Category Archives: Knee Replacement

Top 10 Orthopedic Hospitals by Procedure

Last year, Christmas Eve, to be exact, I wrote a short post about the top ten hospitals for total knee replacement under $50,000.

This year, I’d like to expand on that and discuss the top ten orthopedic hospitals outside of the US for such procedures as Arthroscopy (knee or shoulder), Disc Replacement, and Rotator Cuff Repair.

The website I linked to in my post last year, Archimedicx.com, is the same website I used now to illustrate the difference between costs in the US and elsewhere in the world.

This website is by no means the definitive source of such information. There are other websites that provide similar prices and are only ballpark figures, not actual quotes, or firm prices. Archimedicx’s website will give you a quote once you have chosen from among a list of hospitals you searched for, depending on what procedure you want to have.

I have limited the discussion here to only the three I mentioned above, as arthroscopic procedures for both knees and shoulders, resulted in the same hospitals being displayed.

The price range column indicates those hospitals who charge the amount stated or less, as the website allows an individual to choose the price range they want.

In the table below, the quality score is the ranking algorithm that generates a unique quality score for each procedure in each analyzed hospital (on a scale of 1 to 5). For the sake of clarification, a certain hospital can have different quality scores, depending on the procedure or treatment in question.

 

Table – Top Ten Orthopedic Hospitals by Procedure

top-ten-ortho-hosp

For each procedure examined, there were at least a few hundred other hospitals that one could look at, but I only wanted the top ten, as you see, ranked by quality scores. There are no doubt other hospitals on the website that may score better on other websites, or can provide these procedures for far less than they do.

The idea here is to point out that the US is more expensive than others, and as the following chart shows, we are dead last in terms of care.

nhs-best-system

But it is sad that Americans do not realize this and do what the other countries in that chart have done, provide health care to all.

It is also sad that our system for treating on the job injuries also does not allow people to seek medical care outside of their states or the country. Only two states do that, Washington, and Oregon, but as I’ve said before, there have been exceptions.

Now with a new administration seeking to destroy the social safety net and the ACA, we may see more case shifting and more crowded ER’s and not enough medical personnel to treat them.

And for what?  The commodification of health care for those who can afford it, and for the profit of those who pay for it.

Tug-of-War Over Ailing American Knees: What the Medical Tourism Industry Should Know

Total knee replacements in the US is growing, according to an article today in Kaiser Health News.

660,000 are performed each year, and will likely grow to two million annually by 2030, as reported by Christina Jewett. Knee surgeries are one of surgery’s biggest potential growth markets, and one that the medical tourism industry needs to be aware of.

Ms. Jewett described how an orthopedic surgeon from the Bronx, underwent his own knee surgery in a Seattle-area surgery center performed by a friend of his. The surgery began at 8 am, and by lunch, the doctor was resting in his friend’s home with no pain and a new knee.

Medicare is contemplating whether it will help pay for knee surgeries outside of hospitals, either in free-standing centers or outpatient facilities. Several billions of dollars are spent every year by Medicare for knee replacements, so what may be a bold experiment, may soon be more standard.

However, this issue is dividing the medical world, and the issue of money is just as important as the issue of medicine, according to Ms. Jewett.

Some physicians are concerned that moving surgeries out of hospitals will land vulnerable patients in the emergency room, but proponents say it will give patients more choice and better care. In addition, they contend that it will save Medicare hundreds of millions of dollars.

An “overwhelming majority” of commenters, Ms. Jewett states, said they want to allow the surgeries out of hospitals, as specified in recent rule-making documents.

Even if a policy change is made, according to the article, Medicare would still pay for patients to get traditional inpatient surgery. There would be a huge shift in money, the article reports, out of hospitals and into surgery centers.

Medicare could save hundreds of millions of dollars if it no longer paid for multiple-day stays in a hospital, and investors at outpatient centers could profit greatly, as well as some surgeons, especially those who have an ownership stake in the facility.

An open question remains as to whether this shift is beneficial for patients. Patients on Medicare tend to spend nearly three days in a hospital, and forty percent also spend time in a rehabilitation facility for further recovery.

Data from 2014 suggests that Medicare patients are taking advantage of the post-operation support at hospitals and aftercare centers. However, it is unclear what the percentage of eligible patients would choose outpatient care.

Of equal concern to patients are the financial consequences, and here is where the medical tourism needs to pay attention, because even though less care is given, outpatient procedures require higher out-of-pocket costs.

Medicare covers inpatient procedures 100%, with no co-payment, but outpatient procedures require a 20% co-payment, which could easily add up to thousands of dollars for knee surgeries.

