Unnecessary back surgeries cost Medicare up to $600 million annually

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Key Takeaways

Over three years, U.S. hospitals performed more than 200,000 unnecessary back surgeries on Medicare beneficiaries. That’s one low-value back procedure every eight minutes.
These low-value back procedures cost Medicare about $2 billion in total over three years.
On average, 14% of spinal fusions/laminectomies met criteria for overuse, with individual hospital overuse rates ranging from less than 1% to more than 50%.
On average, 11% of patient visits for osteoporotic fracture resulted in an unnecessary vertebroplasty, with individual hospital rates of overuse ranging from zero to 50%.
New Hampshire, Iowa, Massachusetts, and Pennsylvania had the highest overuse rates of spinal fusion/laminectomy with rates over 18%. Arkansas, Kansas, Oklahoma, and Nevada had the highest overuse rates of vertebroplasty, with rates over 16%.
U.S. News Honor Roll hospitals had varied performance. At Cleveland Clinic fewer than 1% of patient visits with osteoporotic fracture resulted in an unnecessary vertebroplasty, compared to nearly 20% at Mayo Clinic Phoenix.
A total of 3,454 physicians performed a measurable number of low-value back surgeries. Over three years, these physicians received a total of $64 million from device and drug companies for consulting, speaking fees, meals, and travel, according to Open Payments data analyzed by Conflixis.

Hospitals with the lowest rates of spinal fusion overuse

These are the hospitals with the lowest rates of spinal fusion/laminectomy overuse, including all hospitals that performed at least 500 total spinal fusion/laminectomies over three years. The rate of overuse is measured as the proportion of total procedures performed that meet overuse criteria. The average overuse rate for all U.S. hospitals was 14%.

NAME	STATE	Overuse rate	Overuse procedures	Total procedures
Avala Hospital	LA	0.1%	Data omitted to avoid sharing information that could be personally identifiable.*
Northwest Specialty Hospital	ID	1.2%
Fresno Surgical Hospital	CA	1.2%
Baylor Surgical Hospital at Las Colinas	TX	1.3%
CHRISTUS Mother Frances Hospital – Tyler	TX	1.7%	18	1083
McBride Orthopedic Hospital	OK	1.8%	15	840
UC San Diego Medical Center	CA	1.9%	15	783
Hendrick Medical Center	TX	2.1%	18	852
Methodist Hospital for Surgery	TX	2.4%	18	758
Erlanger Baroness Hospital	TN	2.5%	22	876
iLegent Orthopedic and Spine	TX	2.6%	32	1234
Southeast Kansas Specialty Hospital	KS	2.9%	22	771
Asante Rogue Regional Medical Center	OR	2.9%	17	586
Piedmont Augusta	GA	2.9%	31	1061
Morristown Medical Center	NJ	3.0%	28	923
Arkansas Surgical Hospital	AR	3.2%	34	1076
CHRISTUS Santa Rosa Hospital – Medical Center	TX	3.2%	20	629
HonorHealth Scottsdale Thompson Peak Medical Center	AZ	3.2%	19	591
MultiCare Deaconess Hospital	WA	3.3%	23	704
Tallahassee Memorial Hospital	FL	3.3%	21	635

*Exact procedure counts under 11 may not be released under CMS’ rules for using Medicare claims

Hospitals with the Highest rates of spinal fusion overuse

These are the hospitals with the highest rates of spinal fusion/laminectomy overuse, including all hospitals that performed at least 500 total spinal fusion/laminectomies over three years. The rate of overuse is measured as the proportion of total procedures performed that meet overuse criteria. The average overuse rate for all U.S. hospitals was 14%.

NAME	STATE	Overuse rate	Overuse procedures	Total procedures
Mount Nittany Medical Center	PA	62.8%	336	535
The Medical Center of Aurora	CO	42.1%	275	653
Jefferson Abington Hospital	PA	40.6%	295	726
Concord Hospital	NH	40.6%	212	522
Heritage Valley Sewickley	PA	40.1%	203	506
HSHS St. John’s Hospital	IL	39.2%	204	521
Lutheran Hospital	IN	39.1%	459	1174
Baystate Medical Center	MA	38.9%	326	838
Mobile Infirmary	AL	37.5%	221	589
Cape Coral Hospital	FL	37.5%	210	560
Unity Hospital	NY	35.9%	284	792
The Orthopedic Specialty Clinic at TOSH	UT	35.8%	227	635
The Orthopedic Hospital of Lutheran Health Network	IN	35.3%	351	995
Rochester General Hospital	NY	35.3%	207	587
Advocate Condell Medical Center	IL	35.0%	181	517
Mount Carmel East	OH	34.5%	217	629
UnityPoint Health – Iowa Methodist Medical Center	IA	34.1%	287	842
Black Hills Surgical Hospital	SD	33.5%	282	842
Springfield Memorial Hospital	IL	32.8%	265	807
Hospital of the University of Pennsylvania	PA	32.6%	209	641

