The Cost-Effectiveness of HA Injections vs. Knee Replacement Surgery

Key Economic Findings

Health economics research demonstrates compelling value for hyaluronic acid injections:

HA series cost: $1,019-$1,600 vs TKR surgery: $30,000-$50,000+
Cost per QALY: $5,332 (well below $50,000-100,000 threshold)
5-year HA treatment: $2,500-$7,500 total
Surgery delay: 2-3.6 years on average
Medicare OA costs: HA = 5.6% vs TKR = 51% of total spending

Understanding Health Economics

When evaluating any medical treatment, we need to ask: Does the benefit justify the cost?

Health economists use standardized measures to compare treatments across different conditions. The most common is the Quality-Adjusted Life Year (QALY)—a measure that combines both quantity and quality of life gained from a treatment.

A treatment is generally considered cost-effective if it costs less than $50,000-$100,000 per QALY gained. Where does viscosupplementation fall on this scale?

The Direct Cost Comparison

Total Knee Replacement Costs

TKR Cost Components:

Component	Cost Range
Hospital/facility fees	$15,000-$30,000
Surgeon fees	$5,000-$10,000
Anesthesia	$2,000-$4,000
Implant	$3,000-$12,000
Physical therapy	$2,000-$5,000
Post-op care	$1,000-$3,000
Total	$30,000-$50,000+

Chicago-area costs range from $11,200-$30,700; national average approximately $32,570^[1]

Hyaluronic Acid Injection Costs

HA Treatment Costs:

Component	Cost Range
HA product	$400-$1,000
Injection procedure	$200-$400
Office visit	$100-$200
Total per series	$1,019-$1,600

Medicare typically covers 80% after deductible

The Cost Ratio

Treatment	Cost	Ratio to HA
HA injection series	$1,019-$1,600	1x
Total knee replacement	$30,000-$50,000	20-50x

HA injections cost less than 10% of knee replacement surgery.

Cost Per Quality-Adjusted Life Year

What Is a QALY?

A QALY combines:

Life years gained from a treatment
Quality of those years (pain reduction, function, mobility)

One QALY = one year of perfect health. A treatment that provides 6 months of significant pain relief and improved function might provide 0.3-0.5 QALYs.

HA Injection Cost-Effectiveness

Research has calculated the cost-effectiveness of viscosupplementation:^[2]

Cost-Effectiveness Analysis:

Metric	Value	Interpretation
Cost per QALY	$5,332	Well below threshold
Threshold (standard)	$50,000-$100,000	Widely accepted cutoff
Conclusion	Highly cost-effective	~10x better than threshold

Comparative Context

Treatment	Cost per QALY
HA injections for knee OA	$5,332
Hip replacement	$20,000-$40,000
Dialysis	$50,000-$100,000
Some cancer drugs	$100,000-$500,000+

HA injections are among the most cost-effective interventions in orthopedics.

The Surgery Delay Dividend

Years of Surgery Avoided

Large database studies show HA delays knee replacement by 1-3+ years:^[3]

HA Courses	Median Time to TKR
No HA	0.7 years
1+ series	1.4 years
3+ series	2.3 years
5+ series	3.6 years

Economic Value of Delay

Every year that surgery is delayed represents:

$30,000-$50,000 in avoided surgical costs

$5,000-$10,000 in avoided rehabilitation costs

Avoided lost wages during 3-6 month recovery

Reduced revision risk (younger patients face higher rates)

Long-Term Cost Modeling

5-Year Scenario

Patient A: HA Treatment Path

Year	Treatment	Cost
1	HA series	$1,500
2	HA series	$1,500
3	HA series	$1,500
4	HA series	$1,500
5	HA series	$1,500
Total		$7,500

Patient B: Surgery Path

Year	Treatment	Cost
1	TKR surgery	$40,000
1-2	Rehab	$5,000
2-5	Follow-up care	$2,000
Total		$47,000

Savings with HA path: $39,500 over 5 years

Note: Surgery may still become necessary eventually, but delaying it saves money and improves timing.

Medicare Cost Analysis

Where OA Dollars Go

A Medicare claims analysis found:^[4]

Treatment Category	% of OA Costs
Knee arthroplasty (surgery)	51%
Physician visits	22%
Physical therapy	12%
Hyaluronic acid	5.6%
Other injectables	4%
Imaging	3%

Key insight: HA accounts for only 5.6% of Medicare knee OA spending, while surgery accounts for 51%.

