The Cost of an ACL Injury

This is absolutely shocking to me. Had my ACL replaced in the UK privately about 8 years ago (no health insurance, paid out of pocket). Total cost was £3000 (+ £600 for initial scan). I could have got it done for free on the NHS but it would have messed up my term time at university.<p>Like the OP I had meniscal tearing too so more or less directly comparable. (Although obviously 8 years is probably a long time in medical devices so worth bearing in mind).<p>To put in perspective, that is approximate the same total cost (~$5000) as just _one_ of the pieces of equipment ("Cannula Fast Fix CVD") that the OP lists.<p>It's one thing if doctors are more expensive because they have to carry higher insurance charges to protect against negligence lawsuits, etc, but that the equipment alone is multiple times the cost seems crazy.<p>Mental.

Excellent read.<p>One point on disposing of fancy, potentially reusable, tools: We do more than a little precision machining in our lab. When a job matters, the shop buys new tooling. It's lower in cost, especially time, than verifying that a tool is sharp and correct.<p>At first, it seems wasteful to throw away a once-used tool, but if all you do is critical work, you must be certain that your tools are reliable and correct. Once you have a complete set of nice hand-me-down spares squirreled away for coarse work, any subsequent used tools go in the recycle bin.<p>For the computer-inclined, this practice is no different from taking a perfectly functional linux installation you've used for a little while for a side project and using it on a mission-critical task. It's easier and more reliable to reformat and reinstall than to inherit whatever curiosities might emerge from the past.<p>When quality matters, provenance matters.

Interesting read, and a valid criticism of the costs associated with ACL repair in the US. It would be nice to know, however, how much your insurance company actually paid for the procedure. There's probably a large discrepancy there.<p>My own thoughts are that if there were a true free market for healthcare, with insurance only for real medical emergencies, the costs of a lot of these services would drop, including physician fees, equipment etc. Most of the population would not, and likely could not, pay 68,000 for an ACL repair, which would leave medical providers the option of 1) lowering prices substantially or 2) being out of work. Having put ourselves on high deductible health plans, we are super vigilant now about how we spend our healthcare dollars. And having realized the impact of this, since we are medical providers ourselves, we are now transitioning to a model where we are not participating with many insurance plans, but our fees will be completely transparent - published online - and fairly reasonable (I think).

When I was in college, I couldn't afford health insurance (no parents + financial aid does not cover it). I played rugby (generally not the safest sport) for two years, in addition to playing pickup basketball all four years. I very fortunately did not sustain any major injuries.<p>Six months after graduating (and getting a job with health insurance), I tore my ACL while playing pickup basketball. The costs were as insane as outlined in this post, but, again, I had health insurance. However, to this day, I'm horrified at the thought of what would've happened if I'd sustained the injury in college when I <i>didn't</i> have health insurance. Shame on me for putting myself in those sorts of situations, but it feels like there's something wrong when the penalty is so harsh.

The most useful aspect of this article is the pie charts and line-item comparisons. Ignore the dollar amounts themselves. Why? Because almost no one pays that. Why?<p>- In California, MediCal (state-wide health insurance safety net) pays about 20% of the cost (not price) of treatment for those without insurance. So if a surgery costs $10k, MediCal says "Here's your $2k. That's all you get."<p>- Nationwide, Medicare pays something closer to 90%. Much better, but still a loss to the hospitals.<p>- Insurance companies negotiate with hospitals, but (from what I've heard) generally pay 115-125% of the cost, giving hospitals a 15-25% margin. Certainly better, but not necessarily making up for the above.<p>- Some patients with no insurance, especially at major academic medical centers, are rich folks looking trying to get the best care in the world for something particularly complicated. UCSF in my neighborhood even has an in-house Saudi liaison for Saudi royals. These folks pay the full rate, which may represent an enormous markup, which does help subsidize the care of the top two categories.<p>For those without insurance, who don't have the money to pay the full fare (meaning you're not a foreign prince or similar), you're going to get freaked out by the bill, which is based on the last category. But in reality, the moment you ask a billing person about the costs, you'll almost always get knocked down into the insurance rate tier, just for asking. Show proof that you have next to nothing, and you could get well down into MediCal levels.<p>In order to get the ultra-rich to subsidize the patients that generate the loss, the price card needs to be high. Really high. So they give breaks to everyone else, since you can't do it the other way -- "Oh, you look rich, so we're going to charge you double the rate sheet."<p>This doesn't happen in community hospitals quite as dramatically, since they don't have the ability to handle the crazy conditions that will result in the high-revenue customers. So their rack rate for an ACL will be at the low end, while the academic medical centers that offer the $2MM neurosurgery will have rack rates for every procedure on the high end.<p>Is it messed up? Sure. But does it mean that normal people are paying $65k for this ACL procedure? Usually not.

