Lining up for Joint Replacement. Panelists Dr. Shelley Rahn, MassMutual Joe Furlong, RGA Reinsurance Elizabeth Roberge, MassMutual.

Lining up for Joint Lining up for Joint ReplacementReplacement

Panelists

•Dr. Shelley Rahn, MassMutual

• Joe Furlong, RGA Reinsurance

•Elizabeth Roberge, MassMutual

Session ObjectivesSession Objectives

• Anatomy of KneeAnatomy of Knee

• Discuss OA/DJD processDiscuss OA/DJD process

• Underwriting ConsiderationsUnderwriting Considerations

• Claim/CaseClaim/Case

• Impact of Joint Replacement on Impact of Joint Replacement on disability and LTCi claimsdisability and LTCi claims

Knee Anatomy

Osteoarthritis of the knee

•Decrease in cartilage

• Joint space narrowing

•Bone on bone

•Bone cysts

•Bony spurs – osteophytes

•Pain

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).

Loose body

osteophytes

Normal KneeOsteoarthritic Knee

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 DJDRisk of Developing Knee DJD

• Age - single biggest risk factorAge - single biggest risk factor• Obesity –increased impact with rising Obesity –increased impact with rising

incidence of obesity incidence of obesity • TraumaTrauma• GeneticsGenetics• Muscle weakness – especially quadsMuscle weakness – especially quads• Repetitive use – e.g., heavy lifting, Repetitive use – e.g., heavy lifting,

bendingbending

Knee Osteoarthritis Epidemiology

• Highly prevalent among adultsHighly prevalent among adults– Prevalence estimates vary widely by:Prevalence estimates vary widely by:

•symptomssymptoms

•X-ray – as high as 50% by age 65X-ray – as high as 50% by age 65

• Strongly linked to late-life disabilityStrongly linked to late-life disability

• Major cause of musculoskeletal painMajor cause of musculoskeletal pain

Underwriting ConcernsUnderwriting Concerns

• PainPain– Presence and severity is single most important Presence and severity is single most important

factor in shaping factor in shaping perceptionperception of disability of disability• Xrays with substantial osteoarthritic changes Xrays with substantial osteoarthritic changes

^^risk of progression of symptoms^^risk of progression of symptoms• Task modification often precedes self-reported Task modification often precedes self-reported

task difficulty task difficulty • Quadriceps weakness:strongest single predictor Quadriceps weakness:strongest single predictor

of functional limitationof functional limitation• Co-morbiditiesCo-morbidities

– Depression/AnxietyDepression/Anxiety– ObesityObesity

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

ClaimsClaimsThe challenge at claim time is to: The challenge at claim time is to:

• Manage the expectations of the Manage the expectations of the claimant and family.claimant and family.

• Determine expected length of ADL Determine expected length of ADL deficiency.deficiency.

• Determine when recovery has been Determine when recovery has been achieved and the Benefit Triggers achieved and the Benefit Triggers are no longer being satisfied. are no longer being satisfied.

TQ vs. Non-TQTQ vs. Non-TQ

• There is a good chance of qualifying There is a good chance of qualifying for benefits on pre-HIPAA and other for benefits on pre-HIPAA and other Non-TQ Policies.Non-TQ Policies.

• Few claims will satisfy the Chronically Few claims will satisfy the Chronically Ill Individual requirement on TQ Ill Individual requirement on TQ Policies but it can happen, especially if Policies but it can happen, especially if there are complications. there are complications.

Case StudyCase Study

• What can go wrong – a challenging What can go wrong – a challenging case studycase study

Case DemographicsCase Demographics

• At policy issue;At policy issue;– 44 yo male44 yo male– 6’ 205 lbs6’ 205 lbs– Meat Department Manager for a large Meat Department Manager for a large

grocery store chaingrocery store chain– Benign medical history, essential HTN Benign medical history, essential HTN

controlled with 100 mg Tenormincontrolled with 100 mg Tenormin

At time of claimAt time of claim• 59 yo male59 yo male

• 6’ 260 lbs6’ 260 lbs

• History of severe constant bilateral History of severe constant bilateral knee pain for the past several yearsknee pain for the past several years

• On examination moderate crepitance On examination moderate crepitance and minimal varus deformityand minimal varus deformity

• Range of motion is 0 to 135 Range of motion is 0 to 135 ºº

• Weight bearing X-ray examination Weight bearing X-ray examination shows severe degenerative joint shows severe degenerative joint disease disease

Valgus Normal Varus

At time of claimAt time of claim• 59 yo male59 yo male

• 6’ 260 lbs6’ 260 lbs

• History of severe constant bilateral History of severe constant bilateral knee pain for the past several yearsknee pain for the past several years

• On examination moderate crepitance On examination moderate crepitance and minimal varus deformityand minimal varus deformity