One surgery center in California advertises a knee replacement surgery for $17,0300, and those who support the change in policy believe that a strict criteria should be used by doctors to choose which patients are good candidates for outpatient surgery.

All this began in 2012, Ms. Jewett states, when Medicare first considered removing the surgeries from its “inpatient only: list. At that time, many doctors and hospitals protested, calling the proposal “ludicrous” and “dangerous”, and Medicare abandoned the idea.

Another objection cited research that showed that patients who received such surgeries as outpatients were twice as likely to die, and that even one-day stays were twice as likely to need follow-up surgery.

A panel recommended that Medicare remove the procedure from the “inpatient only” list in August, but if they make a change, it will not go into effect for a year or so later.

It is quite obvious to this writer what you in the medical travel industry need to do, but then again, when did you ever listen to what I say?

“Florida, We Have a Problem”

Tuesday, Judge David Langham, Deputy Chief Judge of Compensation Claims for the Florida Office of Judges of Compensation Claims and Division of Administrative Hearings, wrote a rather lengthy post about the differences between cost-shifting and case-shifting in workers’ comp.

Much of what the Judge wrote were subjects that I already discussed in a number of previous posts about cost-shifting and case-shifting, so I won’t go into it here. I am only focusing on the parts that relate to Florida workers’ comp. You can read the entire article yourselves.

But what caught my attention was what he said about Florida and what the Workers’ Compensation Research Institute (WCRI) reported in some of their studies on these issues.

As Judge Langham wrote this week, he wrote a post two years ago that asked the question “Why Does Surgery Cost Double in Workers’ Compensation?”

Judge Langham noted in that post that Florida employers have been documented paying almost double for shoulder or knee surgery that is paid for under workers’ compensation, compared to group health costs.

The implication of case-shifting in Florida, he says, could arguably be a doubling of cost.

He cited a WCRI report released earlier this year that suggests however that case-shifting is perhaps not as likely in Florida.

According to the report, Judge Langham continues, “as of July 2011, six states had workers’ comp medical fee schedules with rates within 15% of Medicare rates. They were California, Massachusetts, Florida, North Carolina, New York and Hawaii.”

However, Judge Langham pointed out that the WCRI concluded that case-shifting is more likely in states where the workers’ compensation fee schedule is 20% or more above the group health rates, and not in Florida.

Judge Langham stated that this analysis of workers’ compensation fee schedules does not appear to include analysis of the reimbursement rates for hospitals, and that It also seems contradictory to the assertions that Florida workers’ compensation costs for various surgeries have been documented as roughly double the group health rates (100% higher, not 15% higher).

Injured workers who missed work in the Florida workers’ compensation system could be compensated in 2016 at a rate as high as $862.51 per week, the “maximum compensation rate.”

So, if recovery from such a “soft-tissue” injury required ten weeks off-work, he wrote, the case-shifting to workers’ compensation might add another four to nine thousand dollars to the already doubled cost of surgical repair under workers’ compensation.

This could be directly borne by the employer if the employer is self-insured for workers’ compensation; or, if the employer has purchased workers’ compensation insurance, the effect on the employer would be indirect in the form of potentially increased premium costs for workers’ compensation following such events and payments, Judge Langham states.

According to WCRI, the Judge quotes, “policymakers have always focused on the impact (workers’ compensation) fee schedules have on access to care as well as utilization of services.

This has been a two-part analysis, he says:

First, fee schedules have to be sufficient such that physicians are willing to provide care in the workers’ compensation system; and second, the reimbursement cannot be too high, or perhaps overutilization is encouraged.

Lastly, Judge Langham points out that the disparity between costs has also been noted in discussions of “medical tourism.”

The last question he posits is this, “might medical decision makers direct care to more efficient providers, across town, across state lines?”

What about national borders?


I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

I am also looking for a partner who shares my vision of global health care for injured workers.

I am also willing to work with any health care provider, medical tourism facilitator or facility to help you take advantage of a market segment treating workers injured on the job. Workers’ compensation is going through dramatic changes, and may one day be folded into general health care. Injured workers needing surgery for compensable injuries will need to seek alternatives that provide quality medical care at lower cost to their employers. Caribbean and Latin America region preferred.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Will accept invitations to speak or attend conferences.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com.

Transforming Workers’ Blog is now viewed all over the world in 250 countries and political entities. I have published nearly 300 articles, many of them re-published in newsletters and other blogs.