A few things to consider:<p>1) You can't turn an operating room immediately. A 1hr surgery requires significant prep time _AND_ cleaning time. These rooms are used for many different kinds of surgeries — changing everything takes time. To make matters worse, each surgeon has their own preferred set up, and it needs to match that.<p>2) All medical supplies are expensive in part because your body is pretty sensitive, and you need to be careful about what's in there, but also because doctors almost always have _COMPLETE_ control over what equipment they use ... including screw and tool brands. This means that hospitals have little-to-no leverage to get lower prices. This is particularly true for implants &#38; other complicated equipment.<p>3) Insured people subsidize the uninsured.

One thing to be aware of in how all of this stuff works; oftentimes medical billing codes don't map 1:1 to exactly how things work in the hospital, so the medical staff puts together a statement of everything they did, and then the billing staff (approximately) maps it to billing codes.<p>This means that they'll overshoot on some codes to make up for other acts and overhead that doesn't have an exact billing code, and every medical provider has different places that they'll overestimate, and by different amounts.<p>Additionally, as most people know, the billed amount is usually FAR in excess of what the insurance company actually pays.<p>I'm not in the industry so I may be off base here, and someone who is can correct me, but I just finished Oreilly's excellent ("Hacking Healthcare") which is about how patient services and billing work.

I was expecting this to be about Access Control Lists being slow or requiring more complex security reasoning (vs owner/group/other). It's not, it's about health care and injuries and something that's part of your knee.

(I am slightly hesitant to publicly share info like this, but what the heck...for science!)<p>I tore my ACL 1.5 years ago playing soccer, and went through a similar surgery as the OP at NYU Langone Medical Center in New York. Interestingly, my final bill for the surgery (including the same things as the OP) was almost the same - $67k and change.<p>However, more importantly, the actual amount paid to the doctor/hospital etc. was $18k, of which I think I had to pay around $2k, insurance covered the rest. So while the sticker price might be $67k, the actual cost is significantly lesser. In the bills that I saw from my insurance company (BCBS), for each line item, they would have a column for "Allowed Amount" or something like that which generally varied between 20-30% of the billed amount.<p>On a different note, I don't whether the cost would have been the whole $67k if I was uninsured. I hope not. But if yes, that's really punitive to the people who can least afford it. For that matte, even a 18k cost is prohibitively expensive for someone who cannot afford insurance.

<i>Achilles tendon harvested from a cadaver</i><p>Yeah, I wouldn't recommend this route, either. I read an article in The New Yorker about body parts harvested from cadavers that were used in transplants. The parts were way past their harvest-by date. This was discovered, at least partially, by someone having an ACL transplant from one of this bad parts, and the recipient of the bad part died from bad infection due to a mold on the tendon.<p>The lack of controls on that business forever made me wary of using cadaver parts for transplants.

ACL stands for Anterior Cruciate Ligament. (In case I'm not the only one who didn't know and was surprised to see this was never mentioned in the article or the comments.)

I had ACL &#38; torn miniscus surgery 16 months ago and live in Canada, here are my experiences (excellent breakdown btw). It changed my life in many ways, but that's another story.<p>Though surgery is voluntary and I injured it playing soccer, the operation is covered by Medicare (which is a mandatory $64/month as I am self-employed).<p>So not including opportunity costs for missed work and time for pre and post-op doctor's visits (about 8 of them), my costs not covered were: - Post-surgery pain killers: $30 for T3's for a week. I refused the Percocet's, although the pain was bad I could still sleep. - Physio visits. They'd have you 2-3X per week for the whole duration if they had it their way, at $70 per appointment. I can't afford that, so I went once a week for three months = $840. - I declined the $900 custom knee brace that helps you get back playing sports sooner. - Rental of crutches for two months $25<p>And crutches are NOT as easy as I once thought, when you'd hop around on hour friends crutches for a few steps. I'm pretty fit, but a few blocks in them has you sore and sweating. Take care of those knees!!

