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Willingness to pay for anterior cruciate ligament reconstruction.

Over 100,000 anterior cruciate ligament reconstructions are performed annually in the USA. (1) With reports of good to excellent clinical outcomes exceeding 90%, it continues to be one of the most successful procedures performed in orthopaedics. (2-6) Despite its success, many orthopaedic surgeons are frustrated with reimbursement and believe Medicare and other payors do not pay enough for this surgery.

Declining physician reimbursement has become the rule in our cost-driven health care system. (7) With over 1.9 trillion dollars spent on health care in the USA in 2005, Medicare and insurance plans have placed greater emphasis on the true value of medical and surgical interventions and their ability to improve quality of life. (8) As a result, economic evaluations, such as cost-effectiveness and cost-utility analysis, have been increasingly used in research to complement clinical outcome measures. (9) Recently, the concept of "willingness to pay" has emerged as an additional economic tool. Although it has seen limited study in orthopaedics, it has been evaluated in several health care fields and has helped provide further information on the true value of an intervention to society. (10-13)

To our knowledge, there have been no published studies evaluating willingness to pay and ACL reconstruction. The purpose of the present study was to examine patients' willingness to pay and to compare it to actual reimbursement from Medicare, as well as patient income and activity level. We hypothesize that Medicare and other payors undervalue ACL reconstruction, and that patients are willing to pay more than current reimbursement.


A two page document was constructed and distributed to volunteers. Participants included patients from the senior investigator's office and medical students at our home institution. The first page of the document included a description of the function and limitations of an ACL deficient knee and the expected function after an ACL reconstruction. (14,15) Choice of graft was not included. The second page was a questionnaire.

The primary question was how much in US dollars would the participant be willing to pay out of pocket for an ACL reconstruction. Other questions included age, previous surgery, prior or current knee problems, and annual earnings. Annual earnings were reported per a constructed scale from 1 to 5 (1 = less than $20,000; 2 = $20,000 to $50,000; 3 = $50,000 to $100,000; 4 = $100,000 to $250,000; 5 = greater than $250,000). Lastly, patients were asked to complete a Tegner activity scale. (16)

After collection of all data, we computed correlation coefficients between willingness to pay and both yearly earnings and Tegner activity level. We compared local and national Medicare reimbursement rates for ACL reconstruction with the patient reported amounts.




One hundred forty-three participants completed the survey. There were 79 male and 63 female subjects, with a mean age of 27.6 years (range: 16 to 68 years). Only nine participants reported prior or current problems with the knee, and two patients had undergone ACL reconstruction. The mean amount that the volunteers were willing to pay for an ACL reconstruction was $4,867 (range $250 to $25,000). The two participants having undergone ACL reconstruction reported willingness to pay of $1,500 and $4,800. The mean annual income per the constructed scale was 2.52 out of 5.0 ($20,000 to $50,000). The mean Tegner activity level reported was 4.2 out of a possible 10.

The correlation coefficient between annual income and willingness to pay was 0.34, as shown in Figure 1. The correlation coefficient between Tegner activity level and willingness to pay was 0.81, as shown in Figure 2. The Medicare allowable rate for ACL reconstruction (CPT 29888) in the geographic area of the study was $1,132.


Anterior cruciate ligament reconstruction has been shown to be both a clinically successful and cost-effective procedure, yet physician reimbursement continues to decline. (17) Although legislation has recently maintained reimbursement, reports from the Centers for Medicare and Medicaid Services estimate as much as a 5% annual reduction in physician reimbursement over the next 5 years. (7,18) As many insurance plans are driven by Medicare, there will be increasing pressure on orthopaedic surgeons to not participate with those which reimburse poorly, shifting increasing financial responsibility onto the patient.

The results of the present study suggest that patients may be willing to accept more of this financial burden. Our data demonstrated that patients were willing to pay over 400% of the amount reimbursed for ACL reconstruction by Medicare in our area. This further supports the belief that the benefit ACL reconstruction provides patients is undervalued by current payors.

