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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