By Jeffrey Binder , CEO, Biomet

U.S. healthcare policymakers are understandably interested in reducing spending on unnecessary and ineffective care. To that end, in some regions of the U.S., Medicare has identified total joint replacement surgery, a highly successful and cost-effective procedure, as presenting potential opportunities for reducing improper payments and utilization.

Several regional Medicare payment administrators have determined that, in order for total joint replacement to be considered "medically necessary," the patient must have failed "conservative care."

Ironically, rather than improving outcomes and reducing costs, these policies may in fact result in the delivery of treatment to some patients that may not be necessary or helpful, while delaying access to needed joint replacement surgery.

For patients clearly indicated for total joint replacement, requiring doctors to administer temporizing measures – regardless of efficacy – only delays the inevitable: after a regimen of conservative care, these patients will still suffer from bone-on-bone arthritis that can only be effectively treated by joint replacement. In these cases, Medicare will end up paying for both the conservative care and total joint replacement surgery. As Losina, et al., state in their study on cost-effectiveness of total knee replacement:

"…delaying [total knee replacement] in patients who have reached end-stage knee [osteoarthritis] that severely limits their functions for any period is never efficient because it leads to a lesser value per dollar spent."

Moreover, the impact of delay can be deleterious to patients’ health. Numerous studies have shown that delaying surgery corresponds with worse outcomes and further deterioration of patients’ ability to conduct routine activities of daily living.

Patients suffering from end-stage osteoarthritis not only endure significant physical limitations, but often present with other health challenges, such as hypertension, depression, heart disease and diabetes. One would not expect that they would get healthier by delaying treatment that could restore their mobility.

In fact, total joint replacement has been shown to contribute to improvements in general health. Research by Lovald, et al., indicated that Medicare patients with osteoarthritis who received total knee replacement had approximately half the risk of death at 7 years, and reduction of a new heart failure diagnosis, compared to a matched group of patients who received no surgery.

This payment policy seems to reflect a sense that total joint replacement surgery is over-utilized. In fact, in the United States, there are 3.6 million patients with symptomatic knee osteoarthritis that are unresponsive to conservative treatment. Yet only a fraction of that number undergoes total knee replacement surgery. It has been further shown that patients "overestimate the pain and disability needed to warrant [total joint replacement]." If anything, patients already wait too long to receive surgery when it is clearly indicated.

It’s understandable that the government is concerned about expenditures on total joint replacement. The procedures and expenditures continue to grow, driven by the growing number of afflicted patients with high expectations for active, productive lives. Everyone with a stake in the viability of the U.S. healthcare system should support efforts to root out waste and unnecessary care.

That said, given the lack of evidence of over-utilization in total joint procedures (and the existence of evidence to the contrary), policymakers should defer to the judgment of surgeons and patients, and preserve their right to engage in shared decision-making. Centralized oversight must be balanced against the need to preserve patient access to timely, personalized care.

Jeffrey Binder is president & CEO of Biomet. This post is re-printed with permission from his blog “Connections”.