Willingness to pay is commonly thought to be affected by personal income, but this was not seen in the present study. A weak correlation with Tegner activity level suggests that patients with a higher pre-injury level of activity were willing to pay more to maintain their current state of health. Although two participants had undergone ACL reconstruction, no conclusions could be reached about their willingness to pay.

Few studies have evaluated willingness to pay for interventions in orthopaedic surgery. Cross and colleagues evaluated 143 patients in Australia who had undergone total knee or hip replacement and their willingness to pay 2 to 3 years postoperatively. They found that over 70% of patients were willing to pay "something" for both total knee and hip replacement, with a high correlation with patient satisfaction and pain relief. (19) Direct comparison to the current study, however, was not possible as it evaluated patients in a different health care system.

There were several limitations in the present study. As with any questionnaire, our results are based purely on opinion and interpretation depends on the accurate reporting of respondents. Although participants were given a description of ACL deficiency and postoperative expectations, evaluating patients who underwent ACL reconstruction may provide even greater insight into the value of this procedure. In addition, medical student participants may have been biased in their responses if they had knowledge of current costs and reimbursement.


In conclusion, our data demonstrates that patients are willing to pay much more than traditional payors for ACL reconstruction. This study supports the value of this procedure and suggests that patients may be willing to accept more of the financial burden in our current health care system.

Caption: Figure 1 Patient's income versus amount willing to pay (US dollars) for ACL reconstruction; Income levels; 1 = (< $20,000), 2 = ($20,000 to $50,000), 3 = ($50,000 to $100,000), 4 = ($100,000 to $250,000), 5 = (> $250,000).

Caption: Figure 2 Tegner score versus amount willing to pay (US dollars) for ACL reconstruction.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.


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(12.) Kerger H, Turan A, Kredel M, et al. Patients' willingness to pay for anti-emetic treatment. Acta Anestehsiol Scand. 2007 Jan;51(1):38-43.

(13.) Lewallen S, Geneau R, Mahande M, et al. Willingness to pay for cataract surgery in two regions of Tanzania. Br J Ophthalmol. 2006 Jan;90(1):11-13.

(14.) Hirshman HP, Daniel DM, Miyasaka K. The fate of un-operated knee ligament injuries. In: Daniel DM, Akeson WH, O'Connor JJ (eds): Knee Ligaments: Structure, Function, Injury, and Repair. New York: Raven Press, 1990, pp. 481503.

(15.) O'Brien SJ, Warren RF, Pavlov H, et al. Reconstruction of the chronically insufficient anterior cruciate ligament with the central third of the patellar ligament. J Bone Joint Surg Am.1991 Feb;73(2):278-86.

(16.) Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985 Sep;(198):43-9.

(17.) Gottlob CA, Baker CL, Pellissier JM, Colvin L. Cost effectiveness of anterior cruciate ligament reconstruction in young adults. Clin Orthop Relat Res. 1999 Oct;(367):267-82.

(18.) Kuhn HB: Letter: Letter to MEDPAC regarding the 2007 physician fee schedule. Washington, DC: Centers for Medicare and Medicaid Services, US Department of Health and Human Services, 2006. Available at: ablegratesconfact/downloads/medpac_letter_estimated_2007. pdf. Accessed December 15, 2006.

(19.) Cross MJ, March LM, Lapsley HM, et al. Determinants of willingness to pay for hip and knee joint replacement surgery for osteoarthritis. Rheumatology (Oxford). 2000 Nov;39(11):1242-8.

Michael P. Hall, M.D., is a Chief Resident, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York. Alexis S. Chiang-Colvin, M.D., is an Assistant Professor of Sports Medicine, Department of Orthopaedic Surgery, The Mount Sinai Medical Center, New York, New York. Joseph A. Bosco III, M.D., is Vice Chairman for Clinical Affairs and an Assistant Professor, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York.

Correspondence: Michael P. Hall, M.D., Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, New York, New York 10003;
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Author:Hall, Michael P.; Chiang-Colvin, Alexis S.; Bosco, Joseph A., III
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2013
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