The number of hip and knee replacements in the U.S. has risen dramatically, costing more than $20 billion in 2014, but millions could be saved by reducing unnecessary procedures and capping the price of the procedures, UCLA researchers said in an opinion piece published in JAMA: The Journal of the American Medical Association on March 13.
The paper was published in JAMA in conjunction with a study that found that the U.S. spent a much higher portion of its gross domestic product on healthcare than 10 other high-income countries, yet ranked near the bottom of the countries in smoking, obesity and life expectancy.
And U.S. healthcare spending is only expected to grow further, by 5.5% a year, 1 percentage point faster than the overall economy, according to a Feb. 14 Centers for Medicare and Medicaid Services report.
The UCLA researchers acknowledged that hip and knee replacements can be "life-changing" for some. "These procedures effectively treat chronic and sometimes debilitating joint pain," wrote Dr. Steven Teutsch, Jonathan Fielding and Vanessa Lam, all with the UCLA Center for Health Advancement.
But "elective joint replacements could represent an area for significant savings," said Fielding, also a professor at UCLA's Fielding School of Public Health and the David Geffen School of Medicine, in a press release.
Citing a 2017 Organisation for Economic Co-operation and Development study, the UCLA researchers wrote that both hip and knee replacements increased by 22% between 2005 and 2010.
As a result, the procedures were done at greater rates in the U.S. than in 10 other wealthy countries: the U.K., Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland and Denmark.
In 2010, the 204 hip replacements per 100,000 people in the U.S. outpaced the 166 per 100,000 done in the other countries. In the U.S., 226 out of every 100,000 had a knee replacement, compared to 126 in the other countries.
Particularly striking was an increase in joint replacements in the U.S. among those ages 45 to 64. While the number of people in that age group rose by 29% between 1999 and 2008, the number of people in that range getting joint replacement surgery tripled from 78,780 to 252,170, the researchers said, citing a 2012 study in The Journal of Bone and Joint Surgery.
That could mean an increase in costly replacements because replacement joints typically last only 20 years, the UCLA researchers wrote.
Noting a 2014 study published in the journal Arthritis & Rheumatology that found that a third of knee replacements were inappropriate, the UCLA researchers said reducing the procedures in the U.S. by a third would save U.S. payers $8.3 billion annually.
Teutsch, an adjunct public health professor at UCLA, said in an interview that the researchers had not examined the reason for the disparity with other countries but suspected a number of factors played a role, including the availability of knee and hip replacements in the U.S.
Providing more information about the risks and benefits of undergoing the elective surgery could reduce the number of patients choosing to get new hips or knees, the researchers said, citing a 2016 study in the journal Osteoarthritis and Cartilage.
That study found that patients were less likely to choose the surgery — 73.2% compared to 80.5% — if a video or another visual decision-making tool was shown.
In addition, UCLA researchers said there are ways to reduce the cost of the joint replacements. The $7 billion that Medicare spent on hip or knee replacements in 2015 varied widely, costing as little as $9,723 per procedure in one state to almost twice as much, $17,604, in another state.
Capping hip or knee replacement payments at the mean Medicare payment of $13,000 would save the program $4.4 billion, the UCLA researchers said.
But Teutsch acknowledged that "fairly powerful interests" would likely oppose cutting prices. The Advanced Medical Technology Association, which represents medical technology companies, and the American Academy of Orthopaedic Surgeons, did not have an immediate comment on the paper.
The researchers also said nondisclosure agreements prevent purchasers from knowing how much others are paying to negotiate lower prices. In addition, the UCLA researchers said Medicare reimburses $9,913 for outpatient knee replacements and $12,381 for inpatient procedures.
If one-fourth of the inpatient procedures were performed on an outpatient basis, the Medicare program could save $714 million a year, the researchers said.