I also had my ACL replaced (hamstring autograft), in SF, about 2.5 years ago after a basketball injury.<p>I'm pretty sure these prices are starting 'list' prices, whereas the negotiated/'allowed' cost that you and your insurance company actually wind up paying tends to be 1/2 to 1/3 these numbers.<p>My surgery was also about 3 months after the injury, which isn't optimal. It took me a few weeks to see a doctor, I didn't like the 1st doctor I saw, and by the time I'd settled on a preferred one, I needed 6 weeks of physical therapy to undo some of the post-injury weakening of surrounding muscles. (Since there's also atrophying due to surgical damage and post-surgery immobilization, it's best for recovery for the muscles to be as strong as possible going in. So diagnosis/surgery ASAP after injury, with muscles nearly at their pre-injury best, is preferred... if you suspect your ACL is torn see a doc quickly!)

For comparison, the full cost of a hernia repair (<a href="http://en.wikipedia.org/wiki/Inguinal_hernia_repair" rel="nofollow">http://en.wikipedia.org/wiki/Inguinal_hernia_repair</a>) in a private hospital in Poland is below $1500. Sure, this is a much simpler procedure than the OP's one, but still -- it involves an operating room, a surgeon, an anesthesiologist, assistants/nurses, and 2 days of hospital care. I don't imagine the materials are much different to the ones used in the US.<p>Even accounting for the lower cost of labor, the prices in the US are insane.

I'd be interested in seeing this analysis using what the actual final cost incurred was (normally the fees you are shown are negotiated down by your insurance company to the amount they actually pay).

I am actually 4 months out from my own ACL surgery, tore mine skiing and one thing the OP forgets to mention is many insurance will never pay that $60k as they have pre-negotiated rated with the hospitals and doctors. My surgery was done in SF (not the cheapest city in the world..) and according to the bill came out to just over 100k, but, my insurance paid 17k. What happen to the rest? Well I assume it was just inflated costs that the hospitals adds to the bill so the insurance can negotiate down.

This is amazing to me. I am from Australia and did my ACL when I was 15, and the cost was around $3000. It was an overnight stay in hospital, the only costs not incurred for the actual surgery and operation were MRI's and physiotherapy. How that could cost 20x the amount in America, I could not possibly fathom.<p>It is always a struggle for me to understand how health insurance is such a major expense in America, but when relatively routine surgery such as an ACL repair costs that much, things are put into perspective.

I had this exact same surgery 7 years ago after tearing ACL/meniscus playing basketball. Patellar tendon graft FTW! (I joke that <i>real men</i> donate their own tissues)<p>For me, the ACL has been perfect ever since. Wish I could say the same for my meniscus and cartilage - I subsequently tore my meniscus 2 more times (each time in a non-vascular area so they just sanded it down, no sutures like you had), and then 5 years later I tore a chunk out of my articular cartilage that had probably been weakened years before when I did my ACL.<p>That led to an OATS procedure where they took bone plugs from a non-weight bearing part of the knee and transplanted them in holes bored where the lesion was. That last procedure was pretty fun as it entailed 6 weeks on crutches, non-weight bearing, during which period my wife and I had our first kid (yay for timing!).<p>Anyway, that just to say hang in there (I imagine your rehab is pretty much over by this point, but it probably still aches?), and I hope your ACL graft (good call with the patellar) holds up as well as mine and your meniscus better. Oh and enjoy the achiness that comes with changing weather. I was rather amused that that apparently is a real thing. :)

Great read. Very well researched and written.<p>As a side note, medical insurance much like construction is a 'cost-plus' industry. The insurance companies actually have incentive to make prices go up.<p>For example, insurance companies are required to spend 80% on medical expenses. So if cost of an ACL surgery skyrocketed $100,000 then, they would make $20,000 off of it. Instead, they only made about $14k off of Calvin's surgery.

I ruptured my left ACL during the final year of our college during a cultural fest (in India). It was a complete tear and required surgery to return to normal knee movement (Instability due to knee cartilages tears/injuries suck, and lead to further secondary injuries).<p>I had to differ my surgery for a couple of months since we had our final exams and I had to walk with a brace and avoid injury-causing activities. The surgery at one of the leading hospitals in the country cost me around ~$3000 and was completely covered by my Health Insurance, the care I received was exceptional and I could see why "Medical tourism" to India is on the raise. The costs are mostly around 1/10 of what any procedure costs elsewhere.<p>P.S. Incidentally, I had a freak accident a few days back and I'm positive I tore one (or many) of my ligaments in the other knee, and I had just started training to run a marathon within the next year :( (Lady luck hates my knees)

