Knee replacements cheaper under controversial scheme

Doing elective knee replacement operations has proven cheaper under a controversial pilot scheme at Auckland's Waitakere Hospital. Photo / Thinkstock

Doing elective knee replacement operations has proven markedly cheaper than usual, in a controversial pilot scheme in which surgeons are paid more than their colleagues.

The pilot, which began last year in elective joint-replacement surgery at Waitakere Hospital in Auckland was so successful that it had been extended to other kinds of elective surgery, including gynaecology, said its instigator, orthopaedic surgeon John Cullen.

Mr Cullen, the head of surgical services at Waitemata District Health Board, will outline the pilot today in Rotorua to the scientific meeting of the orthopaedic associations of New Zealand and Australia, which has attracted 500 surgeons.

He said it was vital for the future of the public health system to find ways to function more efficiently. The gains in the pilot had enabled the DHB to lower the elective-surgery threshold, meaning patients could be treated who previously would have been denied access because they weren't disabled or sick enough.

But Association of Salaried Medical Specialists executive director Ian Powell said putting surgeons and anaesthetists on higher rates than both their colleagues outside the pilot, and other kinds of senior doctors, was divisive and had caused unhappiness at the DHB.

"Medicine is best when it is practised collectively and collegially as part of team work. This notion cuts across it."

Features of the pilot include moving patients through the system in groups of similar age and gender, and the putting the doctors on different employment arrangements.

Mr Cullen said the national prices in the public sector were, for standard operations, $15,657 for a total hip replacement, and $16,671 for a total knee replacement. The pilot on average saved $1886 (12 per cent) on each hip replacement and $2598 (16 per cent) on each knee.

The pilot began as what the DHB calls "in-sourcing" - contracting with its own surgeons and anaesthetists to do work at the Waitakere public hospital that might otherwise have been "out-sourced" to a private hospital.

Some surgeons and anaesthetists divide their time between public hospitals - where they are paid under either the senior doctors' national collective agreement or an individual agreement - and the private sector, where their income is from patients, ACC and health insurers.

In the pilot, surgeons and anaesthetists are paid a higher rate than they normally receive at Waitemata, with the greatest differential understood to be for the surgeons.

In return, the surgeons carry a greater responsibility for patients than they normally would in the public sector.

"They are responsible for the patient during their stay in hospital ... and are on call at night as well," Mr Cullen said.

"In the (usual) public system you would do the operation then the patient returns to the ward. Thereafter [routine medical] care is through the house surgeons and registrars."

Hospitals have senior doctors on call after-hours, but not necessarily the surgeon who treated a particular patient.

Mr Cullen said the pilot scheme reduced the problems traditionally associated with the handing over of patients between shifts on wards.

"The nurses here (in the pilot) have direct access to the surgeons during the stay the patient is in hospital. That means you have (better) continuity of care."

Spending on consumable materials was reduced in the pilot - from typically $3000 to $600 for a shoulder operation, for instance.

Markers of quality, such as rates of infection and hospital re-admission, were virtually the same as for patients in the traditional system.

The facts:

*Costs reduced by up to 16 per cent.

*Operating time reduced by up to 39 per cent

*Length of average patient hospital stay reduced by up to 41 per cent.