tiger Woods and Steve Kerr help others make decisions about surgery? We imagine that they both received care from the most highly esteemed professionals, that cost was not an obstacle, and that their care was attentive. Presumably, their results did not meet expectations discussed with their providers. Steve Kerr has sought to share his experience with others and advised during an April 23 press conference, “I can tell you if you’re listening out there, if you have a back problem, stay away from surgery. I can say that from the bottom of my heart. Rehab, rehab, rehab. Don’t let anybody get in there.” Recent media reports indicate that Tiger Woods not only continues to experience back pain that is impeding his play, but additional consequences include side effects associated with opiate pain relievers.
We hope these high-profile experiences will promote more dialogue about the risks of overuse. Overuse in health care is pervasive, costly, and causes harm to patients, yet it has been remarkably difficult to get the medical profession, health care industry, and general public to acknowledge the scope of the problem or take steps to reduce it. Sometimes, an influential story can be more impactful in changing public opinion than a mound of evidence. We should take this opportunity to discuss these important lessons about the risks of surgery, the downside of too much care, and the fact that spending more on health care does not necessarily deliver the best outcomes.