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Interesting data on growth of total knee replacements that are far outstripping Medicare estimates:

http://online.wsj.com/article/SB1000087239639044408330457801...

At about $15,000 each, the total annual tab for the operations performed on patients of any age is now about $9 billion, the researchers said. By comparison, Medicare spending for 2011 was estimated at $550 billion, according to the Kaiser Family Foundation. For patients too young for Medicare, many insurers offer some degree of coverage if the procedure is ordered by a doctor, but plans can differ widely.

Demand for the operations could reach 3.5 million annually by 2030, according to an editorial accompanying the study, published in the Journal of the American Medical Association.


That would be a 5 fold increase in demand in next 20 years!! Presently there are 600,000 knee replacements annually in US.

"Ultimately there's going to be [only] some number of these we can afford," Dr. Cram said. But how to limit the procedure or who should get it will be a "really contentious debate," he said.

The cost side consideration and what is actually affordable.


Dr. Cram and his colleagues found that the length of hospital stays after knee replacement decreased significantly, to 3.5 days in 2007-2010 from 7.9 days in 1991-1994

Only 3.5 days average stay in hospital for total knee replacement........compare that to MAKO.
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Only 3.5 days average stay in hospital for total knee replacement........compare that to MAKO.

My wife had bi-lateral knee replacements (both at the same time) a few years ago. The hospital stay was short, but that was followed by two weeks residence in a rehab facility, and a couple of months of outpatient physical therapy. Not everyone has coverage that lets them do that, but it would be interesting to know how that stage is different for Mako patients to get a complete comparison.

RH in CT
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MAKO is a long way from doing total knee, and the total knee is most likely not going to see tremendous benefits from MAKO. Certainly they will exist. But in the end, with such high volume, it will need to cost less, or no more, or do the job substantially better. There is no getting around this. Which is one reason why MAKO went for partial knee, and not total knee I believe, even though total knee is such a larger market. And why MAKO has gone for hips before addressing total knee.

Management is not stupid. They know their technology and their markets.

Tinker
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MAKO does not have a system for total knee arthroplasties....as least as of yet.

This is where the 3-D jig system shines.

Our usual length of stay after knee arthroplasty is 2 days.



Alan
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The other piece of this article, if it was the same one I read, was that the shortened hospital stay was pretty much offset by the need for people to come back because something was wrong. In that context, the rapid recovery of partials and the increased precision which *seemingly* one has with the robot, work harken well for real cost reduction. One has to remember that, excluding fraud, any increase in procedures means that there are patients needing the treatment.
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Our usual length of stay after knee arthroplasty is 2 days.

Alan:

That is impressive.....just 2 days and the same article suggests an average joint durability of 20 years before another revision.......also impressive.

But keep in mind that recently we learned that Mako does in fact intend to cannibalize these total knee replacements. It seems they are strategizing not just partial knees which are apparently not a well regarded procedure by orthopedic doctors but instead, they claim, that these total knees have a substantial % that could instead have a Mako.

That is, they believe that this won't be a situation as one poster claimed, that they would need to talk an early diseased knee patient to go under the knife but rather that these total knee replacements don't really need totals........at least many of them.

Your thoughts?
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Sorry Alan....hit send too quickly:

Another important aspect of this article was the extreme cost of knee replacements.......$9 Billion per year with expectation to go up a five multiple or to $45 Billion in 20 years.

The implication of this study was that we cannot afford this as a nation and that the government may have its sights on the growth.

Partials average about 2/3 the cost of totals as I understand so the savings may not be realized.

If there is only so much we as a nation can afford to spend in Obamacare......where shall we spend it?
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If the whole knee is a mess, then a total is the way to go. MAKO could have an opportunity there of increasing accuracy and reducing complications, but that is certainly not the issue at this point. The focus is on people who would not yet be candidates for TKR and are facing years of compromised quality of life, including pain before they qualify.
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The focus is on people who would not yet be candidates for TKR and are facing years of compromised quality of life, including pain before they qualify.

Perhaps I can explain this for you another way.

MAKO believes....they should know the industry better than you or I would you agree?..........MAKO says that when one actually reviews the total knees which are being done now........a substantial percentage of these total knees could have been done with MAKO.

Get it? They are suggesting that they believe they can cannabilize a substantial portion of what would have otherwise been a total knee.

