Assault and battery for money

NYT's Gina Kolata tells you what all of us health services researchers already know far too well. Surgical procedures don't have to be approved by the FDA or anybody else, and even when they are proven to be useless, surgeons keep doing them. She leads with the most notorious example, spinal fusion.

In fact this goes way back. In the 1990s, what was then called the Agency for Health Care Policy and Research concluded that there was no evidence that spinal fusion was beneficial to patients. So, the spinal surgeons society persuaded the Republican congress to eliminate the agency entirely. Quoth:

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 [agency] on low-back pain and with practice guidelines based on that work. . . .

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.³⁰ 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.³¹ 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.

The agency managed to survive, but it endured a 21% budget cut. (It's successor is now known as the Agency for Healthcare Research and Quality.)

Here we are, 20 years later, and surgeons are still doing this procedure, even though, as Kolata reports, randomized controlled trials since then have consistently found no benefit. It's finally stopping now that insurers have decided not to pay for it.

Similar phenomena happen all the time. The hue and cry when the Preventive Services Task Force recommended against routine mammograms for women in their 40s was orchestrated by radiologists, oncologists and surgeons who feared losing business. (Debbie Wasserman Shultz, bless her, was their willing dupe.)  We are finally seeing a movement in medicine to eliminate useless or harmful procedures, as spearheaded by the Choosing Wisely campaign lead by the American Board of Internal Medicine and joined by many other medical specialty societies. Still, physicians' financial incentives work against the goal, and we really need more than voluntarism.