Original Research

Patients’ Perceptions of the Costs of Total Hip and Knee Arthroplasty

Am J Orthop. 2015 May;44(5):E135-E141

With medical economics in the national sociopolitical spotlight, we conducted a study to assess patients’ understanding of the cost of 2 common orthopedic procedures: total hip and knee arthroplasty (THA, TKA). We surveyed 284 consecutive THA or TKA patients, at their first postoperative visit, regarding their understanding of reimbursement and cost.

On average, patients estimated surgeon reimbursement at $12,014. They estimated that the hospital was reimbursed $28,392 for their perioperative care and that it cost the hospital $24,389 to provide it. The cost of the implant used was estimated at $6447.

There is wide variation in patients’ estimates and understanding of health care costs. However, patients substantially overestimate reimbursement to the surgeon both in isolation and as a proportion of the total cost of the surgical procedure.

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References

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2. Hariri S, Bozic KJ, Lavernia C, Prestipino A, Rubash HE. Medicare physician reimbursement: past, present, and future. J Bone Joint Surg Am. 2007;89(11):2536-2546.

3. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785.

4. Foran JR, Sheth NP, Ward SR, et al. Patient perception of physician reimbursement in elective total hip and knee arthroplasty. J Arthroplasty. 2012;27(5):703-709.

5. Rosenthal JA, Lu X, Cram P. Availability of consumer prices from US hospitals for a common surgical procedure. JAMA Intern Med. 2013;173(6):427-432.

6. US Senate Committee on Finance. H.R. 4994: the Medicare and Medicaid Extenders Act of 2010. http://www.finance.senate.gov/legislation/details/?id=9f97aa2e-5056-a032-52d4-8db158b12b11. Accessed March 25, 2015.

7. Zinberg JM. When patients call, will physicians respond? JAMA. 2011;305(19):2011-2012.

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Medical economics has been a major sociopolitical issue in the United States for the past 20 years, with concerns focused on increasing medical spending. These costs are projected to continue to rise, from 15.3% of gross domestic product in 2002 to 19.6% in 2017.¹

Multiple steps have been taken to help reduce the cost of health care, many of which center on physician reimbursement. The Balanced Budget Act of 1997 worked to control Medicare spending by increasing reimbursement for clinic visits by setting reductions for procedural reimbursements. This specifically affects orthopedic surgeons, who between 1991 and 2002 experienced a 28% reduction in reimbursement, after inflation, for commonly performed orthopedic procedures, including hip and knee arthroplasty.² Unfortunately, this system does not take into account the value of services as perceived by patients.

Total hip and knee arthroplasty (THA, TKA) are well-established surgical treatments for advanced osteoarthritis of the hip and knee, respectively. Much research has been done on patient satisfaction with these procedures and on their long-term results and cost-effectiveness. These procedures rank among the highest in patient satisfaction, and improvements in technique and technology have steadily improved long-term results. THA and TKA have proved to be cost-effective in appropriately indicated patients.

The demand for THA and TKA is projected to increase by 174% and 673%, respectively, from 2005 to 2030.³ Legislators, payers, health care providers, and patients are understandably concerned about the rising cost of health care and the implications for access to elective surgical procedures. In a recent study by Foran and colleagues,⁴ surveyed postoperative patients indicated that Medicare reimbursement was “much lower” for arthroplasty than it should be. In addition, they overestimated (compared with national averages) what Medicare reimburses for hip and knee arthroplasty. Many raised concerns that orthopedic surgeons might drop Medicare entirely.⁴

These misconceptions about reimbursement may stem partly from the inaccessibility of health care cost information. Rosenthal and colleagues⁵ recently queried a random selection of US hospitals and demonstrated the difficulty in obtaining THA pricing information.

In a system in which consumers and payers are often not one and the same, it is unclear if consumers understand the cost of their health care. We conducted a study to assess patients’ perceptions of the cost of total joint arthroplasty (TJA) and gain insight into their understanding of health care costs and their sense of the value of this elective surgical procedure.

Materials and Methods

After obtaining institutional review board approval and informed consent for this study, we surveyed 284 consecutive patients who underwent THA or TKA at an academic medical center. Patients had either primary or revision surgery performed (by Dr. Hallstrom or Dr. Urquhart) and were surveyed during their first (2-week) postoperative visit, between March 1, 2012 and December 20, 2012.

Surveys were labeled with patient identifiers to facilitate abstraction of data from electronic medical records. Operative reports and discharge summaries were reviewed for data that included sex, age, diagnosis, procedure, surgeon, implant, admission date, and length of stay.

The survey asked for demographic information, including level of education, insurance coverage, and annual household income, and included a question to verify the surgical procedure and a question to determine if the patient had reviewed a hospital billing statement pertaining to the patient’s admission. The survey also included these questions about reimbursement and cost:

How much do you feel your orthopedic surgeon was reimbursed for your surgery? (EXCLUDING payments to the hospital)

How much do you think your surgeon gets reimbursed to see you IN THE HOSPITAL after surgery?

How much do you think your surgeon gets reimbursed per visit to see you IN CLINIC for follow-up during the first 3 months after surgery?

How much do you think the implant used in your surgery cost?

How much do you think the hospital was reimbursed for your surgery and admission to the hospital after surgery? (EXCLUDING payments to the surgeon)

How much do you think it cost the hospital to provide your surgery and admission to the hospital after surgery?

Responses were limited to numeric currency format using a response area as shown in Figure 1. Overall patient satisfaction was elicited with use of a 5-point scale ranging from 1 (very unsatisfied) to 5 (very satisfied). Regarding type of implant used, patients could select from 6 prominent vendors or indicate “other” or “don’t know.” They were also asked which of several factors should primarily determine surgeon reimbursement: overall patient satisfaction, technical difficulty, amount of risk/possible harm, duration/amount of time, and rate of complications. A free-response comments section was provided at the end of the survey.