Republic of Ireland Reimbursement Scheme: ROI How to apply.

There are over 30 consultant orthopaedic surgeons based here in the sports surgery clinic specialising in all aspects of the skeletal body: the knee, hip, shoulder, elbow, wrist, hand, plastic surgery, spine, foot and ankle.

Knee Arthroscopy

Some of the common conditions people would present with would be sporting type injuries, the typical twisting knee that people may experience, we do a lot of arthroscopic surgery. For someone who has a meniscal tear, this involves a keyhole surgery where you have two small little nixes and you go in to remove any loose fragments of the meniscus or cartilage tissue and smooth away the loose fragments and that’s a very common surgery performed here.

ACL tear

Anterior Cruciate Ligament tear also typically a lot of athletes would present with that. It’s normally a twisting injury to the knee as someone’s running at pace and goes to step off the foot and turn and their knee will normally buckle on them and cause an ACL tear. What that normally involves is taking tissue from another part of the knee. It can be one of your hamstring tendons or your patella tendon and drill two little tunnels. One on the shinbone and one on the thigh bone and pass the new graft material up and fix it with various devices. The picture on the right is an arthroscopic picture (16:42) of a new ACL graft in place there.

Osteoarthritis

Another large majority of cases we deal with is people with osteoarthritis. This normally presents with chronic pain, long-standing pain, people normally unable to walk very far without getting pain in the knee. You may get swelling at night, or pain at night sometimes and probably needing medication to deal with the pain.

What is Osteoarthritis?

It’s a ‘wear and tear’ process on the knee joint itself, you have this shiny material on the end of the knee joint and it helps a smooth gliding of the hinge joint itself and with osteoarthritis basically you get degeneration of that. The picture on the right (17:48) shows the worn away process. This is what an x-ray typically looks like, you can see the picture on the right is completely worn away whereas the other has a nice gap (18:02).

If you present to your doctor initially you are normally given conservative measures to try and deal with the pain and that sometimes consists of weight loss, exercises to try and strengthen up the muscles around the knee and take the pressure off the knee. Painkiller medication sometimes like paracetamol, anti-inflammatories or other times you may need something Codeine based medications. Another conservative measure may be a steroid injection into the knee and if unsuccessful, the next and final step that you may consider is a knee replacement.

A Knee Replacement is essentially shaving away the ends of the bone on the femur and top of the shinbone and putting a metal replacement on either end of that, then a very strong plastic Polyethylene in between that, and that’s your new knee replacement.

On the right-hand side is a picture of what a typical scar might look like after that operation, and this is what a typical x-ray looks like after the surgery as well.

Another option is a partial knee replacement, this is an alternative where you have a very specific ‘wear and tear’ pattern and it’s only on the inside of the knee you may be suitable for this. The advantages of this are that the recovery time it’s slightly quicker, and some people say it feels more like your own knee than a total knee replacement. This is quite a commonly performed operation here as well and it does get good results.

In terms of the aftercare involved of total knee replacement you’re normally in hospital in total 3 days, crutches for about 6 weeks and then it does take a good 6-12 months before you’re back to feeling some level of normality. The initial weeks can be quite tough, it’s all about pushing through and doing as much physiotherapy as you can afterwards to get the movement and strength back in the knee. So getting some physiotherapy sessions is key.

The Hip

Hip osteoarthritis normally the pain presents in the groin you may not be able to walk a significant distance. You may struggle to put on socks and shoes, you get a lot of stiffness and difficulty sleeping with pain.

How do I know if I need a hip replacement?

In terms of options of treatment available; you should go through the conservative line of management first and if all those measures fail you may be considered for total hip replacement. A total hip replacement involves the ball and socket joint. The hip replacement involves removing the ball part of the joint cutting that away and placing an implant down the shaft of the femur and putting a metal socket in the acetabulum and then that’s essentially the new hip joint formed. This is what an x-ray might look like afterwards and a typical scar (22:10).

How long is recovery from a Total Hip Replacement usually?

In terms of rehab for total hip replacement usually, you would stay in the hospital for 3 days in total and on crutches for about 6 weeks.

Rotator Cuff Repairs

A very common shoulder operation performed here is for rotator cuff repairs. Your rotator cuff is a group of four muscles that for into one tendon at the top of the shoulder and those muscles essentially help you lift your arm up and people who have rotator cuff tears will struggle to lift their arm or reaching for something in the cupboard or putting their arms above their head. An operation that’s quite commonly performed is whereby there are some stitches put into the tendon and then the tendon itself is re-attached to the bone that’s done normally arthroscopically, and one of the most common shoulder operations.

Shoulder Impingement

Another common shoulder operation is shoulder impingement. What happens in shoulder impingement is there’s a little bursa, which is a small fluid-filled sac which sits under the top of your shoulder between the ball part of your shoulder and the acromion where sometimes this can get very inflamed and rather than a loss of power it’s more a pain issue where when you lift your arm you get a large shooting pain or your lying in bed at night you feel pain down the side of the shoulder. And that operation is an arthroscopic procedure whereby we go in and remove the inflamed tissue and sometimes remove part of the bone as well which can be a factor in causing the inflammation in the first place, normally that’s a day case surgery and a very commonly performed procedure.

