Newtered: Gingrich's Congress emasculated the one agency capable of controlling health care costs and improving quality. Time to reverse the procedure.

• Author: Brownlee, Shannon
• Position: SPECIAL HEALTH CARE ISSUE - Agency for Health Care Policy and Research

If you've never suffered the agony of low back pain, don't worry--chances are you will. About two-thirds of adults are hit with low back pain at some time in their lives, and for many the pain is sufficiently unbearable to send them hobbling into the doctor s office. Yet although back pain is one of the most common conditions around, and although it costs billions of dollars each year in lost productivity, doctors still disagree over everything from how to diagnose the cause to what to do about it. The vast majority of low back pain--even the excruciating nerve sensation known as sciatica--goes away, inexplicably, on its own. There's little evidence that the two most common surgical treatments, known as spinal fusion and discectomy, are necessarily better than such nonsurgical remedies as over-the-counter painkillers and physical therapy. Practically every aspect of back pain, from the terminology to various treatments to the imaging tests, like MRIs and X-rays, used to diagnose it, is fraught with confusion and controversy.

That's why a federal office known as the Agency for Health Care Policy and Research (AHCPR) impaneled a group of twenty-three experts in 1993 to draft guidelines to help doctors figure out how best to treat low back pain. The AHCPR was created in 1989 during the first Bush administration. Its mandate was to produce evidence-based, clinical-practice guidelines that would help physicians sort through the conflicting data that existed not just for low back pain, but for many other common treatments and tests. Then, as now, the nation's medical bill was rising at an alarming rate, in part due to widespread, inappropriate use of unnecessary or useless treatments. Democrats and Republicans alike hoped that the AHCPR's research would help rein in costs by giving doctors better direction, and offering payers--especially Medicare--the ammunition they needed to make evidence-based coverage decisions. More significantly, the agency promised to improve the quality of health care by helping to ensure that doctors would give patients the treatments they really needed--and refrain from giving them care that could harm them.

But when the AHCPR's panel concluded that there was little evidence to support surgery as a first-line treatment for low back pain, and that doctors and patients would be wise to try nonsurgical interventions first, back surgeons went wild. They knew that once the AHCPR's guidelines were published, Medicare might limit reimbursement for various back surgeries to patients who were enrolled in a controlled clinical trial designed to test the efficacy of the procedure. If the study showed that a surgery was no better than nonsurgical remedies, or only about as good, there was a chance that Medicare would stop reimbursing for it. If Medicare made a back surgery provisional, private insurers were likely to follow.

Sensing a threat to their livelihoods, many surgeons bombarded Congress with letters contending that the agency's panel was biased. One doctor, Neil Kahanovitz, founded the Center for Patient Advocacy, a nonprofit that orchestrated a sustained lobbying campaign against the entire agency. A company that manufactures pedicle screws (devices that are sometimes used during spinal fusion) sought a court injunction to prevent publication of the guidelines. The North American Spine Society, the main professional group for back surgeons, launched an assault on the methods used by the AHCPR experts, charging that the agency had wasted taxpayer dollars on the study.

Their arguments found a sympathetic ear in Newt Gingrich's newly elected Republican majority in the House. The back surgeons' anger at the AHCPR's efforts to discipline medical practice resonated with the Republican fervor for reducing government, and with the party's ideological antipathy for federal interference in what they imagined as a free market. The agency's name soon appeared on a House Budget Committee "hit list" of 140 federal programs targeted for elimination. (The list also included the congressional Office of Technology Assessment, which evaluated the effectiveness of medical technology.) The Republicans saw the AHCPR as a wasteful government agency, and in 1995 the House voted to eliminate its funding, calling it the "Agency for High Cost Publications and Research."

Eventual]y, the agency was rescued with the help of a handful of Republican supporters in the Senate, but it suffered a 21 percent cut of its already meager $159 million budget. Sensing the agency was still vulnerable, its director worked with moderate Senate Republicans to protect the agency by downshifting its mission. Now, the AHCPR would merely be a "clearinghouse" for data, which meant it could no longer offer Medicare explicit guidance when it came time to determine which tests, treatments, and procedures to cover. The word "policy," which smacked of the failed Clinton health care plan, was expunged from its name, and the AHCPR became the Agency for Healthcare Research and Quality (AHRQ).

The back panel's guidelines were published in 1994, but they were ignored by many surgeons who were perhaps emboldened by the Republican smack-down of the AHCPR. Last year, we spent more than $16 billion on back surgeries, and, in the past decade, surgeons have been performing spinal fusions at a furious rate, even though there still has never been a rigorous, independently funded clinical trial showing that going under the knife is superior to cheaper, less invasive remedies. At the same time, the nation's total health care bill continues to skyrocket, propelled in no small measure by procedures that are equally as questionable as spinal fusion. In 2000, America spent $1.3 trillion, a figure that nearly doubled to an estimated $2.1 trillion by 2006. In the view of Peter Orzag, head of the Congressional Budget Office, this has put the U.S. on "an unsustainable fiscal path."

Of course, some of our money is going toward new treatments and tests that help Americans live longer and healthier lives. However, as much as 30 cents on every health care dollar is spent on unnecessary care--or "overtreatment," in medicalspeak. That may sound odd after all we've heard from people like Michael Moore about how everybody from your hospital to your insurer is getting rich by denying you care you need. Yet both problems exist simultaneously. All too often, patients don't get necessary medical treatment. At the same time, we risk being given stuff that not only doesn't improve our health but which may actually harm us. One estimate suggests that as many as 30,000 Medicare recipients die prematurely each year from unnecessary care.

This overtreatment is due in part to an excess supply of...