Back Surgery: Too Many, Too Costly, Too Ineffective

If the present course for health care does not radically change, America will be financially crippled as President Obama warned: "paying more, getting less, and going broke."¹ As example, recently Blue Shield of California announced its plans to raise rates by as much as 59 percent, and as the bellwether Golden State goes, so does the nation.²

Most Americans fail to realize the huge economic impact of the medical industrial complex until they feel the crunch from unpaid medical bills that caused 62 percent of all personal bankruptcies filed in the U.S. in 2007, according to a study by Harvard researchers.³ To the surprise of even the researchers, 78 percent of those filers had medical insurance at the start of their illness, including 60.3 percent who had private coverage, not Medicare or Medicaid.⁴

Dr. David Himmelstein, the lead author of the study and an associate professor of medicine at Harvard, commented: "Unless you're Bill Gates you're just one serious illness away from bankruptcy. Most of the medically bankrupt were average Americans who happened to get sick."

"This study provides further evidence that the U.S. healthcare system is broken," according to James E. Dalen, MD, MPH.⁵ The Harvard study underscored President Obama's argument for health care reform legislation. In a letter to Democratic Senate leaders, the president said:

"Healthcare reform is not a luxury. It's a necessity we cannot defer. Soaring healthcare costs make our current course unsustainable. It is unsustainable for our families, whose spiraling premiums and out-of-pocket expenses are pushing them into bankruptcy and forcing them to go without the checkups and prescriptions they need."⁶

Not only are costs and bankruptcy skyrocketing, so is accountability. During the Obama health care reform debate of the Patient Protection and Affordable Care Act, it was notable that the medical industrial complex – the American Medical Association (AMA), the HMOs, Big Pharma, and the American Hospital Association – was not called before Congress to explain why there is a health care crisis wrought with high costs and poor outcomes.

Unlike the Detroit auto executives and Wall Street bankers, whose feet were held to the fire at congressional hearings, the medical cartel avoided such public humiliation and offered no explanations. Instead, the medical alliance continued to mislead Congress and the public by claiming to be the "best health care system in the world," a notion also told all too often by conservative news media. However, the facts belie that claim.

Some pundits claim America has arguably the best doctors, the best medical schools, and the best hospitals. Undoubtedly those many countries whose health statistics are superior to America's might disagree and argue that high-tech medical diagnostic tools and highly trained surgeons are not the real issues to the health care dilemma. The actual question is, how well does the American health care delivery system really work outside of the operating room?

As the statistics show, inside the operating room is nothing less than a boondoggle. In 2006, doctors performed at least 60 million surgical procedures of all types, one for every five Americans. No other country does nearly as many operations on its citizens.⁷

Not only are surgeries rampant, but many are also ineffective and dangerous. Barbara Starfield, MD, MPH, of the Johns Hopkins School of Hygiene and Public Health, reported that medical care is now the third-leading cause of death in the U.S., causing 225,000 preventable deaths every year as tools to make them safer go unused.^8-9

Over 100,000 people die each year from complications of surgery – far more than die in car crashes; deaths from prescription drugs now rank fourth only to cancer, heart disease, and diabetes, and when added to deaths from botched surgery, over 3,000 Americans die weekly.¹⁰ Such deaths accounted for 23 percent of overall deaths in men and 32 percent of deaths in women.¹¹

Not Much Bang for Bucks

It would seem logical that if Americans spend the most on health care and have the best educated doctors, we would have the healthiest citizens and best health care system in the world, but we do not. According to the World Health Organization (WHO), in 2000 the U.S. ranked #1 in cost, #72 in population health, #37 in health care delivery, with 48 million Americans lacking sick-care coverage.¹² In contrast, France ranked #4, #4 and #1, with only 1 percent uninsured.¹³ Obviously the French are getting more bang for their francs than we are getting for our bucks, despite the fear-mongering in the media about socialized medicine.

The present system was described by TIME magazine: "[W]hat a sinkhole the country's healthcare system has become: the U.S. spends more to get less than just about every other industrialized country."¹⁴ Dr. Ezekiel Emanuel, health adviser to President Obama, also addressed the question whether or not America has the best health care in the world, a mistaken belief held by many people:

"Let's bury this one once and for all. The United States is No. 1 in only one sense: the amount we shell out for health care. We have the most expensive system in the world per capita, but we lag behind many developed countries on virtually every health statistic you can name."¹⁵

To put this cost into perspective, the U.S. spent twice as much on sick-care as it did on food in 2006 and more than China's 1.3 billion citizens consumed altogether. In addition, the increase in U.S. health care spending in the three-year period is more than the amount U.S. consumers spent on oil and gasoline during all of 2006 when energy prices began to reach new heights.¹⁶

These facts did not escape the attention of President Obama: "Today, we are spending over $2 trillion a year on health care – almost 50 percent more per person than the next most costly nation. And yet, for all this spending, more of our citizens are uninsured; the quality of our care is often lower; and we aren't any healthier. In fact, citizens in some countries that spend less than we do are actually living longer than we do."¹⁷ (Emphasis added)

