2025 RESULTS

Unnecessary Back Surgery

Older Americans put at risk; billions of Medicare dollars wasted.

VIDEO: Our October 7th panel discussion featuring David Auerbach, Ph.D, Massachusetts Health Policy Commission; Eugene Carragee, MD, Stanford University; and Vikas Saini, MD, president of the Lown Institute.

The Lown Institute Hospitals Index is the first to evaluate how well individual hospitals avoid overuse of common low-value tests and procedures. The Institute measured overuse of spinal fusion/laminectomy and vertebroplasty at hospitals with the capacity to perform the procedure using Medicare fee-for-service (2021-2023) and Medicare Advantage (2020-2022) claims data. (press release | methodology)

Key Takeaways

  • 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 more than $1.9 billion over three years.
  • Complications of spinal fusion occur in up to 18% of patients and include infection, blood clots, stroke, pneumonia, heart and lung problems, and even death.
  • California, Florida, Texas, and Pennsylvania had the highest volume of spinal fusion overuse, with at least 5,000 unnecessary procedures done in each state.
  • Texas, Florida, and Ohio had the highest volume of vertebroplasty overuse, with at least 6,000 unnecessary procedures done in each state.
  • Variation among U.S. News hospitals: Cleveland Clinic has a 0.5% rate of unnecessary vertebroplasty, while AdventHealth Orlando has a rate of 22.7%.
  • The top 10% of physicians by spinal fusion overuse volume accounted for 60% of the total overuse.

Methodology

Hospital overuse was measured using Medicare fee-for-service and Medicare Advantage claims data for three years of the most recently available data (2021-2023 for Medicare FFS and 2020-2022 for Medicare Advantage). The nationwide counts of low-value procedures includes all hospitals with Medicare claims data available (n=2,547 for spinal fusion/laminectomy, n=2,412 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. An additional capacity filter was used to ensure that hospitals with no vertebroplasties had the capacity to perform the procedure. 

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.

Advisory Committee

Jane Ballantyne, MD
Anesthesiologist and director of the University of Washington Medicine Pain Fellowship

Rachelle Buchbinder, MBBS, PhD
Rheumatologist, clinical epidemiologist, and professor at Monash University

Eugene Carragee, MD
Professor of Orthopaedic Surgery, Emeritus at Stanford Medicine

Ian Harris, MBBS, PhD
Professor of Orthopaedic Surgery, School of Clinical Medicine, University of New South Wales (UNSW) Medicine and Health, UNSW Sydney

Sohail Mirza, MD
Orthopedic surgeon and professor at Dartmouth College

Media inquiries should be directed to Aaron Toleos, vice president of communications for the Lown Institute, at atoleos@lowninstitute.org.