Health Care Waste is a Pain in the Neck

Between our sedentary, desk-based lifestyle and our growing obesity epidemic, it is no surprise that back pain is nearly omnipresent in American society. Eighty percent of people will suffer back pain at some point – 25% have experienced it within the last three months – with many turning to various forms of relief ranging from ER visits to naturopathic remedies.

The widespread prevalence of back pain translates into a significant financial burden for both patients and payers. In their study, Garber et al. tallied healthcare waste for back pain at $362 million per year in the Medicare program. However, the study’s appraisal may be an underestimate as it only identified unnecessary CT and MRI scans and did not account for the added costs of unindicated plain x-rays. On the other hand, the calculated expense may be artificially inflated because it includes all costs incurred in the year after imaging, regardless of their relationship to the initial back pain. 

Despite the fact that 9 different physician specialty societies recommend against imaging for back pain in the first 6 weeks because there are few truly emergent causes of back pain that could lead to permanent paralysis or require immediate surgery, and the majority of patients with back pain will experience significant improvement or complete resolution within 6 weeks, 25% of patients in the study received CT or MRI scans within the first 6 weeks. Prior literature suggests that 50% of patients presenting with back pain receive at least some modality of imaging.  

Most causes of back pain are insidious, slowly worsening over time, and demand gradual interventions such as physical therapy. However, insurance underwriting and inflexible work schedules make such treatment inaccessible to most Americans, resulting in an overuse of imaging, spine surgery, and opioids. 

Employers can do more to prevent back pain by providing ergonomic working environments and gym memberships for employees. Employers can also facilitate conservative treatment through more flexible sick leave policies that allow for frequent short physical therapy or chiropractic visits without full leave. Finally, insurers can disincentivize overutilization of high-cost surgery by providing in-network, low-out-of-pocket coverage for integrative therapies including physical therapy, chiropractors, and acupuncture.

Abstract

OBJECTIVES: Low back pain (LBP) is a common and expensive clinical problem, resulting in tens of billions of dollars of direct medical expenditures in the United States each year. Although expensive imaging tests are commonly used, they do not improve outcomes when used in the initial management of idiopathic LBP. We estimated 1-year medical costs associated with early imaging of Medicare beneficiaries with idiopathic LBP.

STUDY DESIGN: We used a 5% random sample of Medicare fee-for-service enrollees between 2006 and 2010 to determine 12-month costs following a diagnosis of idiopathic LBP. We analyzed costs of care and patient outcomes according to whether or not the patients had been referred for early imaging following their initial diagnosis.

METHODS: We employed an instrumental variables analysis using risk-adjusted physician-level propensity to order imaging for patients without LBP as an instrument for imaging use among patients with LBP. We selected this approach to adjust for confounding by indication when estimating the relative costs of early imaging of LBP compared with conservative management.

RESULTS: Early imaging is strongly associated with increased costs of care in the first year following LBP diagnosis. Patients receiving an early magnetic resonance imaging scan accrued $2500 more in Medicare expenditures than conservatively managed patients, and patients who received computed tomography accrued $19,900 more.

CONCLUSIONS: Medicare beneficiaries with low-risk LBP frequently receive early imaging studies. Early imaging was associated with greater long-term costs than a conservative diagnostic strategy; Medicare expenditures could be reduced by $362 million annually by managing newly diagnosed LBP in accordance with clinical guidelines.

PMID: 30325195

Garber, et al. AJMC. 2018; 24 (10): e332-e337.