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Trends and Issues in Workers’ Comp for 2016

From the ‘What’s happening now in workers’ comp’ department comes two articles written earlier this month by Jacquelyn Connelly in Independent Agent magazine.

The first, written on February 1, talks about new health care trends driving change for workers’ comp. The second, written a week later, deals with the top three regulatory issues to watch for in workers’ comp in 2016.

Let’s start with the first article.

As Ms. Connelly writes, medical now represents on average, 60% of the benefit dollar paid to injured workers, according to Peter Burton, senior division executive for state relations at NCCI (National Council on Compensation Insurance).

Burton said that, “if you went back 25 years ago, it would have been about 40%,” and he went on to say that, “medical is the largest component in most states of the benefit given to injured workers. If you looked at the amount of legislative pricing requested of NCCI during last year, the majority of the requests were medical-related.”

In my White Paper, I cited that “medical costs in 2008 were 58% of all total claims.”

One explanation Ms. Connelly gives is rising and shifting medical costs.  According to Donna Urben, vice president and workers’ compensation product manager at Erie Insurance, “the rise in medical costs, we’ve all seen it on typical health plans and we’ve also seen it on workers’ comp.” She goes further to say that, “what helps with the control of the increase in medical costs are those states that actually are able to direct medical care.”

Some state workers’ comp laws state that injured workers must go to panel physician established by the employer for a timeframe that is mandated by state guidelines, according to Ms. Urben.

If the injured workers receives medical care that fits the injury,” says Ms. Urben, “that ultimately gets them back to pre-injury status and enables them to return to work more quickly,”…”this explains why in some states that permit direction of care, employers are able to see a reduction in the claim cost on the medical claims side, versus those states that don’t permit direction of care, employers see a greater volatility in the medical costs from a workers’ compensation claim.

Another reason given by Ms. Connelly for the rise of medical costs is the duration of treatment.

Medical costs could also transform under the ACA, says Yvonne Hobson, vice president of corporate underwriting at Amerisure, and could cause some cost-shifting in workers’ comp insurance, by authorizing the use of capitation models that designate a set amount for each enrolled plan member, regardless of whether they take medical during that time.

This is not the first time we have seen this issue of cost-shifting and the ACA come up, as I and others have written about it last year.

Hobson explains that, “there are some injuries, such as soft tissue injures or back or knee or shoulder pain, where the cause of the injury isn’t readily apparent if it happened on the job or outside of work.” There is some discretion on the part of the doctors, Ms. Hobson states, when determining if the injury is work-related or not.

On the other hand, Matt Lyon, of Foremost Insurance Group, cited some predictions that the ACA could reduce the frequency of “Monday morning claims”, where someone gets hurt on the weekend, they don’t have health insurance, and come into work on Monday and file a workers’ comp claim, Ms. Connelly writes.

Mr. Lyon noted that some preliminary studies suggest a slight correlation between the ACA and a decline in fraudulent comp claims.

Ms. Hobson concurs, and stated that, “the challenge with cost-shifting is that the research and the data on it is new, so only time is going to be able to tell us how it’s going to ultimately be impacting workers’ compensation costs.

The final trend, Ms. Connelly mentions is the misuse and abuse of opioids and medical marijuana. I have discussed the opioid abuse issue before, so I will not go into that here, and the other trend is medical marijuana, as well as recreational use.

States such as Alaska, Colorado, Oregon and Washington have allowed recreational use, and 23 states and Washington, D.C. have legalized medical marijuana.

In her second article, Ms. Connelly identifies three regulatory issues. These issues are:

  1. Opt-out laws. Currently, as I have written about, opt-out is only in Texas and Oklahoma, but it was reported recently that the legislation in Tennessee has not passed this year, and maybe voted on again next year. Other states proposed for this legislation are Arkansas, North and South Carolina and West Virginia. The group behind the writing of this legislation is called “A-rock” (ARAWC).
  2. Reform efforts. Peter Burton, cited by Ms. Connelly in the last article, said that insurance agents need to be wary of the “attack on the exclusive remedy”. I have also written about this; yet, my research for this article has found that the ALEC (American Legislative Exchange Council), a right-wing, non-profit organization partly funded by the Castor and Pollux of right-wing, libertarianism, the Koch Brothers has drawn up a bill defending exclusive remedy, which I find puzzling, because I would have thought that they would want to let workers try to sue their employers, which is what happened before the enactment of workers’ comp laws.
  3. Independent contractor classification. The Department of Labor’s Administrator’s interpretation sought to classify most independent contractors as employees.

What does this mean?

