The cost of a knee replacement can vary substantially—even within the same geographical area. The final hospital charge depends on many factors. These include:
In the U.S., the average hospital charge for a total knee replacement (TKR) is $49,500. A partial knee replacement (PKR) typically costs about ten to twenty percent less than a TKR. The primary reason for the lower price is that the operation requires a shorter hospital stay (an average of 2.3 days compared to 3.4 days). Keep in mind that hospital charges do not reflect the amount you pay out-of-pocket. Out-of-pocket costs are explained in more depth below.
Expect multiple bills following a knee replacement surgery. In addition to the hospital bills, you will receive bills for all treatments you received from the surgeon while in the hospital and other tasks and procedures performed by the operating room staff. This includes work performed by the anesthesiologist, surgical assistants, physical therapists, and others.
In-patient charges (charges that occur while you are “in” the hospital) from the surgeon and other providers may add an average of roughly $7,500 to the basic hospital charge for the procedure. In the U.S., this brings the average total incurred charges for a total knee replacement closer to $57,000.
In some cases, hospitals will provide discounts if you lack health insurance or aren’t covered by Medicare. If you have no insurance coverage, you should inquire about a possible discount or payment plan before scheduling your surgery. Regardless of your insurance, you should try to estimate your costs in advance by learning what the expected average charges are for your area, and by speaking with your individual healthcare providers, a hospital representative, and your insurance provider prior to surgery. It is important to know what will be covered and what discounts will be applied.
Medicare typically pays 100 percent of in-patient charges related to a procedure and the hospital stay (after you have reached the deductible). Private insurance plans pre-negotiate fees with hospitals and providers and generally pay only a percentage of the total charges. Private insurance varies and it’s important to review your benefits plan prior to a procedure. You should be clear about your deductible and understand which providers are in your insurance network and what services will be covered.
While these in-patient procedure and hospital charges represent the largest portion of your incurred charges, you should also consider that you will be charged for out-patient services before and after your procedure. (“Out-patient” refers to services that occur when you are not in the hospital.)
These additional TKR expenses include pre-operative and post-operative costs associated with office visits and relevant lab work. During your recovery, you will also incur charges for physical therapy and follow-up visits with your surgeon. Medicare typically pays 80 percent of the out-patient service charges for its members. Again, private insurance plans vary. Expect that deductibles and co-pays will usually apply to any out-patient or office visit charges before and after your surgery.
Understanding Your Bill
Although bills vary, here’s what you can expect if you receive a knee replacement:
The pre-surgical evaluation phase consists of a consultation/office visit, imaging and lab work, which usually includes blood work, cultures, and panel tests. The number of expected services, and consequently the total charges, vary according to insurance coverage but also by age group. For example, a patient over the age of 65, and usually covered by Medicare, generally requires more lab work than a patient under 65. This is because an older patient is more likely to have pre-existing conditions that must be fully understood during a pre-operative evaluation. The approximate national average charge for these services, according to what typically occurs within the 90 days prior to surgery, is $1,900 for Medicare patients and $1000 for those with private insurance.
Hospital Stay & Surgery
You will receive separate bills for a TKR. As discussed above, the hospital will bill you for your hospital stay, the time spent in the operating room, and other applicable hospital services, supplies, and equipment used. Providers will bill you for procedure charges that cover services provided by the surgeon, as well as anesthesia, injections, pathology services, surgical assistance (i.e. operation of computer aided or other technology), physical therapy, and coordination of care. The approximate national average charge for these services is $56,000 for Medicare patients and $58,300 for those with private insurance.
Keep in mind that there are many other factors that can affect charges and costs related to a procedure. These include:
- Pre-existing conditions: For example, anemia can increase the hospital charge by as much as 17 percent. Doctors and hospitals also call these pre-existing diagnoses (conditions), or comorbidities. Examples of other comorbidities are hypertension, smoking, obesity and diabetes.
- Complications: Anything that creates a need for additional attention or extra care may lead to an increase in charges.
Recovery and rehabilitation encompasses outpatient physical therapy services, the tools and treatments used in conjunction with physical therapy, and outpatient follow-up. The approximate national average charge for these services, based on what is typical over 12 months after surgery, is $2,600 for Medicare patients and $1700 for those with private insurance.
The average patient out-of-pocket expense in the U.S. ranges dramatically and ultimately depends on your insurance plan. While Medicare patients can expect their out-of-pocket costs to be in the hundreds of dollars, those with private insurance can expect these costs to reach into the thousands. If you are covered by private insurance, you should review your plan carefully and consider that your deductible, co-pay, co-insurance, and max out-out-of-pocket values will come into play.
Keep in mind that the cost of care and services is only part of the overall expense. For example, it is likely that your doctor will also prescribe special equipment, such as a continuous passive motion machine, walker, or crutches. While most insurance plans and Medicare cover these devices (referred to as “durable medical equipment”), they may lead to additional charges that appear on your hospital bill or other bill.
You may also require additional physical therapy or a nurse in your home. If your insurance doesn’t cover these home-care services, expect to pay these costs out-of-pocket. You may also require modifications to your home, including the installation of safety bars and rails, a shower bench, a toilet seat riser with arms, and perhaps other items. If you are not able to return home immediately, and you are released instead to a rehab or nursing facility for extra care, you should expect separate bills for this as well.
If you take time off from work for the surgery or recovery, you will also need to factor in lost income. Talk to your employer and/or insurance provider to find out if there are any disability insurance options available to you that cover time off of work. Disability insurance is a form of insurance that pays out a partial wage to employees who are unable to work due to an injury or disability. In some cases, it may cover time off needed for surgeries such as TKRs.
Options to Save Money
Because of the high cost of a TKR, some patients opt to have the procedure performed overseas. In some cases, such as Mexico, India, or Taiwan, the cost can drop by 50 to 80 percent. If you’re considering taking this route, make sure that the facility is internationally accredited by the Joint Commission International (JCI) before consenting to the procedure. This ensures that the surgeons are accredited and that the facilities and prosthesis meet the highest standards. Also remember that you will likely spend several thousand dollars for airline tickets, hotels, and related expenses.
By knowing the costs up front you can avoid surprises—and potential hardship—down the line.