This is very different than what you are claiming.
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If there is only so much we as a nation can afford to spend in Obamacare......where shall we spend it?

Does this mean that you are advocating rationing? Or that you think rationing by the wallet is the way to go?

The other viewpoint is that there is a medical need here and how are we going to meet it?
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Does this mean that you are advocating rationing? Or that you think rationing by the wallet is the way to go?

I am stating what the article actually stated.

I did not advocate anything but do have thoughts on the matter.
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I don't believe that MAKO believes any such thing. After all, they are not targeting TKR at this point at all. What they are targeting people who are not yet candidates for TKR. That is the whole point! The whole idea is to take someone who is compromised, can't do what they used to do because of the pain, and return them to fully functioning for 10-20 years. These are people who have been making do with pain meds and maybe cortisone injection, often with limited benefit.

If you don't understand that, what in the world have you been talking about MAKO these last months?
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I don't believe that MAKO believes any such thing. After all, they are not targeting TKR at this point at all. What they are targeting people who are not yet candidates for TKR. That is the whole point! The whole idea is to take someone who is compromised, can't do what they used to do because of the pain, and return them to fully functioning for 10-20 years. These are people who have been making do with pain meds and maybe cortisone injection, often with limited benefit.

If you don't understand that, what in the world have you been talking about MAKO these last months?


Tamahs:

This would be a much better place if you would stop attacking me with personal insults against the FOOL's rules for posting.

As to my "understanding", may I direct you to this white paper by MAKO itself:

http://www.makosurgical.com/assets/files/clinical/WP-Annual-...

How Many TKA Patients
Could Be Treated with Early Intervention Procedures? (Kreuzer)
The rationale behind bicompartmental knee arthroplasty (BKA) is that many patients who undergo TKA have isolated bicompartmental arthritis involving only two compartments of the knee and have no significant deformity, excellent motion, and intact cruciate ligaments. This study includes a retrospective review of 406 consecutive total knee cases from a single surgeon. The integrity of the three compartments and the ACL was assessed to examine the applicability of this early intervention procedure.

Only 23% of the reviewed cases had severe joint degeneration including disease in all three compartments and an insufficient ACL, qualifying these patients for a TKA. However, 66% of the cases showed an intact ACL. Based on ACL integrity and presence of compartment osteoarthritis (OA), 16% of these cases could have been indicated for a UKA and 31% could have been indicated for a BKA (Figure 5). This data indicates that many TKA patients have healthy cruciates and disease in only one or two of the three compartments, indicating that TKA is an overtreatment of earlier stage osteoarthritis.</>

You see.....they are going after the TKA market inspite of what you claimed. They are suggesting that as many as 47% of TKA's could be cannabilized by MAKO.

Do you understand this now? Do you see why it may have significance as regards the WSJ article on growth of TKA market?

Please refrain from insulting me further.
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<< If there is only so much we as a nation can afford to spend in Obamacare......where shall we spend it? >>

About 10 years ago, there was an epidemiologic study presented in JAMA that suggested joint arthroplasties, expensive as they are, actually save money because of reduced costs compared to the disability losses that degenerative arthritis entails.



Alan
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<< Does this mean that you are advocating rationing? >>

I see no way around it. Rationing of health care is in our future. We simply can't afford to give everybody everything.

How do you think countries with universal health care systems pay out less per person than we do?

It's simple. They ration care, especially for expensive treatment modalities.



Alan
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>> << Does this mean that you are advocating rationing? >>

I see no way around it. Rationing of health care is in our future. We simply can't afford to give everybody everything.

How do you think countries with universal health care systems pay out less per person than we do?

It's simple. They ration care, especially for expensive treatment modalities.



Alan <<

Alan,

I think you are aware this is a gross simplification. Rationing treatments is part of how many countries restrain medical expenses, but it is certainly not the only way. Nor, for that matter, is there only a single way to ration treatments -different rationing schemes are as varied as the countries that employ them, and the details are critical.

FWIW, I lived in England for four years, and was subject to the pleasures that are the NHS. I remember walking through an internal hall in Hammersmith hospital - one of the highest rated hopitals in all of the UK. One of every four fluorescent lights overhead was working, flickering dimly, just enough to show the dripping insulation peeling from behind the broken drywall, with water droplets running down loose and severed wiring to pool on the dirty floor. I honestly thought I was on the set of a post-apocalyptic horror movie. So that is another way costs are contained - vast underspend on infrastructure.

