The Dartmouth Atlas of Healthcare Shows Geographic Variation in the Frequency of Spine Surgery

This video provides an in-depth exploration of geographic variation in healthcare service utilization, specifically focusing on spine surgery rates across the United States, utilizing data from the Dartmouth Atlas of Healthcare. Dr. Eric Bricker begins by introducing the Dartmouth Atlas as a renowned resource that maps healthcare service utilization, emphasizing its value for understanding regional differences. The core purpose of the video is to apply this macro-level Medicare data to the context of employer-sponsored health plans, arguing that utilization patterns observed in Medicare beneficiaries are likely mirrored in commercially insured populations due to consistent surgeon practice patterns.

The presentation systematically illustrates significant variations in spine surgery frequency by examining specific metropolitan areas. It highlights New York City and San Francisco as regions with relatively low and consistent rates, both averaging around 2.5 surgeries per 1,000 Medicare enrollees. In stark contrast, areas like Dallas-Fort Worth and Houston exhibit much higher rates, with considerable variability even within their own metro areas (e.g., Denton County in Dallas at 8.8 per 1,000 compared to Dallas city at 4.9). This pattern of high variability and elevated rates is further demonstrated in Chicago (Northwest Indiana at 6.8 vs. Chicago city at 2.7), Boston (Plymouth at 6.7 vs. Boston city at 3.4), and Los Angeles (Torrance at 6.5 vs. LA city at 4.0).

Dr. Bricker posits that these dramatic differences are not attributable to greater underlying pathology in certain regions but rather to variations in the surgical practice patterns of orthopedic spine and neurosurgeons. He suggests that surgeons in high-utilization areas are simply more aggressive in recommending and performing surgery. An interesting additional factor discussed is the potential influence of tort reform, noting that states like Indiana and Texas, which have caps on punitive damages, tend to exhibit higher surgical rates, possibly due to a more favorable medical malpractice environment for surgeons. The video culminates by pointing out the highest rates of spine surgery are found in the rural Southeast, averaging around 8 per 1,000, which is a staggering 400% higher than in low-utilization areas like New York or San Francisco.

The implications of these findings are particularly relevant for managing employer health plans. Spine surgery is highlighted as a critical area because it is often elective, highly controversial (with estimates suggesting up to 50% of procedures may be unnecessary), and falls under musculoskeletal conditions, which represent one of the top three cost drivers for employer health plans (alongside cancer and cardiovascular issues). Given these factors, Dr. Bricker advocates for the strategic implementation of second opinion programs. He advises that such programs would be most impactful and cost-effective if geographically targeted to areas with high surgical utilization, such as Dallas, Houston, Chicago, Boston, Los Angeles, and the rural South, rather than being uniformly applied across all employee populations, especially in already low-utilization regions like New York City.

Key Takeaways:

• Significant Geographic Variation in Healthcare Utilization: The Dartmouth Atlas of Healthcare reveals up to a 400% difference in spine surgery rates across various regions of the United States, with rural areas in the Southeast showing the highest utilization compared to metropolitan areas like New York and San Francisco.
• Surgeon Practice Patterns as a Primary Driver: The observed variations in surgical frequency are more likely due to differing practice patterns among surgeons (e.g., some being more aggressive in recommending surgery) rather than a higher prevalence of underlying medical pathology in certain populations.
• Spine Surgery as a Key Cost Driver: Spine surgery is identified as a major component of musculoskeletal costs, which collectively represent one of the top three diagnostic cost drivers for employer-sponsored health plans, making it a critical area for cost management.
• Elective and Controversial Nature of Spine Surgery: A significant portion of spine surgeries are elective, not emergent, and are considered highly controversial, with some estimates suggesting that up to 50% may not be medically necessary, underscoring the importance of careful decision-making.
• Relevance of Medicare Data to Commercial Plans: While the Dartmouth Atlas uses Medicare data, the speaker argues that the observed utilization rates and surgeon practice patterns are likely very similar for commercially insured individuals, making the insights applicable to employer health plans.
• Impact of Tort Reform: States with tort reform (e.g., caps on punitive damages) may experience higher surgical rates due to a more favorable medical malpractice environment for surgeons, influencing practice patterns.
• Strategic Implementation of Second Opinion Programs: To effectively manage costs and improve patient outcomes, employer health plans should consider implementing geographically targeted second opinion programs, focusing resources on high-utilization areas where such interventions are most likely to yield significant benefits.
• Data-Driven Decision Making for Benefits Design: Leveraging healthcare utilization data, like that from the Dartmouth Atlas, allows for more informed and strategic design of employee benefits programs, ensuring interventions are placed where they can have the greatest impact.
• Musculoskeletal Health as a Focus Area: Given its status as a top cost driver, musculoskeletal health, particularly conditions leading to spine surgery, should be a priority for employers seeking to optimize their healthcare spending and employee well-being.
• Understanding Regional Healthcare Dynamics: Companies with employees distributed across different geographies can gain valuable insights into regional healthcare dynamics, which can inform not only benefits design but also broader strategies related to employee health and wellness.

Tools/Resources Mentioned:

• Dartmouth Atlas of Healthcare: An online resource that provides data on geographic variation in healthcare services using Medicare data.
• NCBI (National Center for Biotechnology Information): Referenced as a source for supporting information (specifically, an article on PMC3841934).

Key Concepts:

• Geographic Variation: Significant differences in the frequency or patterns of healthcare services across different regions.
• Utilization Rates: The frequency at which healthcare services (e.g., surgeries) are used by a population, typically expressed per thousand beneficiaries.
• Employer-Sponsored Health Plans: Health insurance coverage provided by employers to their employees.
• Second Opinion Programs: Programs designed to encourage patients to seek an additional medical opinion before undergoing certain procedures, often to ensure necessity and explore alternatives.
• Tort Reform: Legislative changes aimed at limiting the ability of injured parties to file lawsuits or capping the amount of damages they can receive, often impacting medical malpractice environments.
• Musculoskeletal Costs: Healthcare expenses related to conditions affecting muscles, bones, joints, ligaments, and tendons, identified as a major cost driver.