Professor Stover Snook teaches to his Harvard students that total health care expenditures for treating back pain the United States in 1998 were about $26.3 billion. This was three times higher than the total cost of treating all cancer. Pope pointed out in the New York Times on February 13, 2008 that $86 billion was spent in 2005 in treating spine problems
In the the November, 2004 issue of The Spine Journal the editorial by Isador Lieberman pointed out that there were over 1 million spine procedures performed in the United States during the year 2002 with over 600,000 uninstrumented cases and 400,000 instrumented cases. Instrumented cases have grown 6-8% on a yearly basis and the total revenue of U.S. spinal device manufacturers was $2.5 billion in 2003.
Instrumented spine fusion is a expensive endeavor. Even in an high-priced health care system instrumented fusion stands out as an uniquely costly enterprise. This is particularly true because such procedures often engender additional corrective or revision procedures. Multi-level rigid instrumented stabilizations may cost as much as $80 thousand and as much as half of the surgical cost can be attributed to instrumentation alone. The typical hospital mark-up on instrumentation (for handling) is usually about 100%.
Rigid fusion instrumentation, particularly pedicle screw instrumentation, is big business. Most spine-related medical meetings today are “feeding frenzies” for pedicle screw manufacturers and the the manufacturers of artificial disc prostheses. Fusion instrumentation for rigid spine stabilization has taken on a life of its own.
An article in the New York Times (January 30, 2008) also points out that a number of prominent spine surgeons promoting spinal implants have financial conflicts of interest that patients are not being made aware of. This brings up the question of whose best interest is being served.
To a large extent the cost of fusion is driven by marketing and media hype often eclipsing other, sometimes better, treatment options for surgeons and their patients. As in most medical endeavors the “best buy” is sometimes a lower cost “orphan” technology which doesn’t get much attention. Something else which often also doesn’t get much attention is informed consent which requires the surgeon to disclose to a patient the existence of other surgical options.
The initial, and long-term, costs of multi-level instrumented spine stabilization procedures will always be high. Despite extensive use it is remarkable to note that there is little scientific evidence to support the practice and actually good evidence to contradict it. Fusion as a primary treatment for back pain is unfortunately a prevalent therapy in some communities. There is good reason to believe that less stringent therapies such as the introduction of intradiscal polymers will prevail in the future.
In the attempt to reduce medical device costs some hospital have turned to “preferred” or “privileged” providers. The problems with this are the limiting of physician and surgeon choice of devices, the reduction of price competition and also quite frankly inferior devices being selected on the basis of lower cost alone.
By being better consumers patients can obtain a better understanding of the non-invasive, minimally invasive as well as surgical options. This represents not only a patient benefit but can also assist in decreasing the overall cost of spine surgery in the health care system.