Jonathan Chait

More Unnecessary Surgery

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Yesterday, I highlighted a Wall Street Journal story about doctors overusing a costly yet often ineffective spinal fusion surgery, while hiding their ties to spine device companies. It turns out this isn't the first time spine specialists came together to shield spinal fusions from more oversight. In 2003, Health Affairs detailed an attempt by the North American Spine Society to discredit the "Agency for Health Care Policy and Research (AHCPR), which existed between 1989 and 1999 as the leading government agency for health services research":

AHCPR was also confronted in 1995 with an advocacy organization’s active efforts to get it defunded. The source was an association of back surgeons who disagreed with conclusions reached by the PORT on low-back pain and with practice guidelines based on that work. The agency had had previous experience with criticism by medical groups. In 1993 a large prospective outcome study by the cataract PORT came under attack from the American Society of Cataract Surgery, the Outpatient Ophthalmology Society, and the American Board of Ophthalmologists. However, that attack never extended to the agency itself, and it ended when the PORT’s data were useful to ophthalmologists in (1) discrediting a GAO study alleging that inappropriate cataract surgery was widespread and (2) causing Milliman and Robertson, a consulting firm, to withdraw a practice guideline that had led some insurers to refuse to pay for some surgery.

The 1995 controversy over back surgery posed a much more serious threat because it focused on the agency’s appropriation. The surgeons found sympathetic ears among House Republicans who, for reasons already discussed, were prepared to believe the worst about the agency. The events of 1995 followed many years of controversy over the merits of surgical procedures for low-back disorders. AHCPR entered this fray when its PORT on low-back pain reviewed the research and concluded that there was no evidence to support spinal fusion surgery and that such surgery commonly had complications. The North American Spine Society (NASS) created an ad hoc committee, which attacked the literature review and the subsequent AHCPR practice guideline on acute care of low-back pain. In a letter published in 1994 in the journal Spine, the committee not only criticized the methods used in the literature review and expressed concern that the conclusions might be used by payers or regulators to limit the number and types of spinal fusion procedures, but it also charged that AHCPR had wasted taxpayer dollars on the study. An entity known as the Center for Patient Advocacy was formed by Neil Kahanovitz, a back surgeon from Arlington, Virginia, to lobby on the issue. It organized a letter-writing campaign to gain congressional support for its attack on AHCPR. Kahanovitz used personal contacts to gain the support of Representatives Bonilla, who had a staffer who was Kahanovitz’s patient; Johnson; Gerald Solomon (R-NY); and Joe Barton (R-TX). Solomon, Bonilla, and Johnson led the effort in the House to end the agency’s funding, energetically promulgating the NASS/Kahanovitz argument that it was supporting unsound research and wasting the taxpayers’ money.

 

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