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$5080, on average.10 Although this was significantly higher than the actual Medicare reimbursement at the time, a later study, by Foran and colleagues,4 found patients’ estimates of both fair reimbursement and Medicare reimbursement for TJA to be even higher. Foran and colleagues4 surveyed 1120 patients who thought surgeons deserved to be paid $14,358 for THA and $13,322 for TKA, on average. These reimbursement values are nearly an order of magnitude higher than actual reimbursements. For Medicare payments, patients lowered their estimates to $8212 for THA and $7196 for TKA.4 To our knowledge, the present study is the first to use a “postconsumer” survey to assess patients’ perceptions of THA and TKA costs. Our results confirmed that patients substantially overestimated reimbursement for THA and TKA at $11,872 and $12,263, respectively, relative to the average Medicare reimbursements of $1467 and $1530, respectively.11 We also found that patients overestimated both hospital cost and reimbursement for THA at $22,981 and $27,366, respectively, relative to recently published hospital economic analyses showing THA cost and reimbursement to be $11,688 and $15,789, respectively.12 Few patients enrolled in our study demonstrated an understanding of the services included in the global surgical package. Only about 12% of patients correctly indicated there was no additional payment to the physician for initial follow-up appointments. However, patients were fairly accurate in their estimates of implant cost. On average, patients who underwent THA priced their implant at $6823, which is only about 9% higher than the reported median cost of $6072 to $6400.13,14 We also found significant differences in perceptions of cost based on level of education, joint replaced, and overall level of satisfaction. On average, patients with a bachelor’s degree or higher gave estimates of cost and reimbursement that were lower than those given by patients with a lower level of education. Estimates of physician reimbursement and hospital reimbursement and cost were higher from patients who had TKA than from patients who had THA. Comparing perceptions of reimbursement for appendectomy and coronary artery bypass with perceptions for TJA, Foran and colleagues4 found that patients understood the relative complexity of each procedure, as evidenced by their estimates of fair reimbursement for each. However, in comparing patient estimates for the different components of cost and reimbursement for TJA, we found great variability in understanding. Patients in our study overestimated payments to the hospital by 73% but overestimated the cost of the THA implant by only 9%. However, the same patients overestimated physician reimbursement for THA by about 800%. If these patients’ estimates of reimbursement are considered surrogates for relative value, then physicians, based on actual payments, are grossly undervalued relative to implant manufacturers. Our study had several limitations. First, the enrolled patients were all seen at one medical center, in Ann Arbor, Michigan, and our results may not be generalizable outside the region. Second, the survey respondents were postoperative patients who had an established relationship with the study’s principal investigators—a relationship that may have been a source of bias in the consideration of reimbursement as a function of value. Third, despite our efforts to carefully design a survey with open-ended responses, the order in which the survey questions were presented may have influenced patient responses. Fourth, the open-ended question design may have had an impact on responses where the correct answer would have required entering 0.00. Despite these limitations, our study results demonstrated general public misconceptions about cost and reimbursement for common orthopedic procedures. Although more transparency in health care cost information may not immediately result in a more well-informed population,15 our patients, given the opportunity to develop an understanding of the economics of their own medical treatment, may become better prepared to make informed choices regarding changes in health care policy. Dr. Maratt is Clinical Assistant Professor, Department of Orthopaedic Surgery, and Dr. Gagnier is Assistant Professor, Departments of Orthopaedic Surgery and Epidemiology, University of Michigan, Ann Arbor, Michigan. Dr. Gombera is Sports Medicine Fellow, Northwestern University, Chicago, Illinois. Ms. Reske is Registered Nurse, University Hospitals and Health Center, Ann Arbor, Michigan. Dr. Hallstrom is Clinical Assistant Professor, and Dr. Urquhart is Service Chief and Clinical Associate Professor, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan. Address correspondence to: Andrew G. Urquhart, MD, Department of Orthopaedic Surgery, University of Michigan, 1500 E Medical Center Dr, TC 2912, Ann Arbor, MI 48109 (tel, 734-936-6636; fax, 734-764-9159; e-mail, andrewu@umich.edu). Am J Orthop. 2015;44(5):E135-E141. Copyright Frontline Medical Communications Inc. 2015. All rights reserved. References 1. Kumar S, Ghildayal NS, Shah RN. Examining quality and efficiency of the U.S. healthcare
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