I’m a proud millennial. I panic when I don’t have wifi. I forget about my Amazon order until my phone says it’s arrived. And I enjoy a good participation trophy just for showing up on the peloton. Shout out to Jess Sims and Emma Lovewell for never letting me down.
But millennials are also in their 30s, and we’re just starting to get the feel of fiscal responsibility and prudent investment strategies. It’s no secret we would rather work smarter than harder, and we have an increasing appreciation for work-life balance. To enjoy life, we have to plan for the future and invest in ourselves – and that includes our bodies and our joints.
There are few better returns on investment than a total joint replacement. While these operations don’t necessarily save lives, they certainly retain the quality of life my generation values above all.
The operation seems statistically inevitable for many of us, as nearly 2 million patients a year are expected to receive an artificial joint by 2030. While joint replacement surgeons will be the first to tell you we haven’t done the best job of quantifying the society value we provide, it is intuitive that restoring mobility has immeasurable public health and economic benefits. We’ve lengthened lifespans, facilitated independent living, abbreviated the disability list, mitigated overflow into long term assisted living centers, rejuvenated the workforce, and subsequently reignited the global economy with able bodied men and women. Of course, we’ve returned patients to their pastimes, from skiing to quality time with loved ones. Joint replacement surgery is rightfully the operation of the century – but it’s already poised to be the operation for the millennial.
The writing is on the wall that access to hip and knee replacement is under direct threat by the forces governing our healthcare system. The harder surgeons push to fix this, the more powerless we find ourselves. Total joint replacement represents the highest cost center for the Centers for Medicare and Medicaid Services (CMS) and remains a target for devaluation. Without strategic planning, the upcoming generation of patients could suffer.
Despite the best lobbying efforts from the American Association of Hip and Knee Surgeons to raise awareness surrounding the injustice of federal healthcare policy, further Medicare cuts loom in the form of sequestration and the Pay-As-You-Go (PAYGO) statute that could uniformly further decrease reimbursement by a significant percentage in 2023. The goal has transitioned from fixing the devaluation to merely slowing the bleed. Self-determination theory underscores the professional need for autonomy, relatedness, and competency to be fulfilled and motivated. Financial regulations have stripped surgeons – who have dedicated over a decade of the prime years of their life in training – of their autonomy and relatedness with the commoditization of their life’s work. With surgeon fees encompassing a mere 6% of the total cost of care for a joint replacement, regulators continues to target this percentage instead of the steadily rising hospital and administrative costs. Is this really the message we want to send to those we entrust with our life and limbs?
Consequently, more and more surgeons are expected to withdraw from federal and private insurers in favor of cash payment models just to stay afloat. At the current pace, it’s easy to imagine a free market where younger patients begin saving for their potential joint replacement as more surgeons withdraw from payer-driven medicine. Alternatively, converting the hip and knee replacement episode of care into a financial derivative as a future contract that allows for the purchase of the procedure at a predetermined price in the future – with the option to trade on an exchange system if surgery is unneeded – may not be outside the realm of possibility. The going rate today for a single joint replacement episode over 90 days ranges from $18,000-40,000 depending on staffing fees, implant costs, overhead, and other factors. An open market already exists to an extent with patients seeking out specific surgeons and technologies. Direct-to-consumer marketing shows no signs of wavering. It is not inconceivable that all elective hip and knee replacements could go the way of fee-for-service cosmetic and plastic surgery procedures. While loss of function is a far cry from cosmetics and aesthetics, the economic climate says otherwise. Fiscally, insurers are motivated to stop footing the bill for their highest volume and highest cost line item.
All signs indicate that the regulatory and economic climate is forcing doctors’ hands into extreme payment models. Withdrawal from abusive healthcare plans risk exacerbating patient access disparities, but doctors can no longer continue operating at great professional, emotional, and financial loss for the majority of patients. Even if our health insurance plans will still be covering total joint operations for millennials 30 years from now – at a value that is projected to be less than an in-office steroid injection – we would even want to go under the knife of the surgeon willing to accept a relative pittance for reimbursement? Would we even be getting the same surgeon skill if this downward spiral continues? Or would we be getting what we paid for?
Access to high quality care represents the gravest near-term side effect of bureaucratic attempts to lower costs and improve profit margins. In an effort to re-establish the doctor-patient relationship without suffocating third parties, some have engineered innovative ways to circumvent this looming problem. A duo of orthopedic surgeons came together to create Best In Class Medical Doctors (BICMD) to mitigate the access void with the highest quality physicians. By learning from the pandemic to leverage telemedicine and their network of leading orthopedic professionals, BICMD re-demonstrates that medicine is best served when physicians are at the helm. While this model may not be the permanent solution to administrative bureaucracy, it counters the doctor devaluation and returns the power to what matters the most: the patient.
Knowing what we know about failing payer-driven policies and alternative payment models where one size fits no one – and the priorities of a generation that values quality of life at a premium – why wouldn’t we reconsider how we invest in our bionic bodies of tomorrow? Whether the solution is saving more today or establishing future contracts around joint replacement, the current business model for hip and knee replacement surgery requires reimagining.