“Providers Will Run Amok” – Dallas Does Too Many Surgeries

Half of all adults are impacted by musculoskeletal conditions, greater than the number of people impacted by chronic heart and lung conditions, according to the Centers for Disease Control. But because of mismanaged care, many of these injuries are costing patients, their employers, and taxpayers much more than they should. At a recent meeting of the Dallas-Fort Worth Business Group on Health, Dr. Scott Conard of Converging Health moderated a discussion about how to bring down MSK costs between Catalyst Health CEO Dr. Chris Crow, Vice President of Clinical Strategy at Airrosti Dr. Chris Cato, and Administration Services Manager for the City of Plano Andrea Cockrell.

According to government statistics, 101.3 million adults suffer from neck and/or lower back pain, requiring 61.8 million healthcare visits and $53.1 billion in direct costs to treat the injuries. They result in 246 million lost work days, and 12 days away from work per episode.

It is the leading source of medical treatment for all adults age 18-65, impacting around 36 percent of those aged 18-44, and 58.5 percent of those those 45-64. It impacts 68.2 percent of those older than 65, only surpassed by circulatory issues. It is also the leading cause for missed work for all age groups, but treating them can be unpredictably expensive. Dallas is home to a wide range in cost for surgery costs, with a Holmes Murphy study showing that knee replacement surgeries can range from $34,000 to $220,000 in North Texas.

But because of patient ignorance and benefit plans that don’t move employees toward a more conservative path of care, these injuries are often treated with increasingly expensive and often unnecessary surgeries. The standard care pathway for an MSK injury involves an office visit with a primary care physician, physical therapy, imaging, injections, and then surgery if necessary, but only 30 percent of the market follows that process. The standard pathway will often avoid surgery, reducing costs for everyone involved. According to a study of local MSK claims by DFWBGH with the help of Aetna, Cigna, and Blue Cross Blue Shield of Texas, the standard care pathway will result in $624 worth of treatment per episode, while not following it will nearly triple the cost at $1,836.

At the meeting, DFWBGH Medical Director Dr. Scott Conard described how this evidence-based care pathway reduces cost for payors. The office visit will prevent expensive imaging, injections and surgery for around 85 percent of patients, but as of now 85 percent of MSK patients get an X-ray on their first visit because that pathway isn’t frequently followed. Conard quoted Eric Topal’s book The Patient Will See You Now with the alarming statistic that in the future, between three and five percent of cancers may be caused by radiation from imaging by the medical community.

The City of Plano’s top healthcare claim cost was due to MSK injuries, but the city was able to save by partnering with Airrosti, a quickly growing soft-tissue treatment company based out of San Antonio. In 2014, the city began the partnership with Airrosti and created a $25 copay for their therapy. By 2016, the city had required it before an employee could go through with back surgery and increased engagements with employees. The results took a massive chunk out of imaging and surgery utilization.

The city commissioned a study to see how using Airrosti was impacting their healthcare costs, and over three years and 1,466 MSK episodes, found an 11 percent reduction in average total episodic cost, a 57 percent reduction in cost compared to traditional care, and a 90 percent reduction and surgical and imaging utilization.

Only 15 percent of patients need an x-ray after physical therapy, but injections should be done before surgery. There are platelet and other injections that can allow the body to heal itself rather than using drugs or surgery. According to the pathway of care, surgery should only be used if all else fails, but because many patients don’t need to consult a primary care physician before going to see a surgeon due to open PPO networks, this pathway isn’t often followed.

“Patients have no idea where to go for care for musculoskeletal issues,” said Cato. He said that patents are split between visiting primary care, chiropractors, orthopedic surgeons, physical therapy, or another point of contact with the healthcare system. If there isn’t a primary care physician to coordinate care between those points of contact, there is often no collaboration, resulting in low value and high costs.

Conard said that their data showed that only 30 percent of neck and back surgeries performed were done because there was evidence that it was necessary, and that one surgery often led to another for this reason. “The best future predictor of neck or back surgery is current back or neck surgery,” he said. Employers should require and pay for a second opinion, he says. “It will pay for itself.”

Catalyst primary care physicians have long implemented the evidence-based pathway of care for MSK injuries, and their value-based models mean that they have more risk for giving too much care. Crow blamed the audience, mostly made of benefits managers for Dallas employers, for allowing MSK costs to go so high.

“This is all your fault. Providers will run amok if you let us, and you have,” he said. Because some health plans allow employees to skip the visit with the primary care physician or physical therapy before seeing a surgery, too many surgeries are happening, and costs are going up. He said that Dallas is receiving too much healthcare, and that resources should be going into businesses, schools, philanthropy and other places. “We take too much,” he said of the healthcare system. “Two-hundred and fifty thousand dollar surgeries need to stop.”

Crow emphasized the importance of having a primary care physician, citing studies that show how primary care physicians increase life expectancy. Forbes wrote about a Harvard and Stanford study published in the Journal of American Medicine, showed that adding 10 primary care physicians to a population of 100,000 increased life expectancy by 51.5 days, compared to 19.2 day increase for 10 specialists introduced into a community.

Crow said that having a primary care physician who follows this evidence-based pathway of care is a great way to avoid MSK surgery costs, noting that treating back pain is two percent of the nation’s GDP, with healthcare costing around 18 percent overall.

The panelists all described how self-funded employers have the power to design benefit plans to follow the conservative care pathway and require each step in the process before an employee gets surgery, which is often unnecessary and expensive. Crow described how removing barriers to primary care would pay for itself, and advocated for a zero dollar copay for primary care visits and a narrow network for specialists that maintain high quality without the high costs.

“The system has to change,” Conard said. “You guys are the best chance to change the rules of the game.”