Lumbar anatomy back pain
U.S. hospitals and healthcare systems are being accused of supporting high rates of unnecessary elective surgeries, putting profits before patients, and not providing patient-centered, evidence-based care. Doctor-led Vori Health is helping address inappropriate spine surgeries through a more integrated approach to musculoskeletal (MSK) care.
Studies suggest that doing spine and orthopedic surgery for questionable indications or unsuitable candidates has become far too common. Concerningly, over 50 percent of lumbar spine surgeries are deemed unnecessary. U.S. health systems U.S. health systems are complicit in this troubling trend, having built business models reliant on facility fees paid to the hospital for procedures. Even elite hospitals ranked in U.S. News are performing a plethora of unnecessary surgeries.
Failing on a broken foundation
The COVID pandemic showed that when elective procedures were on pause, U.S. health systems suffered significantly decreased revenue with lost surgical revenue comprising 42% of that amount. Specifically the move to “essential hip and knee arthroplasty surgery” was found to have lowered surgical revenue to an already struggling health care system. The findings show that typical U.S. hospitals struggle to earn an acceptable margin by caring for patients who clearly require in-patient medical care (like treating a person having a heart attack or suffering from a severe infection) and instead must rely on facility fees from non-emergency (elective) procedures like orthopedic and spine surgery. Furthermore, hospitals have high overhead costs and the significant increase in hospital administrators has added to this with over 10 hospital administrators per one physician in the U.S., which further suggests problematic allocation of resources. Perhaps unsurprisingly, more and more health systems are getting called out on putting dollars ahead of patients.
Elective surgeries are back and bigger than ever
As the pandemic has subsided, health systems have reopened their doors to elective spine and orthopedic surgeries, with a surge in demand for joint replacements. The Centers for Medicare and Medicaid Services (CMS) expects this trend to continue, projecting a 176 percent and 139 percent increase in hip and knee replacements by 2040, respectively.
Large health plans are all rumbling about how this surge will hurt their bottom lines. More surgeries will drive up costs, but the human cost of inappropriate surgeries resulting in postoperative complications is even of greater concern.
In addition to the high amounts of inappropriate back surgery, 34 percent of knee replacements are also found by researchers to be inappropriate. “Just because these surgeries are now widely available after being put on hold during the pandemic does not mean they are suddenly magically appropriate or necessary,” says Ryan Grant, MD, a neurosurgeon and co-founder and CEO of Vori Health, a nationwide medical practice specializing in value-based, non-operative care for back, neck, and joint pain.
“As a society, now that elective surgeries are back in full swing, we must assess if surgery is truly the best option for any given patient moving forward, or if there are less costly forms of care that can help that patient and move the needle even further on their clinical outcome,” Dr. Grant says. “Often in musculoskeletal and orthopedic care, the treatments that is are most valuable to patients tend to actually be the least costly options because most people get better without surgery.”
Work up for back pain
Beyond the financial implications of unnecessary surgery, a recent literature review discovered that 30 percent of patients are also dissatisfied with the outcomes of their total knee replacement procedures. This dissatisfaction was closely tied to a reduced quality of life, characterized by lingering pain and joint stiffness. Factoring in the significant risks of surgery, including infection, stroke, and cardiovascular complications, the risks and costs of elective joint replacement procedures simply aren’t worth it for many people.
Diagnosing the root of the problem
A significant issue underlying the spike in unnecessary surgeries is that clinicians are not trained in shared decision making, or talking to patients about all of their treatment options and helping them find the one that aligns with their needs and goals. “Many orthopedic and musculoskeletal surgeries are quality-of-life options, not necessities,” says Dr. Grant. “Very few people actually need surgery for back pain or knee pain. Yet, here we are, forced into a corner by a manufactured perception that elective orthopedic surgeries are necessities.”
Orthopedic surgeon Mary O’Connor, MD, co-founder and Chief Medical Officer at Vori Health, says the way out of this impossible situation comes back to basics. “First of all, does the patient have the right diagnosis? Have they been offered adequate non-operative treatment options like the integrative program we offer at Vori Health? If patients do not reach their goals with conservative care, do they understand the likelihood that surgery will get them the outcome they desire? In traditional healthcare, the answer to these questions—especially the latter—is too often ‘no.’”
Even the American Academy of Orthopedic Surgeons (AAOS) acknowledged the concerning lack of patient-centered conversations, stating in 2020: “Our experience suggests that many orthopedic surgeons lack an understanding of how to actually engage in [shared decision making (SDM)] or received insufficient communications skills training in medical school and residency. While some physicians can naturally communicate and already incorporate SDM in patient care, there are still a lot who don’t.”
Driving value to the patient first
When patients are involved with decisions alongside clinicians, they can more clearly understand their treatment options and choose the one that aligns best with their personal values and what matters to them. This approach will drive the best outcomes for patients and families. Typically, surgery is promoted as the only treatment that will effectively relieve pain, however, there are usually other options.
“For medical care to be successful, the needs of the patient must come first,” says Dr. O’Connor, who formerly served as the chair of the Department of Orthopedic Surgery at Mayo Clinic in Florida and as Director of the Center for Musculoskeletal Care at Yale School of Medicine. “My experience with numerous medical centers taught me that traditional care provision struggled with this lesson—not for lack of good intention, but rather by misunderstanding the needs of the patient.”
Vori Health, uses doctor-led care teams that integrate multiple approaches to musculoskeletal (MSK) treatments to guide patients to the care that is right for them. When patients work with specialized teams trained in non-surgical MSK care, less than three percent of patients are referred for surgery. Vori Health’s virtual MSK program helps improve patient outcomes and lower costs care costs with holistic care that embraces individual preferences.