Who is regulating health care, anyway? In Take Charge of Your Chronic Pain I discussed how profitable treating pain is for corporate America. That includes publicly traded pharmaceutical companies and device makers, as well as hospitals, surgery centers, and medical practices. Market forces often seem to drive the type of care provided to patients, as opposed to adhering to best practice guidelines or Evidence-Based Medicine.

Another blatant example of this shows up in an article published in JAMA this month on spine surgery. Dr. Richard Deyo of Oregon Health and Science University in Portland is the lead author. This study followed surgeries for spinal stenosis in Medicare recipients from 2002 to 2007. Spinal stenosis is a common condition of the lower back associated with aging. They found a steep rise in the use of costlier complex spinal fusion surgeries in comparison to simple decompression surgeries, which are far cheaper and safer.

There are huge cost differences between a complex spinal fusion surgery, which they define as involving more than two levels or operating on both the front and backside of the patient, and a simple decompression surgery that does not involve placing hardware in the spine. With the more costly approach, surgeons’ fees are higher, hardware manufacturers make a lot more (they don’t make anything if only a decompression is done), and hospital costs go way up. A complex fusion will cost Medicare about $80,000 while a decompression will cost closer to $20,000. What’s more alarming is the increase in risk associated with the costlier complex fusions, and that includes things like strokes and deaths.

So, how do we take information like this to help improve the health of our society? If we adhere to the doctrine that all medical decisions should only be made between the doctor and his patient, then the above example shows what can sometimes happen; costlier than necessary treatments, wasted resources, and more complications including deaths.

Whose job is it to police the example given above? Is anyone responsible for following up and changing practice behaviors based on this information? Not really. Doctors have a hard time agreeing on what constitutes standard of care and a harder time creating a consensus on anything. Nobody will ever trust the insurance industry to be an unbiased source of treatment guidelines, and patients often lack the medical background to make unemotional treatment decisions. We have already seen how vehemently special interests groups intervene and public paranoia rises when we try to make changes to the system.

If it is too politically incorrect for anyone to take on the role of chief decision maker because there always seems to be a hidden agenda tainting the process, then we must strive to find new ways to reward mechanisms and providers that improve health in cost-effective ways. In other words: no health, no wealth.