CORR Insights®: There Is Wide Variation in Platelet-rich Plasma Injection Pricing: A United States Nationwide Study of Top Orthopaedic Hospitals

Where Are We Now?

The use of orthobiologics has increased dramatically over the past decade, despite some conflicting data on their efficacy and cost-effectiveness. Some of this interest is market- and industry-driven, and some is propelled by stories of high-profile athletes being treated with biologic therapies and making “miraculous” returns to the field after making claims about rapid healing. In addition, some of the demand is the result of a growing clinical experience by thought leaders and investigators who have been using these products in their offices and operating rooms and whose patients report positive symptomatic relief. Of course, some of these beliefs may be confounded in part by insufficient follow-up, assessment bias, and the placebo effect, given the lack of robust clinical trial evidence.

The fact that platelet-rich plasma (PRP) is a safe, autologous product often used for patients with chronic symptoms that have been recalcitrant to other therapies, with very limited risk to the patient except for standard injection-related considerations (local injection site soreness, theoretic risk of infection from bacterial inoculation at the injection site), is even more reason why PRP use has been steadily increasing. And although we don’t like to discuss it, the fact that it can be a financial benefit to a physician’s office while providing this patient care is part of the equation as well.

When the demand for a product in the marketplace surges, the cost for that product is likely to increase as well. Because most insurance companies do not cover PRP administration, physicians set their own prices for the application of the treatment modality. I use the term “application of the treatment modality” intentionally because the type and technique of administration of PRP is highly variable. PRP kits are available from a variety of orthopaedic sports medicine companies, each of which charges a different amount for use of its system.

Once a physician has decided which PRP kit to purchase, the mode of delivery and treatment process also varies, which can add to the cost. Some physicians administer PRP injections under ultrasound or fluoroscopic guidance. Some physicians work in a split-bill environment where a hospital-based and a professional fee are billed for the procedure, whereas others only charge a professional fee. Consequently, the cost for a PRP injection from a more expensive industry vendor injected by a provider who uses ultrasound or fluoroscopy in a hospital-based clinic may be much higher than a clinician who uses a less-expensive product in an office-based setting with no adjuvant imaging. Lastly, some physicians may charge an E&M visit in addition to the “PRP fee” if an evaluation is also performed at the same time, further adding cost to the treatment.

Thus, there is little wonder that in this issue of Clinical Orthopaedics and Related Research®, Tiao et al. [3] reported that pricing for PRP varies widely. The authors found that PRP pricing ranged from USD 350 and USD 2815. In Boston alone, I am aware of price variation between USD 450 in a private practice office and USD 1785 in a large, academic hospital–based setting. Although some of this variation can be explained by the factors above, market-based pricing may also play a role. Based on these discoveries, if a surgeon elects to use PRP in their practice, the surgeon should be aware of the marked variation in pricing that exists across the market.

Where Do We Need To Go?

Patients research not only the therapeutic intervention in question, but also the out-of-pocket costs being charged by an institution and/or provider. Appropriate and fair pricing, as well as value and cost-effectiveness, must be at the center of the conversation. We need to have a better understanding of the actual efficacy of PRP injections for different indications such as osteoarthritis, tendinopathies, muscle injuries, fracture healing, and as an adjuvant treatment to enhance healing in surgical procedures such as rotator cuff repair, Achilles tendon repair, patellar tendon repair, and quadriceps tendon repair, among others. We need to continue the basic science work on the multitude of PRP formulations and understand the role of high- versus low-platelet concentration (platelet-rich versus platelet-poor preparations), the role of leukocytes in the plasma, whether this role differs for an intraarticular environment versus an extraarticular tendon application, and the volume of plasma that is optimal for a therapeutic effect. In addition, we need to clarify the timing of application of PRP after an acute injury, how many injections should be given for a specific indication, what the interval should be between injections, and if there is a role for maintenance therapies/injections. By doing so, the physician can then better educate the patient about the expected outcome, the cost of delivering the care, and thus a cost-effectiveness and value-based discussion with the patient can be performed.

How Do We Get There?

Unfortunately, there are no short cuts to what is needed in the field of orthobiologics in general, and PRP in particular. Basic science studies evaluating formulations of PRP for distinct indications need to be performed, and what the actual histologic effect is on the treated cartilage, tendon, or muscle must be characterized. This should be done in place of the one-size-fits-all scenario that many physicians currently use in their office. Orthopaedic surgeons should continue to investigate the potential of PRP and other biologics to increase healing rates and improve outcomes in their surgical procedures, which vould have far-reaching financial and clinical impacts for patients and the healthcare system with regard to cost-adjected quality-of-life metrics and the avoidance of the need for revision or salvage procedures.

The reality is, there is no reason that such studies cannot be performed. Patients are more motivated than ever to stay active later in their lives. At the present time, there is minimal burden to healthcare payers, since PRP therapies are out-of-pocket expenses to patients. There is one point of view that charging patients out of pocket for unproven therapies is inherently troubling. There are others, me included, who are trying to explore and study alternative treatments in the orthobiologics field in an effort to offer patients options that may provide them benefit. Industry is motivated to further advance indications for this lucrative field, and a partnership with appropriate oversight to invest in multicenter clinical trials can be facilitated.

We live in a world of evidence-based medicine, as we should. Our patients look to us for our guidance and care, and entrust us with some of their most important and personal decisions—their health. This raises a philosophical question, and we need to decide what direction we should go in medicine: If a therapy has a low risk profile and is easy to perform, if it has the potential to provide symptomatic relief and satisfaction to many patients for whom other therapies have failed, if those patients have been educated about the risks and benefits of the intervention as well as the fact that there are no definitive/indisputable Level 1 data that support its use, and there is no burden to the insurance system since it is a cash-based treatment, should we make this product available to the patient in a buyer-beware type of situation? Should we simply let the market set the price for the product, as we do in the rest of the US economy? If the patient thinks one provider is charging too much, the patient may go to a different, less-expensive alternative. And when there truly are limited data as to its actual efficacy, do the issues of generalized equitable availability of the intervention to those who may either choose not to spend their own money or do not have the resources to even consider the therapy, still apply? Although this is clearly a topic for another commentary, it is something that we should all consider when we make the decision to offer PRP injections in our practices and set our prices for that treatment.

Read This Next

• One systematic review highlights how the use and reporting of “orthobiologics” or regenerative therapies in orthopaedic surgery has grown in recent years. In particular, the use of PRP, bone marrow aspirate, adipose-derived cells, and amniotic cell publications has increased. That said, the authors emphasize the need for the establishment of minimum reporting standards because of the heterogeneous nature of most reports [2].

• Another review evaluates the current clinical evidence on the use of PRP, including leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP) to develop evidence-based recommendations for various musculoskeletal indications [1]. Specifically, the authors wrote that “abundant high-quality evidence supports the use of LR-PRP injection for lateral epicondylitis and LP-PRP for osteoarthritis of the knee. Moderate high-quality evidence supports the use of LR-PRP injection for patellar tendinopathy and of PRP injection for plantar fasciitis and donor site pain in patellar tendon graft BTB ACL reconstruction. There is insufficient evidence to routinely recommend PRP for rotator cuff tendinopathy, osteoarthritis of the hip, or high ankle sprains. Current evidence demonstrates a lack of efficacy of PRP for Achilles tendinopathy, muscle injuries, acute fracture or nonunion, surgical augmentation in rotator cuff repair, Achilles tendon repair, and ACL reconstruction.”