Joint venture: What a new hip or knee really costs

   Joint venture: What a new hip or knee really costs (MarketWatch)

Patients’ jaws drop when Dr. Steven Schutzer tells them it takes a whole year to heal after knee or hip replacement surgery.

Schutzer, director of the Connecticut Joint Replacement Institute at Saint Francis Hospital and Medical Center in Hartford, isn’t saying it takes that long for people to get up and functioning. He just means that full healing of the soft tissue and bone generally takes 12 months or more.

Still, the patient might not care about this clinical definition, wondering only when he’ll be able to hit the slopes again. Suddenly, the impatient patient may find himself unexpectedly inactive—or, at the other end of the spectrum, pushing his new joint too hard, too soon.

This is one example of why it’s so important for patients to communicate their expectations for elective surgery, experts say: A mismatch between expectations and reality can lead to patient dissatisfaction, not to mention a waste of money for both patients and the health system overall.

“Making a decision for joint replacement isn’t something you do in five minutes,” Schutzer said. “The patient needs to consider themselves a consumer, and they need to apply the same due diligence as they would when buying a large-screen TV.”

In 2011, there were 645,000 total knee replacements and 307,000 total hip replacements in the U.S. Those totals are both up about 30% from 2006, according to the latest data from the American Academy of Orthopaedic Surgeons. (Perhaps not coincidentally, some leading makers of artificial joints, including Stryker Corp.SYK -0.34% and Smith & Nephew PLC SNN +0.71% , have significantly outperformed the S&P 500 over that stretch.)

These numbers will likely continue to climb as boomers age. Indeed, 55-to-65-year-olds are the fastest-growing age group undergoing these procedures, Schutzer said. Besides sheer demographics, boomers’ expectations about sustaining an active lifestyle are also driving the increase in procedures, experts say.

In light of these trends, researchers are examining the best approaches to hip and knee replacements from both a cost and a clinical perspective. Late last year, the Centers for Medicare and Medicaid Services released data on how patients fared after knee and hip surgeries at hospitals throughout the country . And last month, a study in the Archives of Gerontology and Geriatrics analyzed the effectiveness of costly inpatient rehabilitation following knee and hip replacements.

To operate, or not to operate?

Many factors go into the decision of whether to undergo elective joint replacement. Commonly, severe pain from osteoarthritis, a chronic condition in which the cartilage in the joints breaks down, causes patients to consider the procedure. But the autoimmune disease rheumatoid arthritis and traumatic injury can also prompt the procedure.

Joint replacement surgery is usually considered “elective,” in that it’s generally not medically necessary. Yet since an underlying medical condition leads to these procedures, which can greatly improve patients’ quality of life, health insurance usually covers them. In other words, they’re not elective procedures in the sense that cosmetic plastic surgery is. (Don’t expect insurance to pick up the tab for your face-lift).

Before resorting to surgery, it’s usually best to try other treatments, doctors say. Losing weight can reduce stress on joints, and exercises can strengthen the muscles around the joints, helping to stabilize them. Aquatic therapy is an option when exercising outside the water puts too much stress on joints. Cortisone injections can sometimes help manage the pain.

Some good questions to ask yourself when considering surgery, according to Schutzer, are, “How’s your quality of life?” and “What would you like to do that you can’t do now?” Most athletes can’t run 26 miles on an artificial joint, so a middle-aged patient who says he wants to resume running marathons should know that’s probably not realistic, Schutzer said. If a patient wants to resume skiing, Schutzer will ask: downhill or moguls? The former is probably doable—the latter, not so much.

For Pam Black, a writer and editor in Manhattan, the last straw came when her hip pain started disrupting her sleep. She’d lived with pain and limited mobility for years, but when she started losing sleep she decided it was time to take action. “It’s scary for anyone—you don’t rush into it,” she said.

Where to get it done

Once you elect to have the surgery, the decision becomes one of where to have it done. Patients commonly follow their orthopedic surgeon to whichever hospital she uses, but this can be a mistake, experts say. “Even the best surgeon in the world isn’t going to be a safe choice if you get an infection afterward,” said Leah Binder, president and CEO of The Leapfrog Group, a nonprofit organization that reports on hospital quality.

Binder suggests patients research a hospital’s safety record first, before investigating the doctors who operate there. Leapfrog has a free hospital survey on its website , with information on hospitals’ efforts to prevent medication errors (a very common mistake, according to Binder), among other safety measures. The survey relies on self-reported data. Leapfrog also maintains hospital safety scores , based on a variety of public data.

Consumer Reports ranks hospital safety for subscribers. Rankings are based on Medicare data, and measures include the incidence of bloodstream infections and adverse events after surgery.

Speak up if you find your surgeon practices at a hospital with some safety concerns, Binder said. Asking the surgeon what the hospital is doing to address a given problem “sets the doctor up that you expect him to be your champion,” she said.