Interesting to read of a 'normal' person sustaining an ACL injury and the subsequent fixing thereof (especially detailed costing breakdown - thanks for the detailed analysis). There has been somewhat of an 'epidemic' of ACL injuries in the AFL[0] this year. So far at least 15 players, some of them quite well-known, have succumbed to a season ending ACL injury already[1], much more than previous years. The difference? They have access to a complete rehabilitation package of priority surgery and follow up physio program. Such is the professional sports industry I suppose...<p>[0] Australian Football League; <a href="http://en.wikipedia.org/wiki/Australian_Football_League" rel="nofollow">http://en.wikipedia.org/wiki/Australian_Football_League</a><p>[1] <a href="http://www.abc.net.au/news/2013-04-29/afl-acl-injuries-2013/4658058" rel="nofollow">http://www.abc.net.au/news/2013-04-29/afl-acl-injuries-2013/...</a>

I wonder how the cost would compare at a special-purpose orthopedic surgery center vs. a general hospital? I actually thought that otherwise healthy people are encouraged to utilize specialty facilities rather than hospitals as they can be optimized to the procedures performed, and may have lower risk of post-op infections.

It was $1,600 have ACL surgery on our dog. Think about that one for a while.

I had my ACL repaired in 2007. I don't remember the costs any more, but I had essentially the same procedure using my patella and a meniscus tear repair. While I was able to put weight on my injured leg and was out of physical therapy after only a few months, it has taken several years to "fully" recover; even then I have the occasional gentle reminder that my knee is not the same as before my soccer mishap.

Here is an idea for an awesome law that might fix some of the problems with the medical industry! Remove the ability of the billing departments to determine who has insurance and who doesn't. That way, everyone is charged the same amount for similar procedures. The whole practice of over-billing insurance companies has simply become ridiculous.<p>Why do the insurance companies tolerate this practice?

I dunno about the surgery time which is probably the only overpriced thing worth the money if done right but WTF is this?<p><pre><code> First 30 minutes in the post-anesthesia care unit $2,057 Additional time in the post-anesthesia care unit $3,894 </code></pre> What exactly cost $6000 ? Laying in a room? Seriously? Like you have a choice - which is probably why.

I would like to pose a question to the Hacker News community. If you had to, where would you cut costs? Do you think doctors are paid too much? Or nursing staff? Obviously, we think these services are overbilled but the reality of it is that most of these bills are not paid at all or paid for a fraction of what is billed.

I'd like to see the actual negotiated rate the insurance company paid for those items. I'd be surprised if it was more than 40%, and perhaps it might be less?<p>It's quite bad that those who can afford it the least pay the highest(sticker) prices, though. If Obamacare fixes that one thing, it's done the US health care world good!

The article ends with "this sector needs innovation". Even though it does, what it really needs is better (and tighter) regulation. The situation in the US (costs through the roof, a lot of people that can't get medical care), health is something that can't totally be left to the private sector.

Earlier this month in NY Times: Hospital Billing Varies Wildly, Government Data Shows <a href="http://www.nytimes.com/2013/05/08/business/hospital-billing-varies-wildly-us-data-shows.html?pagewanted=all" rel="nofollow">http://www.nytimes.com/2013/05/08/business/hospital-billing-...</a>

here a link to compare the cost of the same injury in France:<p><a href="http://blogs.wefrag.com/Naudec/2011/11/05/rupture-du-ligament-croise-anterieur-un-an-plus-tard/" rel="nofollow">http://blogs.wefrag.com/Naudec/2011/11/05/rupture-du-ligamen...</a><p>basically it's about 7559 euros all inclusive (MRI, etc..)

It seems to me that the balance of power has shifted far over to the providers and away from the insurance companies. Would allowing more mergers give them more bargaining power and bring these costs down? Or is that just too simple?

ACL Graft Knife $900<p>Here is a pack of 4 on ebay for $35 <a href="http://www.ebay.com/itm/ACL-GRAFT-KNIFE-10MM-REF-232110-DEPUY-MITEK-LOT-OF-4-PCS-/390521554893" rel="nofollow">http://www.ebay.com/itm/ACL-GRAFT-KNIFE-10MM-REF-232110-DEPU...</a>

Contrast this to the cost of a typical ACL injury in Australia: <a href="http://www.injuryupdate.com.au/forum/archive/index.php/t-801.html" rel="nofollow">http://www.injuryupdate.com.au/forum/archive/index.php/t-801...</a>

Wow, so much of that is overpriced.<p>The medication costs, especially the fluids, are much higher. I checked a UK pharmacy for costs for buying small amounts so the discount they get for buying in bulk suggests a very large mark up in price.