Hospitals with the Lowest rates of vertebroplasty overuse

These are the hospitals with the lowest rates of vertebroplasty overuse, including all hospitals with at least 500 eligible patient visits over three years. The rate of overuse is measured as the proportion of patient visits with osteoporotic fracture that resulted in an unnecessary vertebroplasty. The average overuse rate for all U.S. hospitals was 11%.

Many hospitals on this list performed no vertebroplasties over three years despite having opportunities to do so.

NAME	STATE	OVERUSE RATE	OVERUSE PROCEDURES	PATIENT VISITS
MetroHealth Medical Center	OH	0.00%	0	1562
Essentia Health – St. Joseph’s Medical Center (Brainerd)	MN	0.00%	0	1005
Marshall Hospital	CA	0.00%	0	885
Denver Health Main Campus	CO	0.00%	0	795
Benefis Hospitals Inc.	MT	0.00%	0	660
St. Joseph Hospital	ME	0.00%	0	647
Froedtert Holy Family Memorial Hospital	WI	0.00%	0	614
Cayuga Medical Center	NY	0.00%	0	575
AdventHealth Sebring	FL	0.00%	0	506
St. Luke’s Magic Valley Medical Center	ID	0.13%	Data omitted to avoid sharing information that could be personally identifiable.*
St. Luke’s Hospital – Anderson Campus	PA	0.17%
Harborview Medical Center	WA	0.17%
Johns Hopkins Bayview Medical Center	MD	0.17%
Trinity Hospital	ND	0.19%
Essentia Health – Duluth (Miller-Dwan Building)	MN	0.19%
NYC Health + Hospitals/Lincoln	NY	0.20%
Logan Health Medical Center	MT	0.26%
Mayo Clinic Health System – Franciscan Healthcare – La Crosse	WI	0.32%
Boston Medical Center	MA	0.36%
Bozeman Health Deaconess Regional Medical Center	MT	0.38%

*Exact procedure counts under 11 may not be released under CMS’ rules for using Medicare claims

Hospitals with the Highest rates of vertebroplasty overuse

These are the hospitals with the highest rates of vertebroplasty overuse, including all hospitals with at least 500 eligible patient visits over three years. The rate of overuse is measured as the proportion of patient visits with osteoporotic fracture that resulted in an unnecessary vertebroplasty. The average overuse rate for all U.S. hospitals was 11%.

At some hospitals, half of all patient visits with osteoporotic fractures resulted in an unnecessary vertebroplasty.

NAME	STATE	Overuse rate	Overuse procedures	Patient visits
Shannon Medical Center	TX	55.5%	336	605
CHI St. Vincent Infirmary	AR	50.5%	320	634
St. Elizabeth Florence Hospital	KY	48.7%	348	714
Lutheran Hospital	IN	44.6%	300	672
Ascension Providence Hospital – Southfield Campus	MI	42.3%	222	525
Washington Regional Medical Center	AR	38.9%	289	743
Swedish Cherry Hill Campus	WA	38.3%	198	517
Ascension Borgess Hospital	MI	38.0%	381	1004
Ascension St. Mary’s Hospital	MI	37.4%	187	500
Liberty Hospital	MO	37.2%	335	901
Mather Hospital	NY	36.3%	219	603
Texoma Medical Center	TX	36.1%	190	526
Blanchard Valley Hospital	OH	34.9%	196	561
Parkview Regional Medical Center	IN	34.7%	351	1012
Baptist Health Medical Center – Little Rock	AR	34.6%	174	503
Northside Hospital Forsyth	GA	34.4%	207	601
Lakeland Regional Health Medical Center	FL	34.0%	172	506
St. Bernards Medical Center	AR	32.3%	178	552
CHRISTUS Spohn Hospital Corpus Christi – Shoreline	TX	32.1%	251	781
Hays Medical Center	KS	31.5%	158	501

US News honor roll hospitals

Below are rates of overuse among the 2024-25 US News Honor Roll hospitals. Although all of these hospitals are large academic medical centers, their rates of overuse varied. For example, Cedars-Sinai Medical Center performed 355 low-value spinal fusion procedures while UC San Diego Medical Center only did 15. At the Cleveland Clinic, fewer than 1% of patient visits with osteoporotic fracture resulted in an unnecessary vertebroplasty, compared to nearly 20% at the Mayo Clinic Phoenix.

