Lining up for Joint
Replacement
Panelists
• Dr. Shelley Rahn, MassMutual
• Joe Furlong, RGA Reinsurance
• Elizabeth Roberge, MassMutual
Session Objectives
• Anatomy of Knee
• Discuss OA/DJD process
• Underwriting Considerations
• Claim/Case
• Impact of Joint Replacement on disability
and LTCi claims
Knee Anatomy
Osteoarthritis of the knee
• Decrease in cartilage
• Joint space narrowing
• Bone on bone
• Bone cysts
• Bony spurs – osteophytes
• Pain
Osteoarthritic Knee
Normal Knee
osteophytes
Loose
body
A lateral radiograph of the knee is shown demonstrating significant OA of the
patellofemoral compartment. There are prominent osteophytes (white arrows)
and joint space narrowing (red arrow). Large ossified intra-articular loose bodies
are also incidentally present (blue arrow).
Osteoarthritis
• Primary
– “wear and tear”
– More likely to be bilateral
– Other joints affected (hands, hips, back)
• Secondary
– Due to injury or trauma
– May be unilateral
Risk of Developing Knee DJD
• Age - single biggest risk factor
• Obesity –increased impact with rising
incidence of obesity
• Trauma
• Genetics
• Muscle weakness – especially quads
• Repetitive use – e.g., heavy lifting,
bending
Knee Osteoarthritis Epidemiology
• Highly prevalent among adults
– Prevalence estimates vary widely by:
• symptoms
• X-ray – as high as 50% by age 65
• Strongly linked to late-life disability
• Major cause of musculoskeletal pain
Underwriting Concerns
• Pain
– Presence and severity is single most important factor
•
•
•
•
in shaping perception of disability
Xrays with substantial osteoarthritic changes  ^^risk
of progression of symptoms
Task modification often precedes self-reported task
difficulty
Quadriceps weakness:strongest single predictor of
functional limitation
Co-morbidities
– Depression/Anxiety
– Obesity
Knee replacement
Partial (compartment) knee
replacement
Post Knee replacement disability
• Recovery
– Gradual improvement over 3 months but ADL’s within first days to weeks
to first month
– Can improve up to one year post op
• Pain
– 10% to 34% after knee replacement at 3 years
• Disability
– Significantly less than preoperative
– Affected by same factors as risk of progression
•
• Motivation
• Obesity
• Quadriceps strength
Life expectancy of the replacement – now up to 20 years
– Can just replace the liner without needing complete new joint
Claims
The challenge at claim time is to:
• Manage the expectations of the claimant
and family.
• Determine expected length of ADL
deficiency.
• Determine when recovery has been
achieved and the Benefit Triggers are no
longer being satisfied.
TQ vs. Non-TQ
• There is a good chance of qualifying for
benefits on pre-HIPAA and other Non-TQ
Policies.
• Few claims will satisfy the Chronically Ill
Individual requirement on TQ Policies but
it can happen, especially if there are
complications.
Case Study
• What can go wrong – a challenging case
study
Case Demographics
• At policy issue;
– 44 yo male
– 6’ 205 lbs
– Meat Department Manager for a large grocery
store chain
– Benign medical history, essential HTN
controlled with 100 mg Tenormin
At time of claim
• 59 yo male
• 6’ 260 lbs
• History of severe constant bilateral knee
pain for the past several years
• On examination moderate crepitance and
minimal varus deformity
• Range of motion is 0 to 135 º
• Weight bearing X-ray examination shows
severe degenerative joint disease
Valgus
Normal
Varus
At time of claim
• 59 yo male
• 6’ 260 lbs
• History of severe constant bilateral knee
pain for the past several years
• On examination moderate crepitance and
minimal varus deformity
• Range of motion is 0 to 135 º
• Weight bearing X-ray examination shows
severe degenerative joint disease
In the knees, primary OA predominately involves the medial tibiofemoral and
patellofemoral compartments. The asymmetric medial joint space loss (white
arrow) causes a varus deformity on standing radiographs. A large osteophyte
classically forms on the medial tibial articular margin (red arrow). Subchondral
sclerosis and cyst formation may also be found.
Treatment Plan
• Insured failed to benefit from non
operative treatment
• Bilateral total knee replacements were
scheduled for January 18 2011
Surgery and Recovery
• 01/18/11 bi lateral total knee
replacements
• 02/04/11 wound healing, sensory and
motor without deficit, knee range of
motion 50-90º; patient walking with a
moderate antalgic gait with the aid of a
walker
• 2/05/11 PT going well until yesterday,
both knees stiffening. Mild erythema of
the right knee, range of motion 5-80º
Complications
• 03/04/11 Bilateral closed knee manipulation 5
•
•
weeks of physical therapy, Keflex 500 mg 4x day
for 10 days. Patient to advance physical
activities as tolerated.
03/18/11 No erythema, warmth or effusion.
Gait is within normal limits. Knee range of
motion 5-105º Physical therapy 3x week, for
six weeks. Antibiotic prophylaxis and DVT
prophylaxis.
Advance activities as tolerated.
Complications Continued
• 4/1/2011 Moderate effusion on both
knees, worse on left. Left knee range of
motion 0-91º, right 0-98º.
• Additional physical therapy prescribed;
patient remains dependent on walker and
needs assistance of HHA.
• 5/13/2011 2nd bilateral knee closed
manipulation
• 7/20/11 severe contracture of the left
knee
Complications Continued
• 7/29/11 left knee arthroscopy,
debridement of arthrofibrosis, lateral
patellar retinacular release
• 9/9/11 post op visit, minimal pain relief
noted, 8 weeks of PT prescribed
January 2012
• 01/10/12 Patient continues to require a walker
•
and assistance of HHA. PET scans reveals
infected bilateral knee arthroplasties.
New surgical consult, recommendation for 2
stage bi lateral procedures, possibly 4 separate
surgeries for antibiotic spacers followed by reimplantation of right, then left. Surgeries and
recovery expected to last 12 months. Patient
may not recover to pre morbid level of
functioning.
Physical Therapy Notes
• What should we be looking at to
determine progress toward recovery?
• How are they deciphered?
Claim Management
• Frequent contact with the claimant is key.
“How did PT go today? How is the
caregiver helping you?”
• The claimant should have the expectation
that they will recover and that at some
point, care will no longer be required and
benefits will end.
• Managing these claims properly will take
time but it will be worth it in the long run.
Closing a Claim
• How is this communicated to the
claimant? Should not be a surprise.
• Prior communication with the claimant is
key to success here, assuming you have
set the appropriate expectation.
Knee Replacements: Summary
• Generally, should not trigger a claim on a
TQ policy
• Premorbid condition is often worse than
eventual post op
• Long term complications are infrequent
• Managing the claim is key
Questions?