Total knee replacements: A race to the bottom

A total knee replacement is a very common operation and more than 700,000 of them are performed each year in the United States. With a mean cost of about $16,000 each, in 2011 we spent over eleven billion dollars paying for knee replacements. Projections are that, by 2030, we’ll be doing 3.5 million per year. The operation has great results and patients generally do well during and after their surgery.

Anesthetic care has improved dramatically over time. Whereas initially patients who had a knee replaced would be given large doses of narcotic pain medicines (morphine) to deal with their pain, over time anesthesiologists figured out that treating pain in different ways at the same time was better.

Patients began to receive spinals and epidurals in addition to or instead of general anesthetics and to be given non-narcotic medications in addition to their narcotics. In the present day, we provide nerve blocks to dramatically reduce the pain after surgery for about a day to give them time to get over their primary anesthetic. Patients benefited from the lower narcotic doses by feeling less drugged, being at lower risk for respiratory arrest, and experiencing less nausea, urinary retention, constipation, and pruritus after surgery. These techniques evolved over time after prospective, randomized, controlled clinical trials demonstrated their superiority and safety. Furthermore, studies have shown that reducing narcotic-induced adverse effects saved money and shortened the number of days of hospitalization required because they avoided problems.

Or at least we used to do all these things. Let me explain.

Hospitals, in an attempt to appear attractive as the lowest-cost provider for common procedures, have begun to pressure surgeons to reduce the total cost of care for a knee replacement. They want to lower costs to successfully compete for contracts with employers or insurers to provide knee replacements to their employees or enrollees. Hospitals are adding up all the money spent beginning three days before surgery through thirty days after surgery. This includes the hospital fee, implant cost, surgeon’s fee, anesthesia fee, labs, x-rays, medications, etc. The knee implant itself costs anywhere from $1,500 to $12,000 depending on the vendor, with the average being about $8,000, according to the Healthcare Bluebook.

If you’re a hospital, how do you reduce the money spent on these patients? Start with the single greatest cost: the implant. Negotiate aggressively with the implant manufacturers and tell them to come down to a certain price or their implant won’t be available to the surgeons in that hospital. (I’ll let an orthopedic surgeon comment on whether the lack of availability of more expensive premium implants is a quality issue.) Do everything you can to get the patient out of the hospital as soon as possible. Don’t take an x-ray of the new knee in the hospital. Do it in the office on their first visit where it’s cheaper. And tell your anesthesiologists to stop doing nerve blocks and don’t use multimodal analgesia. Wait, what?

Nerve blocks are an extra fee as they are provided for post-operative analgesia. The cost of a nerve block is in addition to the cost of the primary anesthetic. In a Medicare patient, for example, doing two nerve blocks costs $103. So telling me not to do a nerve block saves a hundred bucks in a Medicare patient. In a private insurance patient it may save about $300. Oh, and that fancy celecoxib (Celebrex, $5 a dose) and IV acetominophen (Ofirmev, ~ $17 per dose), both of which have been show to safely and dramatically reduce morphine requirements, forget about those, too. In fact, they’re not even on the hospital formulary (and won’t be).

Total knee replacements: A race to the bottom

I have talked to my surgical colleagues about this, and their plan is to “pickle” the knee with long-acting local anesthetics for pain relief. If one were to ask me, as an anesthesiologist, what I think (they don’t), I would point out to them that I have to use twice as much inhaled anesthetic and orders of magnitude more narcotic when told not do offer nerve blocks. I can tell you that, from the patient perspective, the effects of blocks are miraculous in that they are wide awake and comfortable after the surgery.

As far as I am aware, there is not yet evidence that injecting liposomal bupivacaine is safe as measured by long term effects on wound healing, range of motion, and infection rates. Are there problems with blocks? Yes, of course. But all of those can be dealt with when doctors and nurses put their heads together, each contributing their own expertise, and discuss what is best for the patient. Oh, wait. Is that important anymore?

If I were in need of a knee replacement I would ask some important questions of the surgeon about what to expect during and after my surgery:

  • What is your infection rate like?
  • How long does it take you to do the surgery and how long is your tourniquet time?
  • Are you able to assure me that I will receive the best implant on the market for *me*?
  • Will an anesthesiologist be participating in my care?
  • Will I be offered a nerve block to help with initial pain after surgery?
  • Are modern medications like Ofirmev and Celebrex available to help reduce my need for narcotics and do you use them?
  • How long should I expect to be in the hospital?