		Spinal fusion/laminectomy		Vertebroplasty
NAME	STATE	Overuse procedures	Overuse rate	Overuse procedures	Overuse rate
Brigham and Women’s Hospital	MA	250	16.4%	71	2.0%
Cedars-Sinai Medical Center	CA	355	17.7%	52	2.4%
Cleveland Clinic Main Campus	OH	269	13.8%	45	0.5%
Duke University Hospital	NC	132	12.7%	89	4.2%
Hospital of the University of Pennsylvania	PA	209	32.6%	26	1.5%
Houston Methodist Hospital	TX	239	10.2%	240	17.9%
Massachusetts General Hospital	MA	286	20.9%	408	8.0%
Mayo Clinic Hospital, Phoenix	AZ	55	6.6%	132	19.5%
Mayo Clinic Hospital, Rochester	MN	240	11.7%	229	8.4%
Mount Sinai Hospital	NY	104	12.4%	154	13.9%
New York-Presbyterian Hospital	NY	287	19.5%	177	7.5%
North Shore University Hospital	NY	105	13.1%	33	5.0%
Northwestern Memorial Hospital	IL	78	10.0%	20	1.2%
Ronald Reagan UCLA Medical Center	CA	n/a	n/a	26	1.1%
RUSH University Medical Center	IL	163	12.1%	52	2.3%
Stanford Hospital	CA	314	21.3%	127	4.0%
The Johns Hopkins Hospital	MD	151	13.8%	40	5.8%
Tisch Hospital	NY	158	7.9%	263	8.0%
UC San Diego Medical Center	CA	15	1.9%	51	2.2%
UCSF Medical Center	CA	295	17.8%	47	1.7%

Back surgery overuse by state

Total counts and rates of low-value spinal fusion/laminectomy and vertebroplasty by state. The average overuse rates nationwide were 14% for spinal fusions/laminectomy and 11% for vertebroplasty.

	Spinal fusion/laminectomy		Vertebroplasty
State	Overuse procedures	Overuse rate	Overuse procedures	Overuse rate
Alabama	3344	17.9%	1360	14.2%
Alaska	189	17.5%	16	1.5%
Arizona	1946	10.7%	555	4.5%
Arkansas	792	9.4%	2094	20.0%
California	6679	13.4%	5361	7.3%
Colorado	1766	10.9%	1337	7.4%
Connecticut	1065	13.8%	913	8.6%
DC	408	14.9%	78	9.6%
Delaware	404	15.6%	269	9.2%
Florida	6771	14.0%	7585	14.6%
Georgia	2680	12.8%	2353	13.3%
Hawaii	287	17.9%	218	5.1%
Idaho	562	9.7%	882	6.4%
Illinois	3262	15.4%	4994	10.2%
Indiana	3063	16.1%	3420	15.8%
Iowa	1254	19.7%	927	8.6%
Kansas	894	10.7%	2507	19.8%
Kentucky	1622	16.4%	2642	13.1%
Louisiana	1482	11.5%	1794	10.2%
Maine	477	15.6%	476	4.8%
Maryland	1393	13.9%	955	11.6%
Massachusetts	2703	18.2%	3177	7.8%
Michigan	3679	14.8%	4178	9.5%
Minnesota	1805	13.5%	898	3.6%
Mississippi	679	13.4%	1377	12.6%
Missouri	2654	16.2%	3701	12.8%
Montana	436	13.7%	240	3.4%
Nebraska	876	14.5%	1281	16.1%
Nevada	733	13.1%	731	16.6%
New Hampshire	678	22.3%	640	7.2%
New Jersey	1416	14.4%	885	6.0%
New Mexico	378	17.0%	317	5.9%
New York	3877	15.0%	3011	6.7%
North Carolina	3630	12.6%	2843	9.5%
North Dakota	273	12.1%	625	6.4%
Ohio	5044	16.3%	7099	11.1%
Oklahoma	1030	8.5%	2421	17.9%
Oregon	848	8.5%	430	2.8%
Pennsylvania	5113	18.2%	4030	7.7%
Rhode Island	349	14.6%	384	11.8%
South Carolina	1685	11.6%	1457	10.0%
South Dakota	615	16.9%	499	8.3%
Tennessee	3399	15.7%	1458	8.3%
Texas	5864	10.4%	9262	14.8%
Utah	1066	12.1%	394	4.9%
Vermont	128	17.4%	99	3.0%
Virginia	2365	13.6%	2162	7.6%
Washington	1854	11.7%	1415	5.2%
West Virginia	641	16.1%	494	5.2%
Wisconsin	1359	13.4%	2209	7.8%
Wyoming	99	7.5%	91	5.2%