Shoulder Replacement

For conditions of a shoulder which are due to an osteoarthritic change, you may have a total shoulder replacement or a reverse shoulder replacement if your wear and tear is a result of a long-standing problem with the rotator cuff, where it wasn’t able to be repaired and your general change was a result of that, that’s when a reverse shoulder replacement is considered.

The Spine

One of the most common spinal operations is the spinal decompression for sciatic type pain. Your lumbar or vertebral spine consists of multiple bones on top of each other with a gel-like disc between each one and what commonly happens is some of the disc material bulges out and presses on the nerves either side of your spinal cord causing pain radiating down the leg. The operation involves a small cut in the back, going in and removing that to take the pressure off the nerve.

Foot & Ankle

A very common foot operation would be an osteotomy. It’s essentially breaking the bone and realigning it and then fixing it together with some screws and straightening up the first toe. And the common ankle operation would involve an ankle fusion and sometimes if you’re suitable a total ankle replacement is another common operation.

You must be on the waiting list for surgery within the NHS. When you are applying for your funding you will need a letter to confirm that you are on the waiting list. You can get this letter from your GP or your consultant.

Once you have completed the Republic of Ireland Reimbursement Scheme application form you will have to send this form to the address on the form – The National Contact Centre. http://www.hscboard.hscni.net/travelfortreatment/roi-reimbursement/

They are based in Belfast. It takes about 21 days to get approval and the full amount is paid about three weeks after surgery.

Following your surgery, you then send them a copy of a receipt that you’ve paid and then they will pay you back within roughly three weeks.

The cost of surgery is a significant part of the decision making process for people. All surgeries have different costs involved in them and rather than list pricing we would ask you to contact us directly and we will send you an approximate quote. 

Included in the price that we’re going to give you is your first appointment, your pre-assessment which also would include cardiac echo if you need one, consultation and anaesthetic fees, your surgery, hospital stay. Also now included is your COVID screening and post-op appointments, plus x-ray.

What is not included in the price?

Any additional consultations with other specialists? For example, if you had a heart condition. Or you had a condition with your liver and you even didn’t know about it or it’s a pre-existing condition. So you may need to get clearance before surgery from a specialist. So that’s usually an extra fee of approximately two hundred and fifty euro. You may be able to get your own back in Northern Ireland and get a letter of clearance. Any additional investigations that are not part of the normal pre-assessment screening are not included. We normally do X-rays and ECG, so anything outside of that would not be included.

Appointments and surgery can be completed within about 8 to 12 weeks. Before it would have been 6 to 8 weeks. But with COVID restrictions we have a backlog of work to do since closing. It may vary, but that’s something that is subject to change due to the current situation.

How often will I have to visit the Hospital?
We do try and book all your appointments and pre-assessment on the same day to avoid numerous journeys. If you know for example that you have a pre-existing heart condition, we’ll have to do a heart echo assessment. It would be beneficial to inform the secretary so that we’re including that on the same day to avoid another trip to the hospital.

How long will I need to stay in the hospital after my surgery?
This will vary depending on the procedure you have. At the moment, for joint replacements, the total hospital stay is usually 3 days. More minor surgeries are usually a one night stay or carried out as a day case. Your surgeon will inform you at the initial appointment.

What happens if I need to stay longer?
There will not be an extra charge if you need to extend your stay up to 8 nights. There are local hotels, which are in walking distance from SSC, the Crowne Plaza and the Holiday Inn, SSC have corporate rates with both hotels.

Am I entitled to care following my surgery?
The aftercare we provide will be the same as if you had your surgery in Northern Ireland. You are entitled to physiotherapy in the NHS. It’s very important that you start physio within two weeks of going home so maybe book some private sessions first of all while waiting for your NHS appointment. We can also advise on this if you need the name of a physio.

What information do I need to include on the form?
You are not required to fill out every section of the form, only what is applicable to you. Details that are required; your diagnosis, proof of address, proof of bank details and the letter to prove that you are on the waiting list for surgery. It will ask you lots of questions about prescriptions etc. which may not be applicable to you, or questions relating to being abroad which also may not apply to you.

You are also asked where you are having your surgery and which surgeon?

If you do not yet know this information it is ok to say “undecided at this time or to be confirmed”. Your form will still be processed.
If you have any other queries regarding the form you can contact our team who will assist you with this.

What happens if I need to be readmitted due to a problem with my surgery?
If you are to be readmitted within a month of surgery there is no charge, just call us and let us know there’s a problem and we will arrange for you to come back into the hospital.

Can I book an appointment before I get approval for funding?
Presuming that you are on the waiting list already, from dealing with the Cross Border Directive for the last 3 to 4 years and have never come across anyone that’s on the NHS waiting list who hasn’t received funding. What we are telling patients is to get your application form in, it usually takes three weeks to get approval, and all patients that come down here have their approval before they come down.
If you’re not on an NHS waiting list, you won’t get anything back.

