If the cost of health care is to be reduced in the US, new methods should be established to pay clinicians, pharmaceutical companies and device manufacturers. If graduating medical students are so laden with debt that paying it off is more important than the possibility of ongoing study and academic pursuit, we must lower the cost to the student of medical education. If the cost of drug development is so high that huge prices must be charged for pills, we must find ways to reduce the cost of development of new pharmaceuticals. These fundamental issues in health care have an impact on the standard of care of back pain in the USA.

Guidelines for care of specific conditions, produced by professional medical organizations, should be based on a rigorous analysis of all existing literature about the treatment of the back pain condition. Guidelines for Low Back Pain were published by the American Pain Society advising that many pain treatments were not clearly effective. Another organization objected to these guidelines and claimed that the interventions that most of its members provided were indeed helpful and necessary to the well-being of patients in pain. The APS’ response addressed the need for unbiased assessments of back pain treatments offered by healthcare providers. It may be difficult to admit that what you do as a treating physician doesn’t work well. The results for treatment of low back pain in the US (and elsewhere) are generally not good.

An article in JAMA in 2009 pointed out that even though the expenditures on neck and back pain increased 65% ($34 billion), from 1997 to 2005, the percentage of persons disabled with neck and/or back pain rose from 20 to 25%. We continue to spend more than any other country in the world and yet we have increasing numbers of patients unable to function. The APS article asks for integrity from professionals providing these costly treatments for pain relief. An honest reassessment of our standards of care can help diminish the provision of unnecessary procedures. Clearly some procedures do work for some people, but the indiscriminate use of costly interventions leads to suboptimal care. Incentivizing for the performance of a procedure rather than for its outcome can never produce an efficient health care system. Common sense would tell us that exercise and diet would be the most cost-effective way to improve many common pain complaints. How often do we as doctors, or you as a patient with your doctor, spend time on these interventions?

I held a German medical license for a year in 1998. I spent time with an orthopedic surgeon in Regensburg seeing patients in his office and discussing their non-surgical treatment options. I asked him how he had the time to do this and not be in the operating room doing surgery. His answer was that he made the same amount of money in the office or doing surgery. That would be one way to dramatically change the medical cost of care in the US. Pay more for non-invasive treatment, and less for invasive treatments such as surgery, nerve blocks and spinal cord stimulators. Encourage pain patients to see physicians that provide comprehensive treatment before they are seen by doctors who only do invasive procedures.

Use of ineffective or marginally effective drugs also adds to our run- away cost of care for common back pain complaints. A recent review of Botox for neck pain found that this very expensive treatment was not effective. Some years ago a prominent medical web site for physicians stated that Botox was the only good treatment of muscle/soft tissue pain. The editor of that section received fees as a speaker for the company promoting Botulinum Toxin. That is why we need federal funding to do non-biased head to head comparisons of drugs so that the claims of new expensive pharmaceuticals can be assessed to see if they are any better than what is already available.

~ Norman Marcus, MD
Norman Marcus Pain Institute, New York NY
 
“Your New York City Doctor”

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