For workers’ comp, it means that there are challenges ahead that the industry needs to be aware of, but it also means that business as usual will no longer suffice, nor will doing the same things over and over again, and expecting different results.

As we have seen in Ms. Connelly’s first article, medical costs are rising for workers’ comp claims. She does not mention whether or not this includes expensive surgeries, or is just confined to the immediate treatment of the injury and the subsequent process of returning the injured worker to their pre-injury state.

Some employers have seen reductions in medical costs, but overall, the medical costs keep rising, as evidenced by my White Paper that stated that in 2008, the percentage was 58%. Two percentage points in seven years.

Obviously, something or some things are not working. But as long as the industry ignores alternatives, as long as some people suggest that judges won’t order surgery out of the country (do doctors order executions, I wonder?), as long as these same individuals believe that no injured workers (especially Latino workers) will want to or will accept going abroad for surgery, and as long as the “old men” of the industry cling to xenophobia, racism and American Exceptionalism, holding back the workers’ compensation industry from joining the globalization of health care, comp included, then nothing will change, and costs will continue to rise.

Lastly, it is state laws themselves that need to be changed, modified or outright discarded so that employers across the country can realize huge cost savings in their medical claim costs, when their employees need surgery.

To say this will never happen is like saying Man will never fly, go to the Moon, or any of a thousand other “impossible” things we humans have accomplished. Are you saying that going to the Moon or flying is easier than going to another country to get surgery? Or are you just being xenophobic, racist, and delusional that American health care is the best?

You decide, but while you do, the meter is running on medical costs, and the other issues, such as opt-out, reform and job classification are making workers’ comp challenging now and for the future. But it does not have to be that way.

Fine Print Excludes Outpatient Surgeries in Some Work-Based Plans

Kaiser Health News reported today that the fine print in some work-based health plans exclude paying for outpatient surgeries.

As reported by Jay Hancock, Libbi Stovall, who lives in Carrollton, Texas was shocked to learn that her employer’s 2016 health plan provides no coverage for outpatient surgery.

Stovall, who has a history of back problems, looked at the fine print of her company’s health plan, which supposedly met the strictest standards for employer obligations under federal rules.

Inpatient hospital care, office visits and diagnostic imaging are paid for by her insurance, but it provides not coverage for outpatient surgery; surgeries that account for two out of every three operations in the nation.

Yet, being offered such a plan through her employer, she is barred from federal subsidies to buy more comprehensive coverage on the online marketplace by a company called Open Systems Technologies.

According to Hancock, Stovall’s experience illustrates the latest chapter in the story of employers and insurance designers pushing the limits of the ACA.

Last year, Hancock writes, regulators blocked companies with millions of lower-wage workers from claiming that coverage with no inpatient hospital benefits met the ACA’s strictest standard for large employers.

So-called “skinny plans” are no longer allowed, says Hancock, and therefore insurance administrators and many cost-conscious employers are claiming to meet the rules with a new version that excludes outpatient surgery. Hancock goes on to say that the new plans may not survive regulatory scrutiny any more than the old ones did, according to some experts.

Timothy Jost, a law professor at Washington and Lee University said, “I really wonder whether they can do that.” He added, “Refusing to cover any outpatient physician surgical services is arguably a violation.”

Outpatient surgeries such as hernia repairs, knee arthroscopies and repairing bone fractures are typical of those without an overnight hospital stay. They generally cost less than inpatient operations, Hancock writes, but can still be tens of thousands of dollars.

Leaving these procedures out of a plan saves money for the employer, Hancock states, but it leaves the workers with crippling bills.

The article goes on to discuss in length the way the new rules affect lower-wage workers and how their employers are responding to them.

It is not known what Ms. Stovall’s job is, or how she developed back problems, but for millions of lower-wage workers like her, the rules surrounding the implementation of the ACA means that their employers are sacrificing their health to save money on an already expensive health care system, instead of seeking out other alternatives.

These are the very kind of workers, a woman I had a Skype call with this morning, is trying to help with her company, Trip4Care.

Her name is Maria Maldonado, and she told me about a construction worker who needed double knee replacement, but his union-based insurance deductible was $40,000 and he waited five years before he got the surgery at hospital in Colombia that Maria vetted and sent him to.

I have written before about how medical travel can save money, not only under group health, but especially under workers’ compensation. And since many of the outpatient surgeries these work-based health plans have excluded are common in workers’ comp, it would make sense to tear down the walls between the two silos of group health and workers’ comp, and explore these opportunities to save huge amounts of money on medical bills.

But as long as people discount the validity of going abroad, as long as people in certain industries refuse to admit that not only is the cost lower abroad, but the quality too is better, when you go through someone like Maria Maldonado.