Another way is to shift all the R&D costs from these countries to the US. When is the last time Cuba, or Italy, or Canada developed a new live saving procedure, or imaging technology, or drug? I overstate the case a little bit, but not by much - the vast majority of R&D is performed in the US, because innovators can recoup their R&D costs. Price controls prevent successful amortization of R&D in other countries. So that is another reason the US has more expensive health care - we subsidise medical development for the entire rest of the world.

Then there is the control of medical salaries. Many countries set salaries rather than allowing the market to determine them.

And the elimnation of waste and fraud - many countries reduce this relative to the US, often by eliminating fee-for-service payment schedules. Good US insurance companies spend a considerable sum on auditing treatments to reduce this waste; Medicare doesn't bother too much.

Plus the various rationing schemes - from reduction in available services, which causes longish wait times, which in turn suppresses demand, to out-and-out denial of treaments.

It is a vast and complex subject. There are neither perfect medical systems, nor perfect answers to improve systems without costs. All that being said, I have lived on 5 continents, lived in, worked in, or visited something on order of 50 countries, and the one place I have found medical care to be the best in the world - is the US. Acknowledging warts and all in US medical care, no other system in the world is comparable.

And I do not agree with you that rationing of health care is our future. It is one possible future, but I do not think the best one. At least not with rationing set by centralised technocratic entities.

Brian

Mandatory political PS: Most polls are like mirrors - reflections of reality. Some are funhouse mirrors, distorting what they reflect. Fortunately, there is the one poll that *is* reality, and not a mirror. It occurs Nov 6. Everything until then is just noise.
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Two words, "early intervention".
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Two words, "early intervention".

Did you see that these were TKA's and not "early intervention" before the TKA's were actually performed?

In other words, they intend to cannibalize 46% of the TKA market.

You may not recall that we discussed this in detail on this board a few months ago.

BTW, don't you think that that is very good news for MAKO shareholders since they are implying they don't need to exclusively try to "create" a new market but can in addition be a substitution threat to established TKA's??
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<< < I do not agree with you that rationing of health care is our future. >>

Not only is it part of our future, it's already here. For example:

Medicaid: try getting many tests/procedures performed without an approved TAR (treatment authorization request), administered by bureaucrats; medical bureaucrats, but bureaucrats nonetheless.

Kaiser: Physician over-utilizers are counseled....even dismissed.

Medicare: occaisonally tests and procedures are simply not covered

We may very well go the way of Canada. They will pay for (offer) 20,000 knee replacements for a year. If you make the list, fine. If not, you wait. That's rationing, pure and simple.

Sure, there are other systems of rationing, but I see no way around it.


Alan
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Alan,

Canada can do this because Canadians can just come down to the U.S. for their knees. They do it all the time.

What happens when there is no place to go? That is a quite different scenario.

The American public will not accept a flat number for procedures, given by the great health service. The system will break, by bureacratic administration like this, and that is the problem.

People who don't understand the free market often call for central control of things (not saying you Alan, just a comment here) because that makes sense for them, not realizing, that the free market not only better manages these things, but it grows the pie.

I do not see anyway to manage this fiasco without allowing more free market alternatives for people to opt out of the system and to buy what they want. This will be an explosive pressure cooker in 10 years time if it continues in the manner of the Canadian or British system.

Americans will not stand for being told they cannot buy what they want/need due to some collective bureacrat.

Tinker
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<< .....the free market not only better manages these things, but it grows the pie. >>

Amen to that!! I hope this tenet of our society's culture is never abandoned.


Alan
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How do you think countries with universal health care systems pay out less per person than we do?

It's simple. They ration care, especially for expensive treatment modalities.



Alan
______________________________________________________________________

When Obamacare was 1st debated I made mention of this very fact as well as the fact that all the industrialized nations with universal healthcare were struggling with the cost associated with such coverage (even with rationing).

I don't know what people are thinking when Obamacare promises unlimited health coverage to the whole nation while at the same time promising to save money.

Thanks for reiterating that simple message.

Rob
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currently the US heath care system is rationed by the insurance companies.

Dave
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