
The Cost of an ACL Injury - calvinfo
http://calv.info/the-cost-of-an-acl/
======
dbuxton
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.

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).

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.

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.

Mental.

~~~
apendleton
We hear about medical tourism from the US to India, Thailand, etc., but with
these kinds of price discrepancies between the US and UK private practices, I
wonder why there aren't more Americans who go to the UK for surgery?

~~~
twoodfin
The fraction of patients without insurance but with enough cash and motivation
to fly to the UK purely to seek savings on medical treatment has got to be
fairly tiny.

My impression is that medical tourism from the U.S. is not typically for cost
savings, but rather because particular procedures are either completely
unavailable (experimental stem cell treatments) or could require long wait
times (liver transplants). I'd love some data on this. Wikipedia's rather
poorly written article suggests MT is more popular _from_ countries with
socialized systems in order to reduce wait time, but I'm skeptical.

~~~
defen
> The fraction of patients without insurance but with enough cash and
> motivation to fly to the UK purely to seek savings on medical treatment has
> got to be fairly tiny.

Well, if my options are to spend 60 grand on an ACL repair in the U.S., or
significantly less than that on a first-class ticket to London, some serious
fun, and an ACL repair...I know which one I would choose.

~~~
rogerbinns
Those weren't your options. As with most things health related in the US,
someone else was paying (the "insurer" in this case). Given the choice between
you paying $2,400 in the US (and the insurer paying an amount you don't see or
care about), or you going to the UK and paying 3,000GBP plus accommodation and
tickets, I'll bet you pick the former.

It is in the insurer's interest for you to go somewhere cheaper as it saves
them (not you) money. There are various press articles about this happening
such as this 2009 article
[http://usatoday30.usatoday.com/news/health/2009-08-22-medica...](http://usatoday30.usatoday.com/news/health/2009-08-22-medical-
tourism_N.htm?csp=34)

~~~
kriro
If the insurance company pays the remainder i.e. >60k why don't they offer you
this deal:

\- No out of pocket cost

\- Free all expenses paid one week trip to England with your surgery

Would cost them the 3k pounds+2.5k$ of your share+maybe another 3k for a good
trip..<10k total compared to 60k

I take it they simply can't get that 3k pounds deal as an insurance company.

~~~
woobar
Insurance company will not pay >60K. It will be <10K. Typical insurance pays
around 80%, patient 20% of the 'negotiated rates'.

------
ISL
Excellent read.

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.

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.

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.

When quality matters, provenance matters.

~~~
angersock
To be fair, you're doing exceedingly delicate machine and test equipment
manufacture. The machine shops I know will buy new tools as needed, but reuse
them on large job runs--and throw them out once they lose tolerance.

Something like the $900 knife in the article is/could be a mass-produced
stamped piece of metal, perhaps sharpened on-site or at the factory; unit cost
for that should be easily less than $10.

~~~
larrys
"Something like the $900 knife in the article is/could be a mass-produced
stamped piece of metal"

Very well could be some liability potential wrapped into reuse of a device.
After all part of the cost does go toward covering things that go wrong for
whatever reason.

If you take the device fresh and something isn't right you can claim it was
defective. If it was used for another operation who is to say when something
happened to it?

An inverse analogy might be the difference in potential problems from using a
hard drive that has been previously used where _something is later found_ vs.
using a brand new hard drive.

~~~
ricree
>If you take the device fresh and something isn't right you can claim it was
defective. If it was used for another operation who is to say when something
happened to it?

There's something on the order of 100,000 ACL tears per year. Even with no
reuse, it seems odd that economies of scale can't get that well below $900.

~~~
jonknee
Economies of scale have nothing to do with medical billing in the US. For
example, IV bags of saline don't cost $100 in the real world (more like $1).

~~~
reeses
This becomes readily apparent with medical care for animals. Your vet will
send you home with bags of Ringer's, line, and a bunch of cannulae for $50.

It's not as simple as insurance alone driving the cost, but having a throat to
choke if something goes wrong does contribute to it.

As has been mentioned elsewhere, random overhead is covered in weird places,
as well.

