Uncle Sam is struggling to figure how best to ensure the safety, quality, and accessibility of a major surgery for a sharply rising number of seniors who need it and want the government, through Medicare, to pay for it. Baby boomers, after decades of running, dancing, aerobics, football, basketball, zoomba, and all manner of joint-stressing activity, are lining up for knee replacements. Where should these procedures occur and how should they be paid for and evaluated?
The New York Times has reported that surgeons, some in hospitals and some in free-standing surgical centers, are riven by proposed rule changes that would allow patients 65 and older with Medicare to undergo complex, extensive knee replacement operations on an outpatient basis.
The surgeons who now do these operations in hospitals say this is a risky move for patients, who now typically spend several days hospitalized in recovery. The “hospital” docs say knee replacement is a complex procedure, with high risk of infection and post-operative complications, because, for example, patients receive powerful clot-busting drugs and potent painkillers as part of the surgical regimen.
But the M.D.s who operate in surgical centers say that advances have made knee replacements safer, more routine, and taxpayers could save a bundle by sending more patients home faster to recuperate in a setting where they also might be less inclined to suffer hospital-related complications and infections.
A key component of this argument rests in politics and money, with some partisans arguing for less health care regulation, increased patient choice, and taxpayer cost saving. On the other side, advocates talk about safety and the need to ensure that patients aren’t for cost reasons forced home where they might not have adequate care-giving or suitable post-op accommodations—are they frail or obese and not much mobile to start, and will they be forced to deal with stairs or other obstacles in their houses or apartments? The medical decision-making also affects billions of dollars in Medicare payments, which hospitals would be loath to lose and surgical centers happy to gain.
Knee replacement has become one of the most common Medicare-paid surgeries, which, even with procedural improvements, requires patients to commit to extensive rehab efforts. Federal officials say Medicare already covers 660,000 knee replacements annually, and as the nation grays and more boomers seek to protect their mobility, the numbers could increase to 2 million such surgeries by 2030. Uncle Sam paid more than $7 billion in 2013 just for the hospitalizations tied to knee replacements, with the Medicare costs for the procedure varying greatly across the country, from $16,500 to $33,000.
In 2016, the federal government put surgeons, hospitals, and surgery centers on notice that big changes would be coming in the way Medicare pays for knee replacements (and hip surgeries, too): Uncle Sam launched an initiative in dozens of major markets nationwide to force providers to “bundle” costs for the procedure and to take greater responsibility for quality outcomes. Payers, including Medicare and insurers, are seeking to improve efficiency and cut expenses by forcing more bundling in medical services, in which a number of providers agree to receive one total, set cost for work like a knee replacement, rather than, say, the surgeon putting in one set of charges, the anesthesiologist another, the hospital its own and et cetera.
Besides bundling payments, Medicare’s knee replacement test also calls for greater attention to quality and outcomes in the procedure, with the government collecting information on items like infections, re-admissions, and patient satisfaction. Although patients generally fare better in procedures that surgeons perform in greater volume, data has been hard to come by about orthopedists’ outcomes, so advocates are eager to see results from this quality initiative.
At the same time, questions remain about knee replacement for significant numbers of older patients, particularly those who are overweight or obese, frail, or who already have lost significant mobility due to age related degeneration, including in their joints. Surgeries, with their risks, just may not be the best idea for many seniors. I’ve seen in my own practice and have written about orthopedic surgeons and their potential conflicts of interest in related medical services that can lead to over- or unnecessary treatment. If they, for example, have a stake in imaging facilities, surgical centers, or aspects of surgical equipment, or even if their offices are equipped with pricey MRI or X-ray devices, they may seek to boost these business interests, potentially even ahead of patients’ well-being. I’ve also written that physical therapy and other less invasive and major medical services may be beneficial to patients with knee problems, with one arthroscopic procedure, performed 400,000 times annually, particularly dubious. The pain and immobility that prompts knee replacements isn’t to be taken lightly but neither is the seriousness still of this surgery. Policy-makers are right to boost efforts to reduce costs, while ensuring safety, access, and quality. They also should consider deeply the research, as the New York Times notes that some surgeons have pointed to, that shows that “outpatients were twice as likely as inpatients to die shortly after knee replacements, and that even patients who stayed [only] one day in the hospital were twice as likely to need a follow-up surgery as those who remained in the hospital longer.”