David Leonhardt makes a good point. Controlling health care costs – one of our most important domestic policy problems – will require our politicians to make hard (and unpopular) decisions.
In Idaho Falls, Idaho, anyone suffering from the sort of lower back pain that may conceivably be helped by the fusing of two vertebrae is quite likely to have the surgery. It’s known as lumbar fusion, and the rate at which it is performed in Idaho Falls is almost five times the national average. The rate in Idaho Falls is 20 times that in Bangor, Me., where lumbar fusion is less common than anywhere else.
These numbers come from the wonderful Dartmouth Atlas of Health Care. The Dartmouth researchers adjust the numbers to take into account age, race and sex, which is another way of saying that there is no good explanation for the huge variations they find. Doctors in the Idaho Falls area are probably just being more aggressive than doctors elsewhere.
But it’s not clear that their patients are any better off. The evidence for lumbar fusion is incredibly mixed. It seems to help people with certain kinds of pain, but many others recover just as well without the surgery. Of course, doctors are almost always better off if the surgery is done: The typical hospital bill for lumbar fusion is roughly $50,000.
This is about as good an example as you can find of the health care mess. The number of lumbar fusions performed in this country has more than tripled since the early 1990s, and Medicare now spends more than $600 million a year on the procedure. It’s one reason your health insurance bill has gone up.
But I think Leonhardt’s example is almost too easy. Spinal fusion surgery is so expensive – and its therapeutic benefits are so limited – that I hope we can at least screw up the courage to crack down on the doctors of Idaho Falls. Here’s a much tougher question: should people with back pain get an MRI?
At first glance, the answer seems obvious: of course they should. MRI’s are a diagnostic test (not an experimental surgery), and I don’t want my doctor’s diagnostic process to be constrained by some government bureaucrat. But the medical evidence paints a far murkier picture.
A large study published in JAMA randomly assigned 380 patients with back pain to undergo two different types of diagnostic analysis. One group received X-rays, which provide the doctor with a relatively crude picture of the back. X-rays can reveal tumors or vertebrae fractures, but can’t detect abnormalities in the spinal discs. (They are also relatively cheap.) The other group got diagnosed using MRI’s, which give the doctor much more information about the underlying anatomy. These doctors could see the pinched nerves and herniated discs and inflamed tendons that were supposedly causing the pain.*
Which group fared better? Did better pictures lead to better treatments? There was no difference in patient outcome: the vast majority of people in both groups got better. But stark differences emerged when the study looked at how the different groups were treated. Nearly 50 percent of MRI patients were diagnosed with some sort of disc abnormality, and this diagnosis led to intensive medical interventions. The MRI group had more doctor visits, more injections, more physical therapy and were more than twice as likely to undergo surgery. Although these additional treatments were expensive, they had no measurable benefit for the patient. In fact, the MRI’s may even make things worse. The conclusion of recent report in The New England Journal of Medicine was sobering: “Incidental findings [of disc abnormalities by MRI's] may lead to overdiagnosis, anxiety on the part of patients, dependence on medical care, a conviction about the presence of disease, and unnecessary tests or treatments.” The report concludes that MRI should only be used under specific circumstances, when doctors are examining “patients for whom there is a strong clinical suggestion of underlying infection, cancer, or persistent neurologic deficit.”
Clearly, more evidence is needed before we stop using MRI’s to diagnose people with back pain. But I think this simple case study illustrates just how hard it will be to enact reforms that control health care costs. Most patients, I imagine, won’t be happy to hear that they can’t get an MRI to image their pain. And most doctors, I imagine, won’t be pleased about being constrained by some government cost-control office. But if we are ever going to fix our system, then such disputes will be necessary. You can’t always get what you want, but sometimes you get what you need.
*A well-known study published in The New England Journal of Medicine in 1994 imaged the spinal regions of ninety-eight people with no back pain or any back related problems. The pictures were then sent to doctors who didn’t know that the patients weren’t in pain. The end result was shocking: two-thirds of normal patients exhibited “serious problems” like bulging, protruding or herniated discs. In 38 percent of patients, the MRI revealed multiple damaged discs. These structural abnormalities are often used to justify expensive treatments like surgery, and yet nobody would advocate surgery for people without pain. The doctors concluded that, in most cases, “the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.”