Cost of revision arthroplasty in Singapore

At Limb Salvage and Revision Arthroplasty Surgery we applaud the Ministry of Health in making transparent the cost of joint replacement surgery in Singapore. A quick check on the ministry website makes apparent the relative cost of such knee and hip replacement surgery in Singapore. What is perhaps less apparent is what the breakdown in costs are.

Subsidized versus private rates

Comparisons between private and subsidized costs simply cannot be made. While the cost of the procedures done under private rates are closest to the true costs of surgery those in the subsidized clinics have a massive range that cannot be reflected in the way that is required for easy reading on a website.

Those of us who spent many years in the government sector from early years to positions of policy making know full well the costs involved in joint replacement surgery. The government is to be congratulated for offering this sort of surgery, generally considered lifestyle surgery and not “life and death surgery”, to a population who might not otherwise benefit from such procedures. To be sure such procedures are considered luxuries in other parts of the world including first world countries and can be denied to large sectors of indigent populations. In Singapore, such generous subsidies usually end up with some form of co-payment with the patient paying for the implant and the facility and the government paying for the rest with the provisio that the patient must understand that while he or she is entitled to qualified care this may not be a certified specialist (ie. an associate consultant and above). Usually a senior doctor is assigned to oversee such cases. On this framework, patients on special assistant plans may even have the surgery for 'free' if they are deemed suitable.

True costs

The true costs of surgery can be broken down as hospitalization costs, implant costs and doctors' fees in decreasing order of transparency.

Hospitalization costs include the per day stay which for a 4-bedder room would be about SGD 240 to the Rolls-Royce of suites at SGD 5,000 (!). One needs to factor in a daily cost of treatment of about SGD 240, lodgers SGD100, drugs, etc. One can expect to stay about 5 days after surgery (SGD 2500) These prices are readily available on the hospital websites and are fully transparent. The added operating theatre charges are variable depending on the consumables used, time spent, etc and can’t really realistically be estimated (SGD 4000).

Figure 1. Knee replacement designs have been fairly standard for the last 20 years (left on a) although newer designs (b) now allow patients better range of motion (e). These newer designs pioneered by our surgeons in Singapore have been used for the last 10 years and show excellent results. The future designs like the ceramic knee (d) also first implemented in Singapore by our surgeons represent the next generation of hypo-allergenic low-wear implants. For revision surgery implants the necessary technological enhancements all necessarily add to the cost of the implants (c).

Implant costs can be very variable. For knee replacements (Figure 1), the standard knee replacement designs for primary knee replacements would cost about SGD 3,000 to 4,000. Hip replacements are considerably more expensive because there are added technologies there. Accordingly, a cemented implant with cobalt chrome head would cost about SGD 3,000 (Figure 2) but on the other end of the spectrum a high end uncemented stem, with ceramic articulations and modern ingrowth cups can cost up to SGD 7,000 (Figure 3). To make matters more complicated, it does not necessarily follow that the more expensive implant results in better outcomes (Figure 4). They are really more related to the functional demands of the patient requesting the implant – in a sense a custom solution to the patient’s need. At Limb Salvage and Revision Arthroplasty Surgery this is an important determinant in all joint replacement procedures undertaken.

Figure 2. The classic hip replacement is one with a cemented all polyethylene cup (a) and a cemented stem (b) and represents the gold standard in hip replacements (c).

On the revision surgery side of things no fair generalizations can be made on costs although the implants can be about twice the price of those used in primary joint surgery. The numbers shown on the MOH website do not refer to revision procedures which are uncommon and undertaken by only a handful of surgeons in Singapore.

Figure 3. The top of the line implants with ceramic articulation and ingrowth stems (a) can be implemented in all hip arthritis cases (b). By putting them in specially designed minimally invasive methods (MIS) such patients can have very high levels of function (c). This patient from Myanmar actually returned to have the other side done by the author at considerable cost (d).

When one considers the figures on the MOH website, therefore, at a 75^th percentile cost of knee replacements at about SGD 25,000 and hip replacements at about SGD 29,000 one will realise that this is the true cost of joint replacement surgery - whatever the hospital. This is probably to be expected given the market forces involved- very few people can afford a blank check solution to health care.

Figure 4. You don't always get what you pay for. In all the joint registries of the world, cemented hips out-perform uncemented hips despite being nearly 40% cheaper. Nevertheless, as is shown in Figure 3 there are certain advantages of uncemented designs over cemented designs. We strongly believe that the joint replacement that is best is the one matched for the patient's needs. Hence, at Limb Salvage and Revision Arthroplasty we offer all options to the patients.

Doctor’s fees are usually split between the anesthetist and surgeon.

All these fees are required to be made known to the patient at the time of financial counselling by law.

Conclusions

There can be dramatic exaggerations of the cost of joint replacement surgery in Singapore. The initiative by the Ministry of Health in publishing such costs are illuminating for patients. Nevertheless, it is improbable that a patient in the appropriate circumstance for surgery would make a decision based purely on the cost. The overarching considerations in our opinion is now as ever before one of need and patient-doctor relationship.