*Does not count hospitals outside of the 50 US states and DC, or hospitals with missing state information

INDUSTRY PAYMENTS TO BACK SURGEONS

Industry payments to back surgeons with measurable overuse

Breakdown of selected industry payments by category. Includes payments from 2020-22 to physicians with measurable spinal fusion/laminectomy or vertebroplasty overuse. Data sourced from CMS Open Payments with analysis by Conflixis, Inc.

Category	# of payments	Total amount
Consulting fee	11,761	$40.1 million
Speaker fee	3,236	$11.0 million
Travel & lodging	20,949	$7.7 million
Food & Beverage	107,492	$5.2 million
Other payments & gifts	1,286	$616,000
TOTAL	144,724	$64.6 million

Industry payments, top ten companies

Breakdown of selected industry payments by company. Includes payments from 2020-22 to physicians with measurable spinal fusion/laminectomy or vertebroplasty overuse. Data sourced from CMS Open Payments with analysis by Conflixis, Inc.

Company	# of payments	Total amount
NuVasive, Inc.	10,122	$8.0 million
Medtronic, Inc.	21,229	$7.5 million
Stryker Corporation	13,568	$7.3 million
Globus Medical, Inc.	4,878	$3.5 million
Alphatec Spine, Inc.	4,165	$3.5 million
Medtronic USA, Inc.	7,203	$3.0 million
Medical Device Business Services, Inc.	1,612	$2.3 million
SI-BONE, Inc.	4,397	$1.4 million
SeaSpine Orthopedics Corporation	2,172	$1.4 million
Innovasis Inc.	476	$1.3 million

Facts about back surgery overuse

Spinal fusion/laminectomy

What is a spinal fusion or laminectomy?

Spinal fusions and laminectomies are performed to treat back pain, either by fusing vertebrae together (spinal fusion) or removing part of a vertebra (laminectomy). These procedures are frequently performed together.

When is it overuse?

Lumbar spinal fusion is recommended for patients that have low-back pain caused by issues such as traumatic injury, sciatica, slipped spinal bone, or spinal deformity. However, for patients who have low back pain caused by aging, there is not sufficient evidence of a benefit from these procedures compared to non-surgical alternatives. Unlike with vertebroplasty, there have been no randomized controlled trials comparing spinal fusion/laminectomy to a placebo surgery (known as “sham trials”).

For this study, spinal fusion and/or laminectomy was defined as overuse for patients with low-back pain, excluding patients with radicular symptoms, trauma, herniated disc, discitis, spondylosis, myelopathy, radiculopathy, radicular pain, scoliosis. Patients with neural claudication and spondylolisthesis were also excluded in certain cases. Our exclusion criteria is based on a previously validated overuse measure (Segal, 2015) and consultations with physicians.

Recent systematic reviews/meta-analyses:

A 2016 Cochrane review including 5 randomized controlled trials concluded that “no clear benefits were observed with surgery versus non‐surgical treatment.”
A 2018 summary of systematic reviews found that “the available evidence does not support a benefit from spine fusion compared to non-operative alternatives for back pain associated with degeneration.”
A 2021 meta-analysis including 34 RCTs of various surgical and non-surgical interventions found that “there were no significant differences among the different interventions in improving patient function.”

Vertebroplasty

What is a vertebroplasty?

Vertebroplasty is a procedure to treat spinal fractures caused by osteoporosis, bone cancer, and other conditions. A medical-grade cement is injected into the fractured vertebra through a needle, under light sedation or general anesthesia, and the cement hardens in the bone space to form an internal cast. Vertebroplasty may include a kyphoplasty, in which a balloon is inserted into the fractured vertebra and inflated to create space before the cement is injected.