• Range of motion is 0 to 135 Range of motion is 0 to 135 ºº

• Weight bearing X-ray examination Weight bearing X-ray examination shows severe degenerative joint shows severe degenerative joint disease 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 PlanTreatment Plan

• Insured failed to benefit from non Insured failed to benefit from non operative treatmentoperative treatment

• Bilateral total knee replacements Bilateral total knee replacements were scheduled for January 18 2011were scheduled for January 18 2011

Surgery and RecoverySurgery and Recovery• 01/18/11 bi lateral total knee replacements01/18/11 bi lateral total knee replacements

• 02/04/11 wound healing, sensory and motor 02/04/11 wound healing, sensory and motor without deficit, knee range of motion 50-without deficit, knee range of motion 50-9090ºº; patient walking with a moderate ; patient walking with a moderate antalgic gait with the aid of a walker antalgic gait with the aid of a walker

• 2/05/11 PT going well until yesterday, both 2/05/11 PT going well until yesterday, both knees stiffening. Mild erythema of the right knees stiffening. Mild erythema of the right knee, range of motion 5-80knee, range of motion 5-80ºº

ComplicationsComplications

• 03/04/11 Bilateral closed knee 03/04/11 Bilateral closed knee manipulation 5 weeks of physical therapy, manipulation 5 weeks of physical therapy, Keflex 500 mg 4x day for 10 days. Patient Keflex 500 mg 4x day for 10 days. Patient to advance physical activities as tolerated. to advance physical activities as tolerated.

• 03/18/11 No erythema, warmth or 03/18/11 No erythema, warmth or effusion. Gait is within normal limits. Knee effusion. Gait is within normal limits. Knee range of motion 5-105range of motion 5-105º Physical therapy º Physical therapy 3x week, for six weeks. Antibiotic 3x week, for six weeks. Antibiotic prophylaxis and DVT prophylaxis.prophylaxis and DVT prophylaxis.

• Advance activities as tolerated.Advance activities as tolerated.

Complications ContinuedComplications Continued• 4/1/2011 Moderate effusion on both 4/1/2011 Moderate effusion on both

knees, worse on left. Left knee range knees, worse on left. Left knee range of motion 0-91of motion 0-91º, right 0-98º.º, right 0-98º.

• Additional physical therapy prescribed; Additional physical therapy prescribed; patient remains dependent on walker patient remains dependent on walker and needs assistance of HHA.and needs assistance of HHA.

• 5/13/2011 25/13/2011 2ndnd bilateral knee closed bilateral knee closed manipulation manipulation

• 7/20/11 severe contracture of the left 7/20/11 severe contracture of the left kneeknee

Complications ContinuedComplications Continued

• 7/29/11 left knee arthroscopy, 7/29/11 left knee arthroscopy, debridement of arthrofibrosis, lateral debridement of arthrofibrosis, lateral patellar retinacular releasepatellar retinacular release

• 9/9/11 post op visit, minimal pain 9/9/11 post op visit, minimal pain relief noted, 8 weeks of PT prescribedrelief noted, 8 weeks of PT prescribed

January 2012January 2012

• 01/10/12 Patient continues to require a 01/10/12 Patient continues to require a walker and assistance of HHA. PET scans walker and assistance of HHA. PET scans reveals infected bilateral knee reveals infected bilateral knee arthroplasties.arthroplasties.

• New surgical consult, recommendation for 2 New surgical consult, recommendation for 2 stage bi lateral procedures, possibly 4 stage bi lateral procedures, possibly 4 separate surgeries for antibiotic spacers separate surgeries for antibiotic spacers followed by re-implantation of right, then followed by re-implantation of right, then left. Surgeries and recovery expected to last left. Surgeries and recovery expected to last 12 months. Patient may not recover to pre 12 months. Patient may not recover to pre morbid level of functioning.morbid level of functioning.

Physical Therapy NotesPhysical Therapy Notes

• What should we be looking at to What should we be looking at to determine progress toward recovery?determine progress toward recovery?

• How are they deciphered?How are they deciphered?

Claim ManagementClaim Management• Frequent contact with the claimant is Frequent contact with the claimant is

key. “How did PT go today? How is the key. “How did PT go today? How is the caregiver helping you?”caregiver helping you?”

• The claimant should have the The claimant should have the expectation that they will recover and expectation that they will recover and that at some point, care will no longer be that at some point, care will no longer be required and benefits will end.required and benefits will end.

• Managing these claims properly will take Managing these claims properly will take time but it will be worth it in the long time but it will be worth it in the long run.run.

Closing a ClaimClosing a Claim

• How is this communicated to the How is this communicated to the claimant? Should not be a surprise.claimant? Should not be a surprise.

• Prior communication with the Prior communication with the claimant is key to success here, claimant is key to success here, assuming you have set the assuming you have set the appropriate expectation.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?Questions?