Orthopedics: What Is It, and Does Medicare Cover It?

Orthopedics, sometimes spelled orthopaedics, is a branch of medicine that prevents and corrects problems affecting the bones and muscles. According to a 2018 study published in The Journal of Bone and Joint Surgery, joint replacements are one of the most commonly performed elective surgical procedures in our country.

As joint replacements become more and more common, we thought it was time to reach out to a local expert for more information. 

We turned to Dr. Jacob D. Sams, MD, a board-certified orthopedic surgeon at Decatur Orthopedic Center (DOC), for some insights. DOC does over 1,000 joint replacements per year, and about 60% of their patient base is 65 or older. 

Dr. Sams has provided some excellent insights into orthopedics, and he even gives a physician’s perspective on Medicare Supplements vs. Medicare Advantage.

What Is Orthopedics?

Orthopedics is a specialty of medicine that focuses on the non-surgical and surgical care of bone disorders. Think fractures, broken bones, and hip or knee replacements.

Ortho comes from the Greek orthos, meaning “straight or right,” and pedics comes from the Greek paideia, meaning “child or children.” Many orthopedic patients are children, but as our population ages, that has started to shift.

We’re living longer, and seniors are more active than ever before. Older adults often have arthritis, joint problems from obesity, and pain from past traumas.

Dr. Sams explains that knee arthritis is the most common ailment he helps treat. A close second is hip arthritis. 

“There are a tremendous number of people that have degenerative joints, so they have pain. They look to us to help with pain relief,” he says.

When Pain Impacts Your Life

Joint pain (from hips, knees, and shoulders) is typically the reason people come to see Dr. Sams. Pain keeps you from doing the things you enjoy, and when it gets bad enough, it can even hinder the activities of daily living (things like bathing and dressing).

All too often, people choose to keep living in pain rather than get it resolved. For many, it’s the fear of surgery. And for others, they’ve gotten so used to the pain they don’t remember what it’s like to be pain-free. 

“You don’t need to wait until you’re disabled or can’t move,” Dr. Sams says. “There are things we can do to help you mitigate that pain and allow you to function. Surgery is always the last resort.”

You know it’s time to see Dr. Sams when you’re experiencing symptoms like:

• Pain
• Stiffness
• A sense of fullness in your joint
• Limited range of motion

“People come in all the time with destroyed joints, and surgery is the only true, viable option. But most of the time, we can try other things, and they get a taste of what it’s like to be pain-free,” Dr. Sams explains.

Arthritis

Dr. Sams explains that arthritis is often the cause of joint pain, and unfortunately, it’s not always preventable. Arthritis is part genetic, and sometimes, it’s related to a trauma that happened decades earlier in life.

The good news is that while you can’t always prevent it, you can slow down the symptoms.

“We use medications – some are over-the-counter, and some are prescription – as well as injections. When that all fails, we start discussing surgical intervention,” Dr. Sams says.

Joint Replacements Aren’t What They Used to Be

Advancements in orthopedics have made it possible to recover in record time. In the past, you’d be in the hospital for three or more days before you’d be moved to a skilled nursing facility. Now, with advancements in technique and rehab protocols, Dr. Sams does a significant number of joint replacements as outpatients.

“That’s truly very new,” he says.

With DOC’s outpatient joint program, you can have your surgery in less than an hour and go home the same day. “It doesn’t take months to recover anymore,” he explains. “In many cases, it takes weeks.”

Besides the fast recovery, outpatient surgery is much more affordable than surgery in a hospital. Dr. Sams has seen hospital bills from his patients that top $50,000. “The majority of that expense is the hospital – not us,” he says.

Having a procedure done as an outpatient is a cost savings to our system as a whole, but more importantly, Dr. Sams says it’s truly better for the patient.

Medicare and Orthopedics

Hip and knee replacements are more common than you might think. “A little-known fact is that hip and knee replacements account for the Number 1 and 2 expenditures for Medicare,” Dr. Sams explains.

Medicare helps cover medically necessary surgical procedures. Dr. Sams explains that, for the most part, he doesn’t have to worry about Medicare refusing to cover one of his procedures or treatments.

“We use a lot of evidence-based medicine. When you get into unproven treatments like stem cells, Medicare doesn’t cover it, because it’s not proven,” Dr. Sams explains.

Getting treatment or a procedure that is Medicare-approved is only the first hurdle. If you don’t have a Medicare Supplement, you’re still responsible for your portion of the cost-sharing.

Those costs will vary dramatically depending on whether you’re considered inpatient or outpatient – Medicare has an inpatient or outpatient chart explaining a variety of situations.

Read more: “Observation Status” vs. “Inpatient Status” – The Difference Could Cost You Thousands

Medicare Supplement and Orthopedics

Without a Medicare Supplement, you don’t honestly know what your costs will be until you get the bill. However, if you have a Medicare Supplement, you’ll have low – or no – out-of-pocket expenses. Your costs will depend on the plan type, so here are your out-of-pocket expenses for a few popular plans:

• Plan F: $0
• Plan G: $198 Part B deductible (as of 2020)
• Plan N: $198 Part B deductible (as of 2020) and possible copay of up to $20 for some office visits

Note: Plan F is phasing out. If you are or were eligible for Medicare Part B before January 1, 2020, you will still be able to buy a Plan F. If you become eligible for Medicare after January 1, 2020, you won’t be able to purchase a Plan F.

Medicare Advantage and Orthopedics

Medicare Advantage, an alternative to Original Medicare, is health insurance sold by private companies. Dr. Sams is not a fan of Medicare Advantage.

“From the physician’s perspective, there are more hoops to jump through with Medicare Advantage,” he explains.

For example, he’ll have a patient that’s ready for a hip replacement. With Medicare Advantage plans, you often have to go through a pre-approval process that’s difficult and time-consuming. Medicare Advantage plans can also change your treatment plan if they want to – and that has happened to one of Dr. Sams’ patients.

“I’ll never forget a patient that was told a bunch of misleading things, and when the time came for surgery, their MA plan basically said they hadn’t suffered enough and had to do several more weeks of therapy,” Dr. Sams explains. 

In Dr. Sams’ opinion, that’s not the insurance company’s job, and he fears that many consumers out there aren’t aware of this kind of thing unless they’re in the situation – and at that point, it’s too late. 

“I hands down prefer Medicare with a supplement compared to a Medicare Advantage plan,” he says. He feels he’s better able to help his patients and experiences fewer roadblocks.

Don’t Live in Pain!

It's easy to get used to living in pain when you live with it every day of your life. However, Dr. Sams is confident he can help improve your quality of life with the latest orthopedic advancements.

“We take great pride in offering our community the latest treatments in orthopedics,” he says.

To make sure you don’t get stuck with any hefty out-of-pocket expenses, we recommend a Medicare Supplement, which is also Dr. Sams’ first choice.

You can learn more about Medicare Supplements here: Medicare Supplement Insurance in Illinois

If you have any joint pain, stiffness, or a limited range of motion, schedule an appointment with Dr. Sams by calling the Decatur Orthopedic Center at 217-864-2665.

Dr. Jacob D. Sams, MD, is a board-certified orthopedic surgeon at Decatur Orthopedic Center. Dr. Sams received his medical degree from Southern Illinois University - School of Medicine in Springfield, IL. His special interests include joint reconstruction of the hip, knee, and shoulder, sports medicine, and trauma.