Editor's Spotlight/Take 5: Is There Variation in Procedural Utilization for Lumbar Spine Disorders Between a Fee-for-Service and Salaried Healthcare System?

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No one is surprised that individual surgeons vary in the frequency with which they recommend surgery, or that they sometimes use different procedures to treat the same condition. We can attribute some of the differences to gaps in the evidence base; beyond that, practices differ, as do surgeons' appetites for tackling riskier or more-complicated operations. We also can accept that there might be broader-based differences in surgical utilization. For example, we know that the frequency of hip dysplasia varies widely across geographic locations, both because of genetics and environmental factors (such as swaddling of infants). That being so, it would come as no surprise if the annual usage of interventions to treat dysplasia—whether surgical or nonsurgical—might differ in response to local variations in disease prevalence [6].
Problems arise, though, when there are important differences in utilization of diagnostic [12] and surgical services that we cannot attribute to differences in the frequency of disease, either by geography [3, 7] or over time [11]. These problems become especially concerning when the choices surgeons make seem not to be driven by evidence [2], or, worse, occur despite good evidence against the choices being made [8, 9, 13]. And the problems are most troubling when those choices appear to be driven by physician remuneration.
Surgeons' incentives matter [5], and those incentives are a regular topic on these pages [4, 10] because the public's perception of our profession—and, more generally, our professional integrity—are directly tied to how we handle our sometimes-conflicting interests. Perhaps the largest of those conflicts is that most surgeons in the United States get paid more when they operate more.
For that reason, the article by Andrew J. Schoenfeld from Harvard Medical School about variation in spine-surgery utilization between a fee-for-service and a salaried healthcare system (both in the United States) in this month's Clinical Orthopaedics and Related Research®, is important reading—whether or not you ever operate on the lumbar spine. This study found convincing evidence that surgeons were much more likely to perform major surgery when the care was delivered in a fee-for-service setting than a managed-care system, even when careful adjustments were made for diagnosis, case mix, and geography. These were no mere statistical anomalies; the differences were large. For example, the odds of a patient receiving a spinal fusion in otherwise similar situations more than doubled within the fee-for-service environment. The authors also pointed out that surgeons performed many of these fusions on patients who did not have a generally accepted indication for arthrodesis.
As a profession, we must address studies like these each time they arise. The public will ask important and reasonable questions about studies like this one, both because of costs and because these practice variations seem to expose patients to serious surgical risk without any obvious justification. While these findings do not prove avarice on the part of surgeons, they do add to the already-convincing evidence that incentives to providers in healthcare settings strongly influence the decisions those providers make.
Please join me as I go behind the discovery and talk about some possible solutions with Dr. Schoenfeld from the Brigham and Women's Hospital, first author of this important study, in the Take-5 interview that follows.
Take Five Interview with Andrew J. Schoenfeld MD, MSc, first author of “Is There Variation in Procedural Utilization for Lumbar Spine Disorders Between a Fee-for-Service and Salaried Healthcare System?”
Seth S. Leopold MD:Congratulations on a fascinating and important study.

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