It is my intention to work with Maria to do just that. She has some possibilities that may require my expertise in workers’ comp, while she handles the group health side. If you are an employer who wants to save money on health care costs, contact me and we will work with you.

Otherwise, you will leave your workforce to the mercy of these rather draconian and capricious rules and cause pain and suffering to millions of lower-wage workers. ProPublica/NPR has shown this to be true, but it does not have to be so.

Knee Surgery in Latin America under $20,000

As a follow-up to my post, Top 10 Hospitals for Knee Surgery Under $50,000, here is a graphic I submitted recently to a workers’ comp carrier in Florida I am interested in exploring opportunities with.

The hospitals and costs were culled from the Archimedicx website I linked to in the previous post.

Western Hemisphere Hospitals Knee Surgery under $20,000

I am sure there are many more, and there are more that are between $20,000 and $50,000 that were not mentioned in the first article by Archimedicx.

Even if these figures are not completely accurate, why take the chance that they are not at least representative of the cost difference between what is charged by hospitals in the US. And when you add in all the additional fees one finds on a US hospital, these prices are practically a bargain.

But go on and pay through the nose. Or is that the knee? To quote Forrest Gump, “stupid is as stupid does”.

Final Rule for Bundled Hip and Knee Replacements Published

Four months ago today, I wrote a piece called, “CMS to Require Bundling of Reimbursements for Hip and Knee Surgery”, that said the Centers for Medicare & Medicaid Services (CMS) will require the bundling of reimbursements for hip and knee surgeries.

Today, Health Affairs blog published an article reporting that CMS has recently published the final rule for the Comprehensive Care for Joint Replacement (CJR) model, which is a mandatory bundled payment model for lower extremity joint replacement (LEJR) services in certain geographic areas.

The article, by Patrick H. Conway, Rahul Rajkuma, Amy Bassano, Matthew Press, Claire Schreiber and Gabriel Scott, said that hip and knee replacements are the most common inpatient surgery procedures for Medicare beneficiaries, and can require long recovery and rehab periods.

The authors said that in 2014, more than 400,000 beneficiaries received hip or knee replacement, which cost more than $7 billion just for hospitalization.

They also reported that the quality and cost of care for these surgeries varied significantly by region and by hospital, and was true for both the care received in the hospital and for post-acute care outside.

The variation, they said, is due to the way Medicare pays for this care today, spread among multiple providers, with no single entity accountable for the total patient experience.

Care can be fragmented, they wrote, which leads to adverse outcomes.

Here are the key takeaways from the final rule:

  • the CJR model seeks to incentivize Medicare providers and suppliers to work together to improve the quality and reduce the costs of care for patients undergoing lower extremity joint replacement
  • the acute hospital where the procedure occurs will be accountable for aggregate Medicare expenditures and the overall quality of related care
  • the model will include participant hospitals located in 67 Metropolitan Statistical Areas (MSAs) throughout the country
  • acute hospitals paid under the Inpatient Prospective Payment System (IPPS) and located in the selected MSAs will be included in the model, with the exception of hospitals currently participating in Model 1 or Models 2 or 4 of the Bundled Payments for Care Improvement (BPCI) initiative
  • depending on the hospital’s quality and aggregate spending performance, the hospital may receive an additional payment from Medicare, or need to repay Medicare in the second year if spending exceeds targets
  • hospitals will need to work with physicians and post-acute care providers, such as home health agencies and skilled nursing facilities, to ensure patients get the care they need

This is in contrast to what I reported on in July, when I said that a former CMS official was cited in the Freeman article as saying that mandatory bundled payments for hip and knee surgeries would shutter one in four skilled nursing facilities and trigger “demand destruction in areas such as diagnostic testing, hospital stays, and avoidable readmissions.”

Whether or not this final rule will do what the authors of the Health Affairs article says it will do remains to be seen, but judging by past CMS programs to affect quality and costs, this may be wishful thinking on the part of the authors.

The insistence that one more new initiative, or more incentives, or one more new model or new rule will change the way health care is being provided in the US, just goes to show that until we adopt a single-payer, “Medicare for All” system with less rules and less incentives, some people will continue to game the system, then we will see a radical change in the American health care system.

And if workers’ compensation follows changes in health care under Medicare, especially how it determines reimbursements for hip and knee surgeries, which are also common to workers’ comp, we can expect to see issues in workers’ comp.

Alternatives must be considered to an ever expensive and poor quality of health care for workers’ comp. That alternative is medical travel.