Over the past two decades, the search for relief from back pain led skyrocketing numbers of Americans to a costly procedure that bonds vertebrae together. But as evidence mounted that spinal fusion surgery was used too often for the wrong people, insurer Cigna decided in 2011 to see how its own members had fared.
The news was startling: 87 percent of customers who had spinal fusion to treat pain due to wear and tear on spinal discs were still in so much pain two years later that they needed more therapies or drugs. Nearly 15 percent had more surgery. Total cost of the post-surgery claims: $11 million. That's on top of the initial fusion surgeries, which can carry price tags of $100,000 each, though insurers don't pay that much.
So Cigna joined the growing number of private insurers that limit the circumstances in which they'll pay for spinal fusions. In part because of this trend, the phenomenal growth in spinal fusions — a case study in the debate over runaway health costs — should slow down, according to a report last month from London-based industry analyst GlobalData.
But the nation's biggest insurer, Medicare, has no authority to require up-front approval for the procedures. It can only try to recover money it has paid for surgeries later deemed unnecessary.
Medicare's own auditors say the government insurance program for seniors and the disabled is wasting money on many fusions for lower back pain. In 2012, the program improperly spent $120 million on lumbar spinal fusions, according to the auditors' November report.
A former senior official with the Centers for Medicare & Medicaid, Dr. Robert Berenson, said spinal fusion is a prime example of Medicare's failure to control questionable spending.
Congress would have to give Medicare wider latitude to pre-approve payments, he said, in order for it to get a better handle on costs for certain elective treatments. But leaders show no signs of acting on a recommendation that likely would infuriate Medicare patients, physicians, and the medical industry, he said.
"Congress is not serious about this. It's one of my pet peeves," said Berenson, now a senior fellow with the Urban Institute. "People are imagining fancy new payment systems for Medicare when we've got these straightforward things we could be doing right now."
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Spinal fusion surgery joins two or more vertebrae, usually with metal rods and screws, to stabilize a damaged spine. The original intent of fusions was to treat deformities such as severe scoliosis and spinal tuberculosis. But over the years, it also came to be used for what's known as age-related disc deterioration.
Between 1998 and 2008, the number of procedures performed in the United States increased from nearly 175,000 to almost 415,000. Cases in which disc degeneration was the primary diagnosis more than tripled over that period, making it the top reason for lower back fusions, according to a 2012 analysis published in the journal Spine.
But in 2006, an advisory panel to Medicare determined there was scant evidence to support it was effective for such patients. Several studies, including one by the famed Dartmouth Atlas of Health Care, have found evidence that whether patients get the surgery may depend more on where they live — and how medicine is practiced there — than on necessity.
"In my view and in the view of many surgeons, the number of (fusion) procedures has gotten well beyond what you can justify with scientific evidence," said Dr. Richard Deyo, an Oregon Health and Science University researcher.
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While spinal fusion can be profitable, that isn't the only issue driving the increase, experts say. Back pain is notoriously difficult to treat, and patients who are suffering may demand what they perceive as more powerful treatment than conservative measures like medication, physical therapy and for overweight patients, weight loss.
One issue is that it's hard to pinpoint the source of back pain, said Dr. Gunnar Andersson, a Chicago surgeon and president of the International Society for the Advancement of Spine Surgery. MRIs of hips and knees show more obvious red flags, he said, but images of spines can be tougher to interpret.
Even just a decade ago, there were few criteria for surgeons to follow when picking the most appropriate candidate for a fusion, said Dr. Christopher Bono, a Boston orthopedic surgeon who is president of the North American Spine Society. That group this year recommended nine indications for lumbar fusions. Degenerated discs are included but only when they meet certain criteria, including a failure to respond to conservative therapies.
Bono said he thinks guidance should improve the track record of fusion surgery by focusing on the right cases. But he's worried the pendulum will start swinging too far in the other direction. He said he had two patients with severe problems whose fusion surgeries have been denied by private insurers.
"All fusions got lumped together," he said. "They're throwing out the baby with the bath water."
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Fusion worked for Janet Day of Land O'Lakes. The 69-year-old retired medical assistant credits the 2012 surgery with letting her live again. A 1999 MRI first revealed signs of degenerative discs, she said, which eventually hastened other problems, including disc slippage.
She tried a chiropractor, yoga and injections before the pain eventually knocked her out.
"Walking was very difficult, sleeping was very difficult," she said. "Everything was difficult."
Her recovery from the 5½ hour surgery to join three sets of vertebrae was swift, she said, and she quickly got off pain medications. Today, she walks every morning and does step aerobics. She said she can sometimes feel a twinge if she twists too hard in step class, but if she takes it down a notch, she's fine.
Even with more emphasis on screening patients, though, there continue to be people who undergo the surgery and find no relief. Elizabeth Sheffield, 49, of New Port Richey is one of them. The call center manager suffered from degenerative discs for years.
But after a 2012 car accident the pain became unbearable, she said, and she underwent a laminectomy, in which part of the vertebra is removed to enlarge the spinal canal and relieve pressure. She had complications from that procedure, and in March 2013, she had fusion surgery.
Now, she said, "the back pain is still there."
The pain radiates down her leg. She can't sit. She can't pick up her toddler grandchildren or ride bikes like she once did. With work increasingly difficult, she's applying for disability.
The fusion did nothing to help, she said.
"I almost wish I hadn't done anything."
Times staff writer Connie Humburg contributed to this report. Jodie Tillman can be reached at firstname.lastname@example.org.