Patients are returning for elective procedures. This surgeon is trying to prevent ‘unnecessary’ ones

Patients who delayed non-emergency surgeries during the pandemic are returning for care. And as surgical volume picks up, so too is the conversation about how many of those procedures are really necessary.

UnitedHealth Group executives spooked investors earlier this month when they said that reimbursement costs for surgical procedures are going up (investors in medical device companies, meanwhile, cheered the news.)

What defines an “unnecessary” surgery can be hard to pin down; it's sometimes described as one that had no benefit, something that might only be clear after that fact. But by that definition, the numbers are high: a controversial study last year from the Lown Institute , a nonpartisan think tank, counted more than 106,000 such procedures from March to December 2020. (The American Hospital Association , in turn, countered that the study had “ limitations and flaws.”)

Still, studies have shown wide variation in surgical rates across countries or even between states. The high c-section rate in the United States, for example, has spurred much discussion over whether the procedure is overused. Lumbar fusion is another example of a procedure that’s been performed at significantly higher rates in some parts of the country, while being less common in others.

I recently chatted with Vijay Yanamadala MD, MBA, FAANS, FCNS , a spine surgeon who says there’s an “epidemic of unnecessary surgery.” His own research places the number of unnecessary lumbar spinal fusions above 50%. And he cites the Lown Institute data showing that back procedures, including vertebroplasty for osteoporosis and spinal fusion for back pain, together account for about a third of unnecessary surgeries.

Yanamadala wears two hats on this topic. He is a practicing neurosurgeon who serves as system medical director of spine quality and surgical optimization at Hartford HealthCare . And he’s also the chief medical officer for Sword Health , which provides digital physical therapy. While physical therapy is typically prescribed as a prerequisite before back surgery, Yanamadala argues there’s often poor compliance, something digital programs can improve.

Sword isn’t the only company in this space. Hinge Health , one of this year’s LinkedIn Top Startups, also offers digital physical therapy programs. Moreover, software developers are rushing to apply data analytics and artificial intelligence to help reduce healthcare costs.

Of course, the profit-driven U.S. healthcare system often grapples with competing incentives. Elective surgeries are profitable for hospitals. Neurosurgery residencies filled almost 99% of their spots this year, while spinal cord injury fellowships (a non-surgical specialty) filled less than two-thirds, according to the National Resident Matching Program. Physical therapists are also in short supply, with one report showing that 22,000 physical therapists left the workforce in 2021.

“A lot of times in this country, the wealthy get care they don't need, the poor don't get care that they need, and very few Americans are really getting the right care,” Yanamadala said.

Read on for more of his thoughts on this topic.

The transcript below has been edited for length and clarity.

LinkedIn News: How would you define an unnecessary surgery?

Yanamadala: An unnecessary surgery is a surgery where you are no better off, or you are worse off, than if you had not undergone that surgery.

I'm a neurosurgeon who's focused on spine, and a lot of what I do is revision surgery. I see patients – five, six spine surgeries down the road – who are worse off than they were before their first. Someone might say, Actually, that first surgery was necessary because the MRI showed a disc herniation, and I needed to take it out. And I retort to that, We don't operate on MRIs. We operate on patients, and the ultimate outcome we care about is whether the patient is better or not.

LinkedIn News: Why is the number of unnecessary surgeries so high? 

Yanamadala: There is true ambiguity. Let me tell you about two studies that I did. One was at Virginia Mason Medical Center in Seattle. We published in 2017, and we took 100 patients who had been recommended a lumbar spinal fusion, and we put them through a multidisciplinary conference; we put together a board that had surgeons, but also non-surgeons like psychiatrists, anesthesiologists, pain specialists, physical therapists and occupational therapists. We asked them to review the patient's case and come up with a recommendation. Fifty-eight of the patients who had been recommended to lumbar fusion by an outside surgeon, we said did not need any surgery. 

This has been substantiated by the Walmart Center of Excellence model. Walmart sends all of their employees for spine surgery and joint surgery to one of 10 Centers of Excellence if they've been recommended surgery by a local surgeon. Recent data published in the Harvard Business Review [showed] 54% of the surgeries that were recommended to a Walmart Center of Excellence were deemed unnecessary and did not need to be done.

LinkedIn News: Where does that ambiguity come from? 

Yanamadala: Almost everyone who gets an MRI of their spine will have something. It's normal, because our spine happens to have more than 100 joints that we're constantly moving every day, and these tend to wear out over time. But just because you have a finding on an MRI doesn't mean that that's the cause of your pain, and doesn't mean that you need surgery for it.

Surgeons want to offer something for patients. And we think sometimes that surgery is that magic bullet. Obviously, financial incentives play a role. Surgeons make 10 times more money per hour doing surgery than they do in an office. Surgery is a very intensive, laborious, meticulous, stressful endeavor. So it should be reimbursed accordingly. But the problem is that it also creates incentives [to perform more surgeries]. There's also a trend towards surgeons being employed by health systems as opposed to being in private practices. Health systems tend to push their employed surgeons to operate more. And so when there is ambiguity, you have incentive pushing you in that direction. 

LinkedIn News: How do we reduce the number of unnecessary surgeries?

Yanamadala: I'll tell you a little bit about Sword Health. It's a digital physical therapy solution that allows patients to do physical therapy in their own home. We send patients a tablet and sensors, and a doctor of physical therapy creates a program for them. This overcomes a lot of barriers [that prevent people from doing physical therapy, including] time, transportation and cost. 

We're doing 500 sessions of physical therapy with Sword. What we're showing is people who come in with a positive likelihood to pursue surgery, 60% of those [decide not to get the surgery] by the end of a successful physical therapy course. If we can get more people into physical therapy and get them better, they can avoid these surgeries altogether. 

LinkedIn News: Are there ways to predict who would benefit from surgery?

Yanamadala:  I think AI is going to be really key here. We have tons of data out there in terms of [insurance] claims on people who have undergone unnecessary surgeries. And we can use that to create much better models than we've had so far. 

We just launched something called Predict where we're using claims-based data to identify people six months before they're likely to undergo an unnecessary surgery and then get them into physical therapy and other care because it's very hard to change someone's mind once they've seen a surgeon, and once they're convinced that they need to undergo surgery. 

LinkedIn News: How receptive are surgeons to this idea that so many of the surgeries they perform are unnecessary? 

Yanamadala: There are a few people who truly need surgery right away, don't get me wrong. And one of the fears that non-spine surgeons have is missing those diagnoses. That's why primary-care physicians tend to send their patients straight to a spine surgeon to make sure that they don't need surgery right away. But that's less than 5% of people, and the other 95% who come with pain and pain alone really don't need to see a surgeon first.

Most spine surgeons know that 50% of spine surgeries are unnecessary. No one wants to think that they are the ones doing them. The reality is that all of us have an example or two of patients who underwent a surgery that didn't ultimately benefit them for pain.