~~~
jonknee
And human medical procedures that aren't typically covered by insurance. LASIK
for example, imagine what laser eye surgery would cost if it was billed like
an ACL reconstruction. Instead you have to pay yourself and doctors compete,
the entire bill (at a nice place) ends up being what a couple of ACL knives
cost.

~~~
reeses
Gah, excellent point. Elective retail procedures such as vision improvement
surgery and dental crowns, bonding, veneers, etc., all seem to top out around
the average FSA limits of $5,000 or so. It's especially notable around the end
of the year when advertisements encouraging people not to waste their FSA
funds start picking up on the radio.

Now that the IRS has apparently imposed a limit of $2,500 on FSA deductions, I
wonder if that's going to create pricing pressure on the "high end" procedures
such as custom/wave/whatever LASIK here in the USA.

If I weren't a lazy sod, I'd look up capital equipment costs for medical
procedures such as those and compare them to MRI, EKG, and other items used
primarily for "need" based, insurance paid, procedures.

(Actually, I haven't used any fancyhands requests in a couple months. I'll be
lazy and have someone google for me.)

------
dr_
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.

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).

~~~
larrys
"with insurance only for real medical emergencies"

You then have people putting off preventive care, tests etc and then you have
to cover a bigger problem down the line.

I'll give you an example. You are a landlord with a tenant and you tell the
tenant "you have to take care of minor repairs I will cover anything major".
As a result they don't do normal maintenance either because they forget, don't
care, who knows. Then because of lack of that maintenance the compressor fails
on the HVAC and you end up having to replace a unit. Good luck with trying to
tie that to the lack of maintenance. Or saying you won't cover it.

~~~
kqr2
The idea is to have the right incentives in place. The premium for medical
emergency insurance would go down as you are more proactive in your
healthcare.

For example, by having an annual physical, maintaining your weight, etc. you
would get a discount.

~~~
atgm
> The idea is to have the right incentives in place.

The recent article about Finland's baby box was a great example of this and
their infant mortality statistics show that it worked.

------
goronbjorn
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.

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 _didn't_ 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.

~~~
dionidium
You wouldn't have paid anything like $68k. As mentioned in the article, those
prices are inflated for charging the insurance company, who in turn negotiates
a much better actual price. Similarly, the hospital would have likely worked
out a better deal with you. Or, if you qualified (and it sounds like you would
have), then Medicaid would have initially picked up the tab and _they_ would
have negotiated a better deal for themselves.

In none of these scenarios does anybody actually pay the made-up $68k number.

~~~
goronbjorn
That's true, though even 10% of that number (more than twice the out-of-pocket
cost with insurance) would've been financially crippling.

~~~
rayiner
Possibly, but look at the picture of the sliced out tendon. ACL replacement is
an inherently complicated operation, from a highly skilled practitioner. The
take-away from that is: you can't afford to play a dangerous sport like rugby
if $5-7k is financially crippling.

------
whafro
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?

\- 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."

\- Nationwide, Medicare pays something closer to 90%. Much better, but still a
loss to the hospitals.

\- 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.

\- 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.

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.

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."

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.

Is it messed up? Sure. But does it mean that normal people are paying $65k for
this ACL procedure? Usually not.

~~~
danjayh
This is true, but often the discounts aren't as steep as you'd think. I had a
mitral valve replacement a couple years back (at age 29, due to a one in a
million condition), and the insurance company was billed ~350k for the surgery
+ recovery in hospital. Even after their discounts, the total still came to
$~250k (this is not the normal price - I had a complicated recovery, and spent
an abnormal amount of time in the cardiac ICU). I, however, only had to pay
~$4,500 or so (high-deductible plan).

~~~
whafro
Yup, and if course it varies. Complications are a huge driver of costs, so
making marginal improvements to the complication rate (either by improving the
standard of care OR by insisting that you go to a place with a low
complication rate) can have an outsize impact on the cost of care in the
aggregate.

Companies like ConsultingMD (horrible name, <http://consultingmd.com>) are
taking this approach to reducing costs.

------
milesskorpen
A few things to consider:

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.

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 & other
complicated equipment.

3) Insured people subsidize the uninsured.

~~~
angersock
So, it sounds like we need to stop coddling the doctors and standardize on a
particular set of tools.

~~~
epmatsw
The issue with that is that no hospital is willing to be the first.

Hospital: We're going to lower costs by not letting doctors choose their
equipment.

Talented surgeons: Welp, don't want to work there.

Patients: Why would I go to the hospital that doesn't have any of the good
surgeons?