Do you need medical insurance for the journey for treatment?
No, there isn’t any insurance that covers you for that. It is mentioned on the form, but that would be applicable where you have been on holiday when the injury occurred.

What is the typical waiting list time frame for hip surgery?
At the moment, due to the current situation, it would be approximately 8-10 weeks for most types of surgery, which you would have your consultation and pre-assessment all complete before then.

I have Osteoarthritis in both hips and wondering if there is a hip resurfacing procedure?
In terms of hip resurfacing no one at this hospital do hip resurfacing, but it may well be worth seeing a hip surgeon just to go over what the options are, for hip resurfacing it’s normally a very specific indication for that generally the track record of a hip resurfacing isn’t as good as a total hip replacement itself, it may well be worth chatting to one of the surgeons to see what the options are basically. If you’re over 40 you’re probably more likely to benefit from an uncemented hip replacement. The liners that they use nowadays are very good a lot of times they would use ceramic on a poly liner which has a good track record. If you’re hitting over 40, you’re probably more likely to benefit from a total hip replacement rather than resurfacing. We have hip specialists here who do hip arthroscopy as well who are specialised, so if you want to give one of us an email on the GP line, we are happy to direct you to one of those consultants.

What way can payment be made? Is it in Euro or Sterling?
All our accounts are in euro; we can’t accept sterling; we don’t have a sterling account. All our quotes that we give are comprehensive; it’s a package that will include your initial consultation, pre-assessment, your surgeon’s fees, your stay in the clinic, anaesthetists fees, a post-op x-ray, a post-op review, a follow-up review and a COVID screen. That will be paid before or on the morning of admission so what we would say is if you wish to pay that directly to our bank account, please do so about five days beforehand as it usually takes about five days to hit our bank account. And to advise anyone that may be paying by card, I’ve had a few patients that have been charge the surcharge by paying with their card which can sometimes be 2-3% which if you’re paying for a hip or knee can amount to €200-300, so ring your bank beforehand and let them know just to make sure there is no surcharge but anyone paying directly to the bank account seems to be the easiest way. We have an online portal you can go on and put in your card details, and there it will automatically issue a receipt. We do accept Euro cheques; however, we don’t accept personal cheques or cash, for patient’s safety.

Does the price change depending on how long you stay in the hospital?
No, it doesn’t, when we give you the price, we will provide you with an idea of how many days you will likely be in the hospital depending on the procedure. For example, for hips and knees, for a hip replacement, our package would include between 5 and 6 nights, and then we will include night 7 and 8 free of charge. This is really to give patients peace of mind, you don’t want to be in a situation where you have to stay for medical reasons and you’re not covered, so you are covered up to 8 nights and anything over that would be quite unusual, and very rarely go beyond that.

Are ankle fusions performed at the UPMC Sports Surgery Clinic?
Most of our foot and ankle specialists don’t do ankle fusions unless maybe you have a referral specifically for this procedure they could review and decide if you are suitable. If you do have a referral for this procedure, certainly do send it into gp@sportssurgeryclinic.com and we can have it reviewed by our foot and ankle specialists, and make a decision.

Will the cross border scheme expire?
The cross border scheme is valid until 31st December 2020 obviously, we have lost 3 months of this year due to the pandemic. We don’t know yet whether they will extend that on to maybe the 31st March 2021 we haven’t been made aware yet. However, once you get your approval it is valid for 9 months.

Are Osteotomies performed here?
We do perform Osteotomies, tibial osteotomies and sometimes femoral osteotomies. Normally it’s either an opening wedge osteotomy of the tibia or closing wedge osteotomy of the femur. But rotational osteotomies, again I don’t think there are any of the consultants here that perform rotational osteotomies, it would be quite specific and probably would need to see the patient to take a look and see exactly what is required. We can take a look at the referral letter and see whether it’s suitable for here or not.

How much is refunded by the NHS?
We have found that it’s about 50-60% that you will be refunded. You are refunded in sterling and the prices that we quote are in euro so just to give you an example so let’s say if you were to come in for a hip replacement, what we would charge for the hip replacement is €12,338 as explained earlier is a comprehensive package, includes everything. What you would get back from the cross border is £6,500 to give an approximate idea of what you would receive back from the cross border.

Would you have to have a Hip replacement before a knee replacement if both are needed?
Not necessarily, it depends which pain is worse. It would be a case of having to review the person to have a chat and assess, but not necessarily no.

How long after a knee replacement would you recommend that someone goes back to work? And what about driving?

It depends on exactly what job you are doing but in general about 4-6 weeks before you can go back, if it’s an office job maybe you’ll get back a bit sooner or if it’s something heavier again it might take a bit longer. For driving it would be a similar time frame as well about 4-6 weeks.

For a rotator cuff, how long will it take to get an appointment?
The current waiting list is about 6 weeks for a consultation and for surgery, roughly about 6-8 weeks.

Click here to download the application form for the  Republic of Ireland Reimbursement Scheme 2021.