Cost Implications

For every $1 spent on HA injections that delays surgery by even one year:

Medicare saves approximately $10-20 in surgical costs
The system gains a functioning, active beneficiary
Surgical resources are freed for patients who truly need them

International Evidence

Colombian Cost-Effectiveness Study

A Colombian health economics study found:^[5]

Viscosupplementation was dominant (more effective AND less costly)
$576 reduction in treatment costs compared to conventional therapy
More QALYs gained at lower cost
3-year delay in TKR on average

Spanish Savings Analysis

A Spanish cost analysis of 224 patients found:^[6]

HA delayed knee replacement by 2.67 years on average
Net savings of €36 million over three years
Significant reduction in hospital resource utilization

Italian Health System Analysis

Italian researchers found HA cost-effective compared to NSAIDs and acetaminophen:^[7]

Incremental cost-effectiveness: €3,161-€3,846 per QALY
Well below the €25,000 threshold
Superior long-term outcomes

Additional Economic Benefits

Medication Cost Reduction

HA injections can reduce reliance on expensive medications:

Reduced NSAID use (and associated GI/CV complication costs)

Reduced opioid prescriptions (and associated addiction costs)

Fewer ER visits for pain crises

Lower overall pharmacy costs

Productivity Preservation

For working-age patients (covered in detail here):

Avoided missed workdays (19 days/year with untreated OA)
Reduced presenteeism (productivity loss while at work)
Delayed early retirement due to disability

Avoided Complication Costs

TKR surgery carries risks that add costs:

Complication	Additional Cost
Surgical site infection	$20,000-$50,000
Blood clot (DVT/PE)	$10,000-$30,000
Revision surgery	$30,000-$60,000
Extended rehab	$5,000-$15,000

Delaying surgery = avoiding these risks and potential costs.

The Insurer Perspective

Why Coverage Makes Economic Sense

The Coverage Paradox:

Some insurers are restricting HA coverage while continuing to cover:

Unlimited NSAID prescriptions (with GI bleeding and CV risks)
Opioid prescriptions (with addiction potential)
Expensive knee replacement surgery ($40,000+)
Surgical complications and revisions

This is economically irrational. Restricting the $1,500 treatment that delays the $40,000 surgery doesn’t save money—it accelerates costs.

Medicare’s Approach

Medicare has covered viscosupplementation since 1997 because the cost-benefit analysis supports it:

Documented medical necessity criteria
Repeat courses allowed every 6+ months
Coverage maintained despite guideline debates
Recognition of long-term value

What This Means for Patients

For Those Considering HA

HA is a proven, cost-effective treatment option

Even if surgery is eventually needed, delaying it has value

Years of preserved function and avoided surgical risk

Potential cumulative savings of $20,000-$40,000+

For Those Fighting Coverage Denials

If your insurer denies HA coverage, the economic evidence supports appeal:

Cost-effectiveness is well-documented
Medicare and major payers maintain coverage
Denying HA often accelerates more expensive treatments
Request peer-to-peer review with clinical and economic data

The Bottom Line

HA Injections: A Sound Investment

The health economics are clear:

HA costs less than 10% of knee replacement
Cost per QALY ($5,332) is among the best in orthopedics
Surgery delay saves $30,000-$50,000 per year postponed
Long-term costs are dramatically lower
Quality of life is preserved without surgical risks

For patients, insurers, and the healthcare system, viscosupplementation represents excellent value. The evidence supports coverage, not restriction.

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References

CareCredit. Knee Replacement Cost. CareCredit
Samuelson EM, et al. Cost-Effectiveness of PRP vs Hyaluronic Acid for Knee Osteoarthritis. Arthroscopy, 2020;36(12):3072-78.
Altman R, et al. Hyaluronic Acid Injections Are Associated with Delay of Total Knee Replacement Surgery. PLoS One, 2015. Full Text
AHDB Online. Knee Osteoarthritis Treatment Costs in the Medicare Patient Population. AHDB
Colombian cost-effectiveness study. PubMed. PMC7508284
Spanish cost analysis. Revista Española de Cirugía Ortopédica y Traumatología. Elsevier
Italian cost-effectiveness analysis. PMC. PMC6659788

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