~~~
angersock
So, have a deal that says "Hey, if you want to be able to receive
Medicare/Medicaid payments, you have to standardize tools."

All the hospitals will say "Wow, holy shit, alright", and the surgeons will
have to play ball--because a surgeon without a proper OR is basically just a
butcher or barber.

EDIT: Please explain why this is a bad idea instead of just downvoting.

~~~
drdoc
As an anesthesiologist, this is a bad idea for various different reasons.
There are a numerous reasons why a physician needs the tools that he needs.
The type of procedure, the type of patient and the familiarity of the
equipment. I routinely intubate patients with a particular type of tool
because that is what I feel most comfortable with and I have trained with.
Yes, I can intubate with the myriad of other devices but there is that 1 out
of a 1000 chance (slim but not unrealistically slim because I do >1000
intubations a year) that I cannot intubate you and you need to have a
tracheostomy or worse, you die.

Some may argue that we should all train with the same equipment, but even
then, what about inherent differences in the physician or the patients. Maybe
where I trained, all my patients had large tongues and I need a particular
blade more often so I became better skilled with that or maybe my hands are
just better with a particular blade.

~~~
angersock
If I dropped a Linux admin off at a shop which didn't have emacs on their
boxen and he refused to work because he might accidentally screw up a config
file, he'd be laughed out of the joint.

If I dropped a plumber off at a job site and she didn't have a particular type
of ergonomic monkey wrench she'd grown accustomed to and said she couldn't do
the job, she'd be mocked endlessly.

If I dropped a line chef off at a kitchen and they didn't have their favorite
knife available and they held up orders for a whole night, their boss would
fire them.

~

This custom bespoke medicine nonsense is increasingly seeming to be just that:
nonsense.

Sure, there's this .1% chance that you might screw up an intubation, but that
seems to be more of an issue of bad training than bad equipment.

As far as your point about differences in patients or physicians: that's a
cop-out. Part of being good at what you do (as a dev, as a maker, as a person)
is being flexible enough to make do and succeed.

In a system which costs as much as ours does to people who simply can't afford
it, we (as a society) cannot afford to cater to the whims of overspecialized
professionals.

~~~
dragonwriter
> If I dropped a Linux admin off at a shop which didn't have emacs on their
> boxen and he refused to work because he might accidentally screw up a config
> file, he'd be laughed out of the joint.

The kind of errors made by a Linux admin who is more familiar with emacs using
vi don't have as much likelihood of ending up with dead customers and massive
liability for the Linux admin and/or his employer as the kind of errors that
could be expected from a surgeon being forced to use non-preferred equipment.

So the situations aren't exactly parallel.

> In a system which costs as much as ours does to people who simply can't
> afford it, we (as a society) cannot afford to cater to the whims of
> overspecialized professionals.

In a system which costs as much as ours does _compared to every other advanced
country_ , while providing worse access and not producing better outcomes, we
certainly can't afford to not do some research to figure out what everyone
else is doing _right_ and we aren't.

But somehow I don't think letting surgeons choose the tools used for a
particular surgery based on their own expertise and understanding of the needs
of the particular surgery, rather than having one standard kit used for all
surgeries regardless of the specific details of surgeon and patient, is the
difference.

~~~
angersock
_"But somehow I don't think letting surgeons choose the tools used for a
particular surgery based on their own expertise and understanding of the needs
of the particular surgery, rather than having one standard kit used for all
surgeries regardless of the specific details of surgeon and patient, is the
difference."_

In isolation, your intuition is correct. But, with thousands and thousands of
surgeons performing hundreds of thousands of surgeries a year, we end up with
a logistical nightmare. This doesn't scale.

It's perhaps not the main difference, but I'm willing to wager it is at the
least a symptom of whatever the underlying problem is.

~~~
dragonwriter
> It's perhaps not the main difference, but I'm willing to wager it is at the
> least a symptom of whatever the underlying problem is.

I doubt its even a symptom: because I don't think the other OECD countries
that spend less for broader access and equal or better outcomes use one-size-
fits-all-surgeries standardized equipment kits, either. But even if it was a
symptom, it would be better to treat the underlying problems.

------
showerst
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.

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.

Additionally, as most people know, the billed amount is usually FAR in excess
of what the insurance company actually pays.

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.