Back Pain Dilemma

Undoubtedly the annual cost of health care, nearly $2.4 trillion, could be reduced substantially if unnecessary treatments were decreased. Of the Top 10 list of diseases in America, "back pain" stands at number eight, which according to Forbes.com costs over $40 billion annually for treatment costs alone;¹⁸ other estimates that include disability, work loss, and total indirect costs range between $100 and $200 billion per year.¹⁹ Back pain sent over 3 million people to emergency rooms in 2008 at a cost of $9.5 billion, making it the ninth most expensive condition treated in U.S. hospitals.²⁰

"Work-related musculoskeletal disorders remain the leading cause of workplace injury and illness in this country," according to OSHA head David Michaels.²¹ Although not the killer that heart disease or cancer is, crippling back pain is expensive, disabling, and often leads later in life to osteoarthritis, which ranks ahead of back pain on the Top 10 list at $48 billion; when combined, these two musculoskeletal conditions rank fourth on the list at $88 billion.²²

Recently a new wave of data by researchers has revealed the high cost and ineffectiveness of most medical back treatments. Yet these revelations have fallen on deaf ears in the medical profession as the use of opioids, epidural steroid injections, and spine surgeries has radically increased despite these warnings.

Ironically, now the chiropractic profession, long ostracized by the medical profession, has emerged as a fiscal conservative to champion this call for reducing costs in health care. Despite the historic medical prejudice, spinal manipulation has now been shown to be the most clinically and cost-effective method for the epidemic of low back pain, which happens to be the single largest cause of disability today.²³

According to Pran Manga, PhD, MPhil, health economist, "There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management."²⁴ He is not alone in his assessment. Numerous international and American studies have shown that for nonspecific back pain, manipulation was heads above all other treatments. In fact, Anthony Rosner, PhD, testified before the Institute of Medicine: "Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option."²⁵

Chiropractic care not only has catapulted to the top of the list for back pain care, chiropractic patients are also extremely positive about their treatments. TRICARE, the health program for military personnel and retirees, has evaluated patients' response to chiropractic care. The enormously high patient satisfaction rates astounded the TRICARE administrators with scores of 94.3 percent in the Army; the Air Force tally was also high with 12 of 19 bases scoring 100 percent; the Navy also reported ratings of 90 percent or higher; and even the TRICARE outpatient satisfaction surveys (TROSS) rated chiropractors at 88.54, which was 10 percent "higher than the overall satisfaction with all providers" (78.31 percent). But despite these glowing satisfaction rates for chiropractic care, TRICARE continues to limit access to chiropractors at only 42 of 131 military treatment facilities due to an intransigent medical bureaucracy within the Department of Defense.²⁶

Not only are patients well satisfied with chiropractic care, in fact, the more investigators look into this back pain epidemic, the more the medical management has come under attack and, remarkably, that chiropractic treatment has been found best for the vast majority of nonspecific low back and neck pain.

After nearly a century of warfare against the chiropractic profession, defaming it as an "unscientific cult" that deserved to be "eliminated,"²⁷ research now has shown chiropractic care to be very effective and, ironically, now seriously questions the efficacy of the medical management of back pain – opioid drugs, epidural steroid injections, and spine surgery. Indeed, the claim to be unscientific and dangerous now seems to be on the other (medical) foot.

The Call for Restraint in Spine Surgery

It must be bitter medicine to swallow for the medical profession to realize that back surgery "has been accused of leaving more tragic human wreckage in its wake than any other operation in history," according to Gordon Waddell, DSc, MD, FRCS. As director of an orthopedic surgical clinic for over 20 years in Glasgow, Scotland, he determined: "Low back pain has been a 20th century health care disaster. Medical care certainly has not solved the everyday symptom of low back pain and even may be reinforcing and exacerbating the problem."²⁸

Richard Deyo, MD, MPH, also mentioned the problems with medical treatments and physician incompetence in diagnosis and treatment of low back treatments: "Calling a [medical] physician a back-pain expert, therefore, is perhaps faint praise – medicine has at best a limited understanding of the condition. In fact, medicine's reliance on outdated ideas may have actually contributed to the problem."²⁹

Undoubtedly, another knife in spine surgeons' backs occurred in 1994 when the U.S. Public Health Service's Agency for Health Care Policy & Research (AHCPR) conducted the most thorough investigation into acute low back pain in adults and concluded the following finding in its Patient Guide:

"Even having a lot of back pain does not by itself mean you need surgery. Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In some people, surgery can even cause more problems. This is especially true if your only symptom is back pain.³⁰ (Emphasis added)

The AHCPR study also concluded that spinal manipulation was the preferred initial professional treatment for acute low back pain. The Patient Guide stated: "This treatment (using the hands to apply force to the back to 'adjust' the spine) can be helpful for some people in the first month of low back symptoms. It should only be done by a professional with experience in manipulation."³¹

This recommendation was, in effect, an endorsement of chiropractic care, since chiropractors do 94 percent of all spinal manipulation in the U.S.³² After a century of defamation, it was a sweet vindication for the chiropractic profession finally to be endorsed by the U.S. Public Health Service. Of course, the North American Spine Society, consisting primarily of spine surgeons, took a dim view of this precedent and politicked to have the AHCPR's mission to establish guidelines eliminated with help from Newt Gingrich's Republican Congress. It should be noted that of the 14 guidelines done by AHCPR, the acute low back pain guideline was the only one attacked by the medical profession.

