Recent Newspaper & Online Columns by Kate Scannell MD

When Good Hips go Bad -- And the Price(s) We Pay for That

February 17, 2013

Tags: JAMA, hip replacement, health care costs, access, DePuy lawsuit, health care consumer empowerment

By Dr. Kate Scannell, Syndictaed columnist
First Published in Print: 02/17/2013

Hips. We tend not to think much about them -- until they hurt or need replacement -- even as they support our ability to walk, climb stairs, sit and dance.

With the exception of Lucille Clifton's celebratory poem, "Homage to My Hips," poetic works have largely ignored these workhorse joints in favor of hands, backs, necks -- even ankles. Hips rarely qualify as subjects of serious literary concern. In fact, entering "hip" into Amazon's book search window mostly delivers stories about American pop culture, hipsters and bunnies who hip-hop.

All this to explain why it's remarkable that hips have grabbed so many current headlines. Are we finally getting hip to hips, and all that they can teach us?

I certainly hope so.

For example, let's review two such stories which are ... well, joined at the hip, and see what we learn about money, deception, shopping hassles, and, yes -- there's more!

The first story involves an otherwise healthy, uninsured, 62-year-old grandmother seeking hip-replacement surgery for which she must pay out-of-pocket. The cost being of great concern, her dutiful granddaughter calls hospitals throughout the country, in quest of the lowest "complete bundled price" -- that is, cost inclusive of both hospital and physician fees.

The diligent granddaughter calls each of 122 hospitals up to five times -- two randomly-selected hospitals in each state (and the District of Columbia!) as well as 20 of U.S. News and World Report's top-ranked orthopedic hospitals.

But what she mostly finds is ... difficulty. Fewer than half of the top-ranked and only one-tenth of the other hospitals can quote her a complete bundled price. She obtains 57 additional estimates only after having to separately contact the hospital and physician for their respective fees. Another 46 hospitals provide only one or the other fee, and 19 offer no pricing information whatsoever.

If that weren't frustrating enough, the granddaughter is left with wildly different quotes: between $12,500-to-$105,000 at the top-ranked hospitals, and $11,500-to-$125,800 at the others. How is she to understand a nearly tenfold price variation across hospitals for the same procedure? How is she supposed to make a rational choice?

In truth, the grandmother is a fictional character, her granddaughter is an academic researcher, and the "story" is a study published in last week's Journal of the American Medical Association.

I love this study because it was conducted "real-world" style -- by a person who could be any one of us, doing all she can to uncover consumer prices for a very common surgical procedure performed more than 325,000 times a year in the U.S. It vividly demonstrates that, despite a lot of rosy political rhetoric, formidable barriers block patients from becoming savvy and empowered "health care consumers" who can drive down health care costs by just shopping smarter.

Still, one might argue that grandmother might have saved a whopping $100,000 by choosing a bargain-basement hip replacement at the lower end of the price scale. And yet, wouldn't she -- and you -- want to understand just why a certain option was so seemingly "cheap?" Was the prosthesis manufactured from recycled bottle caps? Were the doctors 90 percent less qualified than the pricier surgeons? Was the hospital desperate for patients because they had lost so many to postoperative complications? Do you have to bring your own hospital gown and footsies? There's no easy way to tell.

This brings us to the second headline news about hips, which (spoiler alert!) casts an even darker pall on these dilemmas for grandmother and granddaughter. It speaks to the problem of trying to make rational, cost-conscious health care decisions when critical information affecting them is being withheld.

So let's keep our narrative alive and assume that grandmother somehow made a superb choice for hip replacement. The hospital was impeccably clean and efficient, the surgeon masterful and delightful. Having suffered no postoperative infections or blood clots, grandmother walked out of the hospital and limp-free for the first time in ten years.

But here's the kicker. A few years pass, it's 2013 and grandmother is sitting -- now, somewhat uncomfortably -- at the breakfast table, catching up on The New York Times. In the Jan. 25 paper she sees this headline: "Maker Hid Data About Design Flaw in Hip Implant, Records Show." She reads that manufacturing executives knew about the flaw years before they recalled the faulty hip implant in 2010, and that they had concealed that information from physicians and patients.

She also reads testimony confirming that the hip maker's own estimates had predicted implant failure within five short years in nearly 40 percent of patients receiving it -- fully eight times the failure rate of most orthopedic implants. A Feb. 10 editorial further alleges that the hip manufacturer continued to market the implant aggressively, even after becoming aware of these problems.

Grandmother puts down the newspapers. She thinks about all the time and money she spent trying to be a wise health care consumer in the medical marketplace, increasingly feeling as though she's been thrown down a dark rabbit hole. She wonders if her implant is faulty, whether she could go through it all again. She wonders what other information the manufacturer has withheld, and the price she'll have to pay for it.
Kate Scannell is a Bay Area physician and the author, most recently, of "Flood Stage."
Copyright 2013, Kate Scannell

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