~~~
danielweber
[http://www.thedailybeast.com/articles/2013/02/22/how-
hospita...](http://www.thedailybeast.com/articles/2013/02/22/how-hospital-
administrators-hide-the-umbrella.html)

 _His expense report comes back from accounting with everything approved
except the umbrella. He appends a note to the report explaining that the
umbrella was destroyed in the line of duty and resubmits. Back comes the
expense report, with a rather severe note from accounting to the effect that
umbrellas are not on the list of allowable expenses._

 _...Our frustrated manager tears up the old report, then sits down and fills
out a whole new form: $3.94 for lunch, $12.75 for laundry charges, and so
forth. Which he sends to accounting with a note attached: SEE IF YOU CAN FIND
THE UMBRELLA NOW!_

------
tbrownaw
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.

~~~
calvinfo
Good point, updated the title to be a bit more clear.

------
tsycho
(I am slightly hesitant to publicly share info like this, but what the
heck...for science!)

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.

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.

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.

~~~
smartician
The way understand it, yes, the uninsured person would receive the $67k bill,
but can then go and negotiate to lower the amount payable. Insurance companies
just did that negotiation beforehand and have a standing agreement with the
provider. All of this reeks of huge inefficiencies to me. There are people at
both the insurance companies as well as at every health care service provider
whose full time job is to negotiate rates with each other?

~~~
rsanders
I've been in this situation, and there is no comparison at all. Nobody but the
very wealthy can afford to pay out of pocket for healthcare. A single, minor
injury can cost you $50,000 - $100,000. A chronic condition, cancer treatment,
or major surgery can easily head north of $1 million.

Sure, you can try to negotiate pretty much anything. But what kind of leverage
do you think you have? Insurance companies can put many millions of dollars of
revenue at risk with the threat of dropping a stubborn healthcare provider
from their network.

In contrast, your negotiation position is A) please? and B) I may be forced to
declare bankruptcy, in which case you may or may not get your money. If you
have enough assets, then option B is basically another form of A: "please,
don't take away my house or the savings I've spent my life earning." The
bigger your bill, the greater the incentive to deal with the annoyance
involved in collecting from you. The likely consequence of your personal
financial ruin doesn't enter into their calculations.

------
dkl
_Achilles tendon harvested from a cadaver_

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.

The lack of controls on that business forever made me wary of using cadaver
parts for transplants.

~~~
matwood
_The lack of controls on that business forever made me wary of using cadaver
parts for transplants._

I didn't know that, but cadaver parts freak me out so when I had my ACL done I
did the standard patellagraph. If I tear the same knee again I'll have to go
cadaver or hamstring, but hopefully that never happens (knock on wood). The
problem with the hamstring is it never quite heals as strong.

As an aside, pro-athletes typically go cadaver because the time to heal can be
quicker. They probably aren't getting bad ones though.

------
omaranto
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.)

------
medell
I had ACL & 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.

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).

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

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!!

------
gojomo
I also had my ACL replaced (hamstring autograft), in SF, about 2.5 years ago
after a basketball injury.

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.

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!)

~~~
matwood
Depends. An ACL tear can feel better on it's own after a few weeks assuming
you don't go running into any hard direction changes. Many docs would prefer
pre-hab prior to surgery in order to get maximum flexibility and strength for
every patient, but most insurance will not pay for it.

------
jwr
For comparison, the full cost of a hernia repair
(<http://en.wikipedia.org/wiki/Inguinal_hernia_repair>) 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.

Even accounting for the lower cost of labor, the prices in the US are insane.

~~~
Komodo9
I don't know the statistics overall, but in my case the comparison of the
inguinal hernia repair is even more damning: I'm positive it was more costly,
but to add insult to injury, it (my hernia repair) was done as an outpatient
procedure.

Although I am not a doctor (just a patient), if anyone tries to pitch you this
as a good idea, _run_. The effective recovery time was insane, and not to
mention the pain/temporary disability (also insane). An inpatient stay wasn't
even offered, but in hindsight it shouldn't have even been optional.

By contrast, an unrelated abdominal surgery a few years later, despite being a
much more involved procedure, had a much faster recovery. (10 day inpatient
stay + probably 5 days of that with some physical therapy.)

Health care costs are a secondary issue to me, right behind health care
quality. Unfortunately, I don't think either can be fixed unless they are
entirely divorced from each other.

------
timcederman
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).

------
zsiddique
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.

