Study: Unnecessary Orthopedic Procedures for Veterans on Medicare Vary Wildly by Region

Where you live determines whether your doctor sticks a needle in your spine for a fracture that isn't even causing symptoms. A new study of Medicare data reveals this geographic variation and points to a much bigger systemic problem.

Researchers led by Samantha Auty, PhD, at Boston University analyzed Medicare fee-for-service claims from 2017 to 2022 for veterans age 65 and older who saw an orthopedic surgeon, according to the study published in JAMA Network Open and reported by MedPage Today. They tracked five procedures considered "low-value" when performed on patients whose clinical records didn't justify them: vertebroplasty, spinal fusion, spinal injections, advanced spinal imaging, and knee arthroscopy.

A claim only counted as low-value when the patient's actual medical record didn't match the reason the procedure is supposed to be used for. Vertebroplasty for someone with an asymptomatic spinal fracture is the textbook example the researchers cite.

The geographic spread was massive. In the highest quartile of hospital referral regions, certain low-value procedures were performed at rates above 72 per 100 Medicare-enrolled veterans. In other regions, the same procedures were rarely done at all, according to the study.

One notable twist: a region with a high rate of one low-value procedure didn't necessarily have high rates of the others. Auty and her co-authors said that means blanket crackdowns won't work. "These findings may inform procedure-specific strategies for reducing orthopedic LVS [low-value services], such as prior authorization or insurance network design based on procedure-specific utilization," they wrote.

A Much Bigger Problem Than Spines

This pattern extends far beyond orthopedics. According to the Epoch Times, a 1996 independent task force recommended doctors stop giving urine tests to patients with no symptoms of a urinary tract infection, because a positive result doesn't mean the patient is actually sick. Nearly 15 percent of Medicare seniors still get that test every year, costing the program about $1 billion annually.

The Epoch Times, citing a landmark 2012 study, reported that more than one-third of Medicare beneficiaries receive some form of low-value care every year, costing billions of taxpayer dollars. Vitamin D blood tests and MRIs for mild lower back pain made the list too. Donald Berwick, who ran the Centers for Medicare & Medicaid Services under President Obama, called it "waste that comes from subjecting patients to care that, according to sound science and the patients' own preferences, cannot possibly help them."

The federal government has had the tools to fix this for 16 years. Since 2010, the HHS secretary has held the legal authority to ban 21 specific kinds of low-value care from Medicare coverage outright. Not one HHS secretary has used it. That includes current Secretary Robert F. Kennedy Jr., according to the Epoch Times.

Oz Tries, Congress Says No

CMS Administrator Dr. Mehmet Oz has publicly flagged low-value care as a driver of Medicare's financial problems and launched a voluntary pilot program this year to reevaluate coverage for some of these services, the Epoch Times reported. In June, the House Appropriations Committee pushed back on the pilot with unanimous, bipartisan objection.

Lawmakers who opposed it raised a fair concern: a federal algorithm flagging a procedure as "low-value" in aggregate data doesn't always know an individual patient's full picture, and seniors on fixed incomes have limited room to fight a coverage denial or pay out of pocket if the government gets it wrong. That's a legitimate worry about how any national low-value-care policy gets implemented, not just whether one exists.

But the bipartisan resistance also reflects the plain political reality the Epoch Times points to: Medicare covers 70 million seniors who vote, and touching their coverage, even wasteful coverage, is politically radioactive for both parties.

The Math Doesn't Care About Politics

The U.S. Treasury's annual report projects Medicare could become insolvent by 2033 absent reform, with a $60.4 trillion shortfall over the next 75 years between what the program will collect in premiums and payroll taxes and what it's obligated to pay out, according to the Epoch Times. Options on the table range from raising premiums and deductibles to cutting people off the program entirely.

None of that requires guesswork about whether waste exists. The BU study demonstrates with hard Medicare claims data that unnecessary spinal procedures for veterans get performed at wildly different rates depending purely on geography. That reflects inconsistency the data can measure and Washington has chosen not to fix.

The open question now is whether CMS's pilot program survives the next appropriations fight, or whether it joins the pile of Choosing Wisely recommendations from the last 15 years that hospitals and doctors simply ignored.