In addition to its general safety data, Medicare’s Hospital Compare website recently added information on how patients do after hip and knee replacement surgeries. Hospitals are ranked as better, worse or average on the metrics of readmission and complication rates following surgery. The information can be found under the “Readmissions, complications & deaths” tab under each hospital’s entry at this Web page .

Critics say the Medicare data isn’t that useful. For one, the vast majority of hospitals are ranked average, as the term would imply. An analysis of the results by Kaiser Health News found that out of some 4,000 Medicare-certified hospitals across the country that reported results, 95—or just 2.4%–had rates that exceeded the national average in one or both of the two problem categories, and 97 hospitals had rates that were better than average in one or both categories.

What’s more, research suggests that the biggest determinant of how joint replacement surgery turns out is usually the patient him or herself, said Dr. Wael Barsoum, vice chairman of the department of orthopedic surgery at the Cleveland Clinic, who has studied the topic. Hospital rankings don’t fully reflect this patient factor, in part because surgeons often neglect to properly document their patients’ histories. (Cumbersome electronic medical records are partially to blame, he noted.) If researchers can’t document patients’ condition before surgery and their compliance with medication and physical therapy afterward, patients need to take hospital outcomes data with a grain of salt, Barsoum said.

While you may be the biggest factor in your operation’s success, it helps to find an experienced surgeon. Nationwide, most knee and hip replacements are done by surgeons who perform fewer than 30 of these operations a year, Schutzer said. Research has shown that high-volume surgeons and high-volume hospitals tend to have the lowest rates of complications. “Overall, the more specialized you are, the better your outcomes,” said Dr. John Santa, medical director, Consumer Reports.

Of course, those in good health with no risk factors might be well served by a lower-volume surgeon. But those with more complex situations, from poorly managed diabetes to obesity to prior knee or hip surgery, should consider a doctor with a higher-volume practice who has operated on more like patients, experts say. Hence, asking about how frequently a potential surgeon performs the procedure is a must-do.

Pricing it out

With high-deductible health insurance plans on the rise, more patients are going to want to know what the surgery costs. The bad news is that, “Ninety-nine percent of the time, the doctors have no idea what anything costs,” Santa said. They know what they charge, but that can be different from what insurance pays them for the procedure, and different also from what the patients is billed.

Prices can vary greatly even within one medical group, Santa said. Doctors designated as preferred providers for a particular insurance plan might accept lower payments in exchange for a higher volume of patients.

The Wall Street Journal’s Melinda Beck reported on health care pricing earlier this week with an analysis that included Medicare data on joint-replacement surgery. It found prices ranging from $5,300 for the surgery in Ada., Okla. to $223,000 in Monterey Park, Calif. Healthcare Bluebook, a free online repository of health-care procedure quotes based on actual fees negotiated between insurance companies and health-care providers, quotes a total fair price for total hip replacement at $22,606, with total knee replacement at $22,720. While insured patients wouldn’t pay these amounts, it’s possible that uninsured patients would get such a bill.

Bottom line? Ask your doctor and hospital about all the charges. You may get shunted around to a few departments before you get an answer, but hospitals are increasingly fielding such questions these days and should be able to give you a quote, experts say. The total bill would include not just the surgery itself but other related charges, such as fees for the anesthesiologist and any inpatient rehabilitation, for example.

Of course, you should also call your insurer to verify that your surgeon and hospital are included in the plan’s network. This can have a great impact on the amount you need to pay. The insurer should be able to tell you the percent of the bill you’ll be responsible for, both for in-network and out-of-network services, plus any deductibles and copayments that apply.

Committing to rehab

Undergoing joint-replacement surgery means also committing to the rehabilitation process. The duration of physical therapy required after surgery is “very patient-specific,” Barsoum said. It also depends on the joint: Knees, which tend to get stiff if not moved, require more rehab work than hips, he said.

Generally, patients with a total hip replacement can expect to go to physical therapy a few times a week for four to five weeks, while those with a total knee replacement can expect to go for eight weeks, Barsoum said.

Those who get partial knee replacements can expect a quicker recovery than those who get the whole knee replaced. The former surgery is experiencing a resurgence among patients who have arthritis in just one of the three compartments of the knee, have a good range of motion and are a healthy weight, Barsoum said. (Partial hip replacement, by contrast, isn’t very common.)

Most patients go straight home after surgery, but some higher-risk patients get discharged to an inpatient facility for rehabilitation. While a costlier setting than homes or outpatient centers, inpatient rehabilitation can greatly improve patients’ motor functioning following total hip and knee replacements, according to a recent study in the Archives of Gerontology and Geriatrics.

If the surgery and rehabilitation go well, patients can expect to be pain free, said Kenneth J. Ottenbacher, director of the division of rehabilitation science at theUniversity of Texas Medical Branch at Galveston, and an author of the Archives of Gerontology and Geriatrics study. “When patients get the procedure they expect to benefit from it,” Ottenbacher said. “Generally, they do.”