------
lobe
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.

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.

------
bjhoops1
I had this exact same surgery 7 years ago after tearing ACL/meniscus playing
basketball. Patellar tendon graft FTW! (I joke that _real men_ donate their
own tissues)

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.

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!).

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. :)

------
bayton
Great read. Very well researched and written.

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.

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.

------
ameen
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).

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.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)

------
australis
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...

[0] Australian Football League;
<http://en.wikipedia.org/wiki/Australian_Football_League>

[1] [http://www.abc.net.au/news/2013-04-29/afl-acl-
injuries-2013/...](http://www.abc.net.au/news/2013-04-29/afl-acl-
injuries-2013/4658058)

------
ams6110
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.

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

~~~
systematical
Crazy, but dog lifespan is considerably less. How long does the repair really
have to last for?

~~~
jordan0day
I doubt that has a significant impact on the cost of the procedure, though,
right? I mean, sort of like replacing the clutch on a car -- the cost isn't
(necessarily) based on the lifetime/quality of the new clutch, but rather the
labor required to pull the engine, install the clutch, button everything back
up.

------
chinpokomon
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.

------
jostmey
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.

Why do the insurance companies tolerate this practice?

------
ck2
I dunno about the surgery time which is probably the only overpriced thing
worth the money if done right but WTF is this?

    
    
       First 30 minutes in the post-anesthesia care unit  $2,057
       Additional time in the post-anesthesia care unit   $3,894
    

What exactly cost $6000 ? Laying in a room? Seriously? Like you have a choice
- which is probably why.

------
drdoc
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.

------
jwatte
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?

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!

------
louischatriot
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.

------
stevewilhelm
Earlier this month in NY Times: Hospital Billing Varies Wildly, Government
Data Shows [http://www.nytimes.com/2013/05/08/business/hospital-
billing-...](http://www.nytimes.com/2013/05/08/business/hospital-billing-
varies-wildly-us-data-shows.html?pagewanted=all)

------
gregcrv
here a link to compare the cost of the same injury in France:

[http://blogs.wefrag.com/Naudec/2011/11/05/rupture-du-
ligamen...](http://blogs.wefrag.com/Naudec/2011/11/05/rupture-du-ligament-
croise-anterieur-un-an-plus-tard/)

basically it's about 7559 euros all inclusive (MRI, etc..)

~~~
djulius
In fact, in the link you provide, the 7559 euros also cover 75 sessions of
physical therapy, a nurse coming at home every working day during a month and
various drugs.

It would be interesting to have a global comparison (operation+therapy).

Here, the operation including all appointments before is about 5274 euros.

------
pkulak
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?

~~~
dragonwriter
> It seems to me that the balance of power has shifted far over to the
> providers and away from the insurance companies.

That's because you are looking at an accounting of the _nominal charges_ , and
not what the insurance actually _paid_. If you look at what the insurance
actually paid based on those nominal charges, you'll see that the balance of
power isn't where you think it is.

~~~
pkulak
Oh yes it is! I know exactly what my insurance company's negotiated prices are
(because I pay them!) and they are astronomical. I just had an emergency visit
and the nominal charge was $1700. The negotiated charge was $1500. That's
_nothing_. I added up the medicare schedule prices for the entire visit and it
was about $350. So, yes, a large insurance plan (like medicare) seems to be
able to negotiate far better than my insurance company.

------
topbanana
ACL Graft Knife $900

Here is a pack of 4 on ebay for $35 [http://www.ebay.com/itm/ACL-GRAFT-
KNIFE-10MM-REF-232110-DEPU...](http://www.ebay.com/itm/ACL-GRAFT-KNIFE-10MM-
REF-232110-DEPUY-MITEK-LOT-OF-4-PCS-/390521554893)

------
akandiah
Contrast this to the cost of a typical ACL injury in Australia:
[http://www.injuryupdate.com.au/forum/archive/index.php/t-801...](http://www.injuryupdate.com.au/forum/archive/index.php/t-801.html)

------
tomwalker
Wow, so much of that is overpriced.

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.

~~~
stonemetal
Did you include the cost of having a trained medical professional administer
them? The cost of hospital aspirin isn't the pill it is the doc deciding to
give them to you and the nurse who dispenses the pills( don't forget the
billing person who charged you for the pills, the staff lawyer who was
retained just in case you sue over the aspirin, and the payout to the last guy
who sued and won).