When is it overuse?

For this study, vertebroplasty was defined as overuse for patients with spinal fractures caused by osteoporosis, excluding patients with bone cancer, myeloma, or hemangioma. Overuse rates of vertebroplasty were measured as a ratio of low-value procedures as a proportion of total patient visits for osteoporotic spinal fracture. This overuse definition is based on a previously validated overuse measure (Schwartz, 2014).

Relevant research reviews:

Vertebroplasty for treating spinal fractures due to osteoporosis (Cochrane, 2018)
The Efficacy and Safety of Vertebral Augmentation (American Society for Bone and Mineral Research, 2019)

After two landmark trials in 2009 found a lack of benefit for vertebroplasty compared to a placebo (“sham”) procedure, the rate of vertebroplasties in Medicare declined by about 60% (Journal of the American College of Radiology, 2017).

What are the harms?

Vertebroplasty complications include bleeding, fever, infection, and cement leakage. Serious cases of cement leakage can lead to blood clots in the brain or lung, heart damage, or even death. The rate of complications is estimated at 1% – 8.6%, with a mortality rate estimated at 2.1%. (Johns Hopkins, 2024, Global Spine Journal, 2020).

methodology

Hospital overuse was measured using Medicare fee-for-service and Medicare Advantage claims data for three years of the most recently available data (2020-2022 for Medicare FFS and 2019-2021 for Medicare Advantage). The nationwide counts of low-value procedures includes all hospitals with Medicare claims data available (n=2,545 for spinal fusion/laminectomy, n=2,417 for vertebroplasty).

The cost of low-value back surgeries was calculated using Medicare’ procedure price lookup tool for outpatient procedures, using the most frequent CPT code for the procedure. The cost of inpatient procedures was calculated using the average Medicare cost of the most frequent Diagnosis Related Group (DRG) code for the procedure, using Medicare FFS claims data. We assume that the cost of these procedures is similar for Medicare FFS and Advantage patients.

The lists of hospitals with highest and lowest overuse rates are limited to hospitals with high volumes, defined as performing at least 500 total spinal fusions/laminectomies (when measuring spinal fusion/laminectomy) or having at least 500 patient visits for osteoporotic fracture (when measuring vertebroplasty) over three years.

Spinal fusion and/or laminectomy was defined as overuse for patients with low-back pain, excluding patients with radicular symptoms, trauma, herniated disc, discitis, spondylosis, myelopathy, radiculopathy, radicular pain or scoliosis. For spinal fusion only cases, patients with stenosis with neural claudication and spondylolisthesis were excluded. For laminectomy only cases, patients with stenosis with neural claudication were excluded. Overuse rates of spinal fusion/laminectomy were measured as a ratio of low-value procedures as a proportion of total spinal fusion/laminectomy procedures.

Vertebroplasty was defined as overuse for patients with spinal fractures caused by osteoporosis, excluding patients with bone cancer, myeloma, or hemangioma. Overuse rates of vertebroplasty were measured as a ratio of low-value procedures as a proportion of total patient visits with osteoporotic spinal fracture.

Unnecessary Back Surgery

Older Americans put at risk while billions in Medicare funds wasted

Key Takeaways

Hospitals with the lowest rates of spinal fusion overuse

Hospitals with the Highest rates of spinal fusion overuse

Hospitals with the Lowest rates of vertebroplasty overuse

Hospitals with the Highest rates of vertebroplasty overuse

US News honor roll hospitals

Back surgery overuse by state

INDUSTRY PAYMENTS TO BACK SURGEONS

Industry payments to back surgeons with measurable overuse

Industry payments, top ten companies

Facts about back surgery overuse

Spinal fusion/laminectomy

Vertebroplasty

methodology

Key Takeaways

Hospitals with the lowest rates of spinal fusion overuse

Hospitals with the Highest rates of spinal fusion overuse

Hospitals with the Lowest rates of vertebroplasty overuse

Hospitals with the Highest rates of vertebroplasty overuse

US News honor roll hospitals

Back surgery overuse by state

INDUSTRY PAYMENTS TO BACK SURGEONS

Industry payments to back surgeons with measurable overuse

Industry payments, top ten companies

Facts about back surgery overuse

Spinal fusion/laminectomy

Vertebroplasty

methodology

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