Hold That Sacred Cowboy!

Dolors & Sense

by Sanford Rose

KISSIMMEE Florida—(Weekly Hubris)—8/22/11—Our problems only seem insoluble. Basically, economic growth is the solvent for outsize ratios of debt to GDP.

At the end of World War Two, our debt burden just about equaled the national product. Twenty years later, it had fallen to less than half the size.

The reason: mostly a healthy growth of output in the range of 3 percent per annum which, of course, yielded a lot of extra tax revenue.

But let’s turn, as Republicans do mistakenly, from the revenue to the spending side of the debt problem. What do we cut?

Obviously, Medicare entitlements.

Just wait. Before we start means-testing not only Part B but the whole shebang, let’s consider some anomalies on the supply side of the Medicare mess.

Doctors are among the country’s most creative entrepreneurs. We know from the influential work of Dr. Atul Gawande (http://en.wikipedia.org/wiki/Atul_Gawande) that there is an enormous difference in per-capita Medicare costs between regions within the same state.

We know that these differences are not related to health outcomes but, rather, to the concentration of doctor-owned medical facilities.

Doctors own a much larger fraction of the hospitals and testing facilities in those high-cost regions than they do in the lower-cost ones.

So . . . they order more tests and do more operations in the regions favored by their entrepreneurship.

Old people require more tests and operations, or at least they think they do.

Doctors readily oblige. Many also become what are called “hospitalists”; they rush to put their older patients into hospitals for treatments that can readily be dispensed in offices.

Let’s look at an example. Old people have loads of lower-back problems. Such problems may be divided by etiology into mechanical and inflammatory.

Mechanical problems usually start with the progressive age-related dehydration and, therefore, friability of the discs that separate the vertebrae.

As the discs shrivel, the attachments to the vertebrae, known as facets, enlarge to take over some of the support duty once performed by the now shrunken disc cartilage.

And as they enlarge, these bony facets, together with parts of the extruded nuclei of those friable discs, invade spinal canal space and tend to impinge upon the spinal nerves.

Result: Over 500,000 back operations per year, both for simple disc and more complex disc, bone and ligament impingements, collectively described as spinal stenosis.

The cost of these operations ranges widely. Direct surgical costs can start at about $25,000. But all-in costs rarely fall below $100,000. And when both bone and disc are removed, often at several vertebral levels, surgeons will routinely fuse the spine, which massively escalates the tariff. It can exceed $200,000.

The problem is that reputable studies keep pointing out that 90 percent of these back operations are unnecessary.

Most patients’ pain and disability will resolve, usually within a year, without the operation. In the interim, more conservative treatment modalities will generally alleviate the severe pain.

So this commonplace and pricey procedure is rarely necessary. Even more irritating is that, in a fair portion of instances, the operation actually worsens the patient’s condition. Although they may be fewer than in the past, cases of what is called “failed-back surgery syndrome” still abound.

Assuming a $100,000 mean cost, that’s perhaps $45 billion a year wasted or more than wasted on bad treatment of just one condition.

Surgery, says one knowledgeable physician, is the sacred cow of medicine, which makes surgeons the sacred cowboys who milk it.

If we want to rein in runaway health costs, doesn’t it make sense to start by unhorsing some of those sacred cowboys?

The emasculated Obama health legislation made a stab at doing so, but even that feeble effort is now imperiled.