As with every service industry from the local pizza joint on up COGS(Cost Of
Goods Sold) is one of the smallest parts of the pricing puzzle.

~~~
DanBC
Is the cost of staff included in the cost of the meds, or elsewhere? Are they
double-billing for staff costs?

~~~
rsanders
If you read the recent Time cover story about medical costs, you'll see
examples of people being recursively double-billed for items, at least
according to the Medicare guidelines. e.g., and my memory's a little fuzzy on
the specifics, but I believe one case was being billed for the operating room,
then billed for the prep kit (which is supposed to be included in the room
charge), then billed for every individual item in the prep kit.

If I hire a contractor to do something and he charges $X/hour, I don't expect
him to mark up the materials he might use, too. I'm already paying for his
time and expertise. I shouldn't also be paying the drywall for his expertise.

------
adamconroy
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.

------
yohann305
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)

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

~~~
ianstormtaylor
Yeah I also don't get that. Would they not be able to just be disinfected and
resealed?

~~~
dragonwriter
> Would they not be able to just be disinfected and resealed?

Blades that need to be very sharp and of very particular dimension are going
to need sharpened, which is going to change their dimensions. So there is
limited, if any, reusability in any case.

And the keeping, transporting to a cleaning facility, cleaning, sharpening,
etc., is going to come with an additional cost cost and risk of accident that
you don't have with immediate disposal.

------
wild91
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.

------
harryh
The insurance company didn't pay that much.

This article is silly.

Our health care system certainly has lots of problems but at least know how it
works before sharing commentary on it.

------
tylee78
this is an industry not just ripe for disruption but instead ripe for some
anti-trust laws and investigation for fraudulent behavior

------
DanBC
So, I have a few questions.

> 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.

Is that because you're paying for the cost of nurses here, rather than
breaking that cost out elsewhere?

> This centimeter-wide cutting machine cost $900 according to the price sheet.

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?
(<http://www.arthrex.com/products/AR-2285-10>) Because they sometimes turn up
on Ebay ([http://www.ebay.com/itm/Arthrex-AR-2285-10-Parallel-
Device-1...](http://www.ebay.com/itm/Arthrex-AR-2285-10-Parallel-Device-10mm-
Qty-1-EX-/300801588750))

> but the blades get thrown out after just a single use

One reason for that, at least in the UK, and maybe this is historical, is
because of diseases like CJD.

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.

> Most of the other drugs cost between $40-60 per dosage.

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.

> 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:

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.

What I'm particularly curious about is why this market doesn't seem to work.

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?

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.

I hope your knee heals well and that you start to feel the benefit of that
surgery!!

~~~
jordan0day
> So why don't insurance companies seem to be driving the costs down?

They are driving down costs -- as the OP mentions elsewhere in this thread,
while he was _billed_ nearly $49k for facilities/equipment, the insurance
company only _paid_ $15k.

There certainly are a lot of rich doctors and hospital executives who are
being paid ludicrous amounts of money (especially considering the hospitals
themselves are billed as not-for-profit), but the insurance companies are
making money hand-over-fist in the current regime.

~~~
DanBC
That feels, and I'm not sure what the right word is, "corrupt"?

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

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

------
chm
For the sake of clarity:

Tendons link muscle to bone; Ligaments link bone to bone;

He tore a ligament, and it was replaced with a ligament, not a tendon.

------
maskedinvader
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

~~~
medell
If you don't plan on playing semi-competitive sports ever again, I wouldn't
recommend surgery. It's all about the planting of the foot and changing
direction, which you don't do with straight line activities like running or
biking.

Forget about working the first week after surgery. You need to elevate and
extend your leg constantly for the first few months, which gets uncomfortable
when sitting.

Pre-surgery you need to strengthen the muscles around the knee to speed up
recovery, so my physio got me to go to the gym 3X a week for two months,
biking hard. Post-surgery you need to use some gym equipment as home rehab
doesn't cut it.

Also it takes two years to fully heal. After seven months I could hike and
bike, but now I'm sixteen months in and only now have started to play light
competitive sports again. However mine is more complex as I have torn miniscus
and some residual scar tissue that may be removed in the future. Let me know
if you have other questions about the process, it's a long one!

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

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

------
elfinforest
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.

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

------
urbangangster
Great Read