When I claim that, for knee replacement surgery, it’s a “race to the bottom,” I mean that hospitals are trying to slash costs to appear attractive to potential payers. In a true open market, prices would be published, along with details on what that price includes, to allow patients to compare the services being offered and make a choice. Like this place. That’s not the case today in most markets.

Clark Venable is an anesthesiologist who blogs at Waking Up Costs

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  • DeceasedMD

    All this cost cutting is going to do is result in increased morbidity and mortality. But this may never be identified with Press ganey scores.

  • Thomas D Guastavino

    The place to get the most inexpensive knee replacement already exists. Its called medical tourism. Good care and you gets tropical vacation out of it. Of course if you have a complication or want to sue your out of luck. If there is a race to the bottom for the american health care system it will be reached when Medicare decides to pay for patients to go overseas. I give two, three years tops.
    By the way, to those who are pushing NSAIDS for post-op pain, how are we supposed to do that and safely give anticoagulants for DVT prophylaxis?

    • Lisa

      I was taken celebrex when I had my second hip replacement; I was told to continue taking it pre-surgery and after surgery. I was also given warfarin. My anticoagulent levels were monitored closely. My doctor told me to stop taking the warfarin after two weeks, once I started out patient PT. I stopped taking the celebrex in the same time period because I read that it could inhibit bone growth. As my prosthesis is cementless, that concerned me. Also, I felt like I didn’t need it to deal with pain anymore.

      Before I started taking celebrex, I was given a great deal of information about possible side effects and increased risk of heart attack and strokes. The only reason I took it was I could no longer take other nsaids without a good deal of stomach pain. I am glad I don’t need it now.

      • Thomas D Guastavino

        I am glad you did well. Were you also warned about potential increased bleeding risks when Celebrex is taken with anticoagulants? The fact you were getting stomach pain was a real red flag.
        I did not want to say it, but the point I was trying to make is that it is disingenuous to criticize someone (In this case the surgeon) for not doing something (In this case not using Celebrex for pain control) when the criticizer ( an Anesthesiologist) is not the one who would have to deal with the side effect. (potential bleeding). The Balkanization of medicine does not help and unfortunately is one of those things that is just getting worse.

        • Lisa

          I was warned about the increased risks of bleeding, but my surgeon specifically wanted me to continue taking the celebrex and thought the benefits outweighed the risks.

          The whole thesis of this article bothers me, as it implies that an open market with transparent pricing allows patients to compare and make a choice. I think that thesis is incorrect. I think patients will tend to opt for whatever is in vogue at the time and don’t really consider effectiveness or cost. When I had my first hip replacement metal on metal hips were popular, especially for younger active, patients and I was interested in one. I was lucky my surgeon told me why he didn’t use them.

          • Thomas D Guastavino

            Great that your surgeon discussed the bleeding risks, as long as you were comfortable with the decision. For me, I found that more judicious use of narcotics worked the best.
            I totally agree about price transparency not working.You certainly can’t shop around in an emergency. We are moving in the direction of patients becoming more aware of, and responsible for, those costs, but the procedure has to be totally elective for cost consideration to go into the decision making. That is why medical tourism will continue to grow.
            By the way, I also was suspicious of MOM hips because at the time the benefits did not clearly outweigh the risks. Very glad you did not get one.

          • Lisa

            As a patient, I find it can be hard to determine what the benefits and risks of a procedure or medication are. There is a lot of garbage parading as information.

            Price transparency does nothing about the degree of profit built into prices for medical services.

  • Lisa

    I spent some time perusing the link, given in this article, for the Surgery Center of Oklahoma. I would question the fact that their prices are that low. First of all the prices quoted include the surgeon fees, the facility fee and anesthesiologist fee. Hardware or implants are not included. The fees also do not include hospitalization; an overnight stay can be arranged on a case by case basis. Given these two items, I suspect the pricing they offer similar to the prices obtained by insurance companies who negotiate with providers. And if they file insurance paperwork, the prices listed on this website don’t apply to you.

  • Suzi Q 38

    My uncle died several months after his TKR surgery. He was a happy, energetic 70 something year old who loved to bicycle, hike, walk, and run. The tough thing was that his knee hurt, so he opted for the surgery.
    He survived the surgery but was given http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0044745/ Celebrex
    and aspirin 325 mg T. I. D. for months until he started bleeding out of his skin in the stomach area. His wife took him to the hospital, but alas, they could not control the bleeding and he died.

    I am going to avoid this surgery if I can, as I am in my late 50′s.

  • Lisa

    What I inferred from the link is that price transparency will not drive down prices because the price of medical care still involves profits.