There is a cost in not getting your ACL repaired. I waited 4 years (due to the fact that the buffoon physios / doctors I saw didn't diagnose it correctly) and put on 20kg in the interim because I stopped playing sport.

Coming from the mobile app market where consumers are reluctant to spend 99 cents on your app/game, this is revolting. Something has to be done (in the medical field and in the mobile app field as well)

Why don't the medical tools get reused? That seems absolutely insane to me.

I had ACL surgery in November in Italy and it costed 2200€(I did not pay anything we have public health care luckily). US health care system is just crazy in my opinion.

The insurance company didn't pay that much.<p>This article is silly.<p>Our health care system certainly has lots of problems but at least know how it works before sharing commentary on it.

this is an industry not just ripe for disruption but instead ripe for some anti-trust laws and investigation for fraudulent behavior

So, I have a few questions.<p>&#62; Going in, I had anticipated that doctors would take the lion’s share of the costs. I was surprised when the facilities ended up being the dominant cost; over 40% of the total.<p>Is that because you're paying for the cost of nurses here, rather than breaking that cost out elsewhere?<p>&#62; This centimeter-wide cutting machine cost $900 according to the price sheet.<p>That seems to be a bit much. I'm used to silly prices for tools and equipment in electronics, but still. Perhaps they're charging you for the whole tool, and not just the disposable blade? (Which would seem to be a bit cheeky.) Have you tried to get a price quote from anywhere else? (<a href="http://www.arthrex.com/products/AR-2285-10" rel="nofollow">http://www.arthrex.com/products/AR-2285-10</a>) Because they sometimes turn up on Ebay (<a href="http://www.ebay.com/itm/Arthrex-AR-2285-10-Parallel-Device-10mm-Qty-1-EX-/300801588750" rel="nofollow">http://www.ebay.com/itm/Arthrex-AR-2285-10-Parallel-Device-1...</a>)<p>&#62; but the blades get thrown out after just a single use<p>One reason for that, at least in the UK, and maybe this is historical, is because of diseases like CJD.<p>But as ISL said a sharp blade is a good blade and when you're slicing people you want the best blades you can get.<p>&#62; Most of the other drugs cost between $40-60 per dosage.<p>In England everything is free at the point of delivery. Medications are a bit different. If you're in hospital they're free. Most people get exemptions from paying. The people who do pay need to pay about £7.50 per line item per month. There are discounts for people who need a lot of meds.<p>&#62; The screws and washer are made out of titanium. I haven’t had any problems with MRIs or the metal detectors at the airport, but they do show up very clearly on my x-rays:<p>When my father died he had left me his artificial knees in his will. Luckily he had also asked to be cremated, so it was nice and easy to get them.<p>What I'm particularly curious about is why this market doesn't seem to work.<p>Insurance companies want customers to pay them. Insurance companies don't want to pay too much to hospitals because that's cutting the margins. So why don't insurance companies seem to be driving the costs down? Are insurance companies equipped to investigate the costs reported by hospitals?<p>Some kind of anonymised crowd-sourced data would let people know if their operation was around the same price as other people were paying. Perhaps you'd need to break the price down so people were able to compare similar things.<p>I hope your knee heals well and that you start to feel the benefit of that surgery!!

Is there any way to get data about how much insurance companies actually pay? I'm assuming it's different from amount billed.

Reading the article my knees both began to ache and I started to rethink my choice of sports - squash and indoor soccer...

For the sake of clarity:<p>Tendons link muscle to bone; Ligaments link bone to bone;<p>He tore a ligament, and it was replaced with a ligament, not a tendon.

this is an amazing article for me since I also tore my acl and am considering getting the reconstruction described in the article done, any one out here who recommends/ does not recommend this ? I am developer with a 9-6 desk job and usually go jogging rarely and don't find time to work out due to a busy schedule

Had the same procedure done and paid equally as much. I was shocked how much it cost.

Had ACL repaired privately as a Canadian and the total cost was around $7000

great presentation and vibrant discussion. I wonder: how much attention does this article owe to effective use of highcharts, a clean palette, and freight sans pro? Not knocking, just wondering.

I saw "ACL injury" and my first thought was "ultimate frisbee."

Great Read