Despite the medical resistance, these warnings are escalating as the call for restraint is growing from a whisper into a roar. Certainly when leading medical professionals from prestigious universities, journals, and the U.S. Public Health Service openly criticize the onslaught and ineffectiveness of spine surgery, this has become an epidemic of legitimate concern for payers and patients alike.

References

1. Text of President Obama's health care speech, June 15, 2009, reprinted by MarketWatch.
2. Calvan CC."Blue Shield Stands By California Health Care Premium Hikes." The Sacramento Bee, Feb. 11, 2011.
3. Himmelstein DU, Thorne D, Warren E, Woolhandler S. Medical Bankruptcy in the United States, 2007: results of a national study. The American Journal of Health, August 2009;122(8):741-746.
4. Arnst C. "Study Links Medical Costs and Personal Bankruptcy, Harvard Researchers Say 62% of All Personal Bankruptcies in the U.S. in 2007 Were Caused by Health Problems -- and 78% of Those Filers Had Insurance." Business Week, June 4, 2009.
5. "Harvard Study: 60% of Bankruptcies Caused by Health Problems." Consumer Affairs, June 4, 2009.
6. Arnst C, Op Cit.
7. Gawande A. "The Cost Conundrum." The New Yorker Magazine, June 1, 2009.
8. Starfield B. "Is US Health Really the Best in the World?" JAMA, July 26, 2000;284(4):483-485.
9. Nalder E, Crowley CF. "Patients Beware: Hospital Safety's a Wilderness of Data. Hearst Newspapers, March 21, 2010.
10. Gawande A, Op Cit.
11. Dunham W. "France Best, U.S. Worst in Preventable Death Ranking," Reuters, Jan. 8, 2008.
12. World Health Organization. The World Health Report 2000: Health Systems--Improving Performance, 2000.
13. Rodwin VG. "The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States." Am J Public Health, January 2003;93(1): 31-37.
14. Tumulty K. "Can Obama Find a Cure?" TIME, Aug. 10, 2009.
15. Emanuel E, Brownlee S. "Myths About Our Ailing Health-Care System," Washington Post, Nov. 23, 2008.
16. Farrell DM, Jensen ES, Kocher B. "Accounting for the Cost of U.S. Health Care: A New Look at Why Americans Spend More." McKinsey Global Institute, Nov. 8, 2008.
17. Text, Op Cit.
18. Van Dusen A. "America's Most Expensive Medical Conditions," Forbes.com, Feb. 6, 2008.
19. Guyer RD. "The Paradox In Medicine Today--Exciting Technology and Economic Challenges." The Spine Journal, March/April 2008;8(2):279-285.
20. AHRQ News and Numbers: "Aching Back Sends More Than 3 Million to Emergency Departments." Feb. 3, 2011.
21. "Anti-Regulatory Forces Launch Full Assault on Public Protections." OMB Watch, Feb. 8, 2011.
22. "Top 10 Most Expensive Treatment-Disease Costs." www.mostexpensiveworld.com/diseases/top-10-most-expensive-treatment-disease-costs.html
23. Woolf AD, Pfleger B. "Burden of Major Musculoskeletal Conditions." Bull World Health Organ, 2003;81(9):646-656.
24. Manga P, Angus D, Papadopoulos C, Swan W. "The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain." Funded by the Ontario Ministry of Health, August 1993.
25. Testimony before the Institute of Medicine: Committee on Use of CAM by the American Public, Feb. 27, 2003.
26. Chiropractic Care Study, Senate Report 110-335 accompanying the National Defense Authorization Act for FY 2009; letter sent to Congressmen by Ellen P. Embrey, Deputy Assistant Secretary of Defense, Sept. 22, 2009.
27. Memo from Robert Youngerman to Robert Throckmorton, Sept. 24, 1963; plaintiff's exhibit 173, Wilk.
28. Waddell G, Allan OB. "A Historical Perspective on Low Back Pain and Disability." Acta Orthop Scand, 1989;60 (suppl 234).
29. Deyo RA. "Low-Back Pain." Scientific American, August 1998:49-53
30. Bigos S, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Pub. No. 95-0642; December 1994. Patient Guide, (1992):12.
31. Ibid, p. 7.
32. Shekelle PG, et al. RAND Corporation Report: The Appropriateness of Spinal Manipulation for Low-Back Pain.

Editor's note: Part 2 of this article appears in the next (April 9) issue.