Waiting game

by Jamie Moorhouse

Employers are paying the price while their employees wait for hip and knee replacement surgery.

For two years Ken Carruthers lived in pain--so much that he had to take a two-year absence from his job and go on disability.

Carruthers, 49, an electrician at Coldstream Concrete in Ilderton, Ont., suffers from arthritis and waited two years for a hip replacement. He relied on painkillers to tide him over until the surgery, which he finally received in December 2000.

"I met a lot of people who were getting the same kind of procedure, and they were waiting a long time too," he says.

Fortunately, Carruthers' employer was flexible. "They were very accommodating," he says. "When it got to the point that I couldn't work, they just said 'OK, when you get done there's a good place here for you.' They were excellent."

More than 40,000 hip and knee replacements are performed in Canada each year, and that number is rising annually because of an aging population, says the Canadian Institute for Health Information.

According to the first annual report from the Canadian Joint Replacement Registry, between 1994/95 and 1999/2000 there was a 45.2% increase in the number of total knee replacement surgeries in Canada, and a 19.3% increase in total hip replacement surgeries.

The median waiting times for these procedures vary across the country, depending on age, geography, urgency and scarcity of resources. And different jurisdictions and health organizations define waiting times differently.

The Institute for Clinical Evaluative Sciences (ICES) monitors waiting times from the date of orthopedic consultation to the date of surgery. In Ontario, the median waiting time for hip procedures was approximately 139 days, or almost five months in 2000. For knee procedures, the median waiting time was 181 days, or six months, in 2000.

Nationally, the median waiting time for joint replacement surgery can reach nine months, up from close to six months in 1999, says the Fraser Institute's latest survey, Waiting Your Turn: Hospital Waiting Lists in Canada.

In the meantime, employers are bearing much of the financial burden while their employees wait for surgery.

In 1997, bone and joint-related disorders, such as arthritis, accounted for $17.9 billion in lost productivity, or more than $49 million per day, say The Arthritis Society (TAS) and Canadian Orthopaedic Association (COA).

Of the 18% of Canadians suffering from bone and joint-related disorders, almost two-thirds are under 65 and of working age, says Dr. Elizabeth Badley, director of the Arthritis Community Research and Evaluation Unit at the Toronto Western Research Institute. A lot of them have to give up work because of the pain, she says.

Some patients waiting for joint replacement can work at first, says Dr. Michael Stanger, an orthopedic surgeon practising in Victoria, and past president of the B.C. Orthopaedic Association. "But as time goes on, you become less able to work because of the pain. It could be six months, or it could be several years that it gradually deteriorates and gets worse."

And the longer the wait, the bigger the impact on the patient's ability to work, says Marg Bellman, principal of Marg Bellman and Associates, a disability management consulting firm in Georgetown, Ont. "The longer the delay from the point of disability to the time the person is treated, the longer the return to work," she says.

For patients who aren't able to work, there's a financial cost for the employer, says Dr. Arif Bhimji, president of At Work Health Solutions Inc. in Concord, Ont. "Costs are definitely going to go up," he says. He says those costs include lost productivity, income replacement and the cost to hire and train replacement workers.

Dr. Bhimji says there's a quality of life issue too. "These people, even when they were at work, were probably only at 60% or 50% of what they were capable of working at, until they became so ill they couldn't come into work."

Long-term disability claims due to waits for hip and knee replacement surgery are on the rise, says Brenda Rusnak, CEO, Active Health Management, based in Toronto. "It used to be a short-term disability because they would get in for surgery and back to work within three months. And now what's happening is that's rolling into long-term."

Bellman says some employers are trying to help employees stay on the job before they become so disabled they have to leave. One popular means of intervention is making the workplace ergonomically friendly. "Many workplaces either have workplace ergonomists, or are turning to ergonomists to come in and look at the workplace," she says.

Some employers are getting employees waiting for surgery into rehabilitation programs, offers Rusnak. "That keeps them in shape," she says. "You don't want somebody . . . going off and sitting around for two months, because they get used to that lifestyle." Rusnak says half-day rehab programs motivate patients to get up and be somewhere--they get into a routine again.

"By keeping them in shape prior to surgery, at least you can cut down on the recovery time--it can cut two or three weeks off," she says.

Other employers are taking their involvement in their employees' health a step further. Jane Petruniak, a consultant at Watson Wyatt in Toronto says her clients near the border aren't shy about sending employees to the U.S. to avoid the long waiting lists in Canada.

According to Rusnak, more employers are considering that option. "Clearly, there's a need for privately paid surgeries," she says. "When you look at how much is being spent on keeping people on waiting lists versus how much the actual surgery would cost an employer or insurance company, the longer waiting lists get, the more sense it makes to pay for surgery."

Rusnak says 10 years ago employers weren't convinced of the business case for getting involved. Now, she says, it's very clear to them it's easy to do a cost-benefit analysis, showing them even though there's money spent on getting people into private centres, there's a huge cost-savings on the back-end. "What you have is an increased likelihood of this individual actually returning to work."

But employers should be careful about their level of involvement. Petruniak says if an employer refers an employee to a particular clinic, and "something doesn't go quite right," the employer could be found liable. "That said, whenever possible I think employers would rather try to help an employee fast-track," she says.

Each employer has to decide what to do, if anything at all, says Petruniak. She points to the U.S. where many employers got more involved in arranging care for employees. "They're now back-pedalling very fast," she says. "They're trying to put more of that emphasis on the employee. We have decided the employer's position is as a facilitator, rather than a provider, of access." The trend in the U.S. is to get more employees to help themselves by picking their own providers, she says. "For an employer to get involved is a bit of a Pandora's box."

The wait DEPENDS on where you live

• Saskatchewan: 23 months
• New Brunswick: 19 months
• British Columbia: 11 months
• Alberta: 10 months
• Quebec: 7 months
• P.E.I.: 7 months
• Ontario: 7 months
• Manitoba: 6 months
• Nova Scotia: 6 months
• Newfoundland: 6 months