This is the second in a series of three articles addressing the complex issues surrounding the definition of value in the world of healthcare. In the first article, we discussed how the unsustainable growth in healthcare costs is pushing the need to define value for all healthcare services. We presented the following formula to assess value:
We also used this formula to show how the differing perspectives of multiple stakeholders in healthcare affected the perceived value of glucagon-like-peptide 1 (GLP1) receptor agonists (i.e. Ozempic, Wegovy, and Trulicity). In this second article, we will use the same construct to evaluate the value of robotic surgery.
There were two initial drivers for the development of robotic technology: War, and Space Exploration. What do these two have in common? In both environments, it is very difficult to get medical personnel to patients in need. Imagine trying to bring a surgeon and all the necessary equipment to the front lines of a battlefield, where a critically wounded soldier needs urgent life-saving care. Now try to get that care to an astronaut in space. The initial intention was to develop a completely autonomous robotic surgeon (similar to a self-driving car) that would be able to travel to these tough-to-reach environments. Unfortunately, the complexities and variations in human anatomy have put that goal out of reach for the moment, but significant advances have been made: The first robotic surgery on a human was a neurosurgical biopsy performed in 1985 using the PUMA (Programmable Universal Machine for Assembly) system. This single-arm, table-mounted robotic device was a logical place to start because the potential damage to the brain was greatly reduced by using the robot, whose movements could be programmed to the utmost precision. Since that original model, there have been several advances forward, most notably in 2000 when the FDA first approved the use of the da Vinci robotic system for use in the United States. Since the da Vinci system operates as a manual extension of a surgeon who uses a remote-control (which may be distant from the robot itself), it paved the way for telepresent robotic surgeries. Using this technology, surgeons have performed operations on patients that are continents away from themselves. Da Vinci and similar robotic technologies are now routinely used in General Surgery, Urology, Gynecological Surgery and Orthopedics. There is no question that this technology is truly revolutionary, but does it have value? Again, the answer depends on your perspective.
If you are a Patient, the value of robotic surgery is complicated. There is significant data showing that there are potentially faster recovery times and lower complication rates with robotic surgery as compared to traditional open or laparoscopic surgery. On the other hand, sometimes these surgeries take a much longer time to perform, which could potentially increase the risk of medical and anesthetic complications. Robotic surgery has allowed the performance of some procedures that would otherwise have been impossible (i.e., some brain procedures), but also exposes the patient to the risk that a robotic procedure may not work and would need to be converted to an open procedure at the same surgical setting. This would again expose the patient to increased risk, albeit small. The biggest question is whether or not robotic surgeries actually provide better long-term results for the patient. Medical literature is very mixed on this topic. Some studies show improved long-term outcomes with robotics while most studies show no clinically significant difference. Almost all parties agree that results are no worse by using robotics, but it is hard to conclusively say currently that robotic surgeries are “better”. Can we say that robotic surgeries may ultimately end up improving clinical results in the future? The answer is a solid maybe.
Current value to patients: Mixed
If you are a Private Insurance Company or the Government, robotic surgery is essentially a non-entity. In most cases, the insurance companies are not paying substantially more for robotic surgery as compared to traditional surgery. Robotic surgeries are considered by payors as a type of minimally invasive surgery. Payors pay the same or similar rates for all minimally invasive surgeries (which includes endoscopic, arthroscopic, and some microscopic procedures), so for the same cost the insurance companies are getting remarkably similar patient results independent of the surgical technology being utilized.
Current value to Insurance Payors: Neutral.
If you are a Medical Device Manufacturer, specifically the implant companies that manufacture the robotic platforms, this is an absolute windfall. These robotic systems cost upwards of one million dollars per unit installed, and they all require maintenance and disposable parts that need constant replacing. The marketing of robotic systems is robust – manufacturers are regularly pushing hospitals to buy more and more, noting the tremendous amount of room for further development and utilization of these systems.
Current value to Robotic Manufacturers: Astronomical.
If you are a Healthcare Provider, currently there is little value in robotic surgeries. First, there is an extensive learning curve to master before one can safely perform these procedures, and the time spent learning is time away from clinical practice. Second, as already stated, these procedures typically take a longer time to perform (especially early on), resulting in fewer procedures that can be performed in a given day. Add to that the time taken by implant companies’ marketing efforts, as well as fellow physicians pushing clinicians to adopt this technology in the name of innovation. That’s a lot of time taken from a surgeons’ day, despite little clinical advantage to the patient.
Current value to clinicians: Low
If you are a Hospital System, robotic systems can be a nightmare. First and foremost, they are remarkably expensive to obtain and maintain. Add to that extensive training time and costs required for Facility nurses and technicians to be able to assist the surgeons with these procedures. As newer and different robotic technologies are developed, the hospitals are coerced by physicians and patients to “keep up with the Joneses”. All these costs are solely absorbed by the hospitals, inevitably resulting in “cost shifting”: Because the hospital can’t charge more for the robotic surgery, they will charge $20 for a Tylenol pill. These increased charges are exceedingly difficult to recoup from insurance companies. All this extra cost and hassle is to be perceived as a “leader in the industry.”
Current value to hospitals: Abysmal
In conclusion, there is no question that robotic surgery is a technological marvel. To be able to bring the world’s best surgeons to the remoteness of space, the dangers of the battlefield, and the poorest medically underserved areas of the world is nothing short of incredible. But given the ever-more-limited resources for basic healthcare, it is difficult to assign “value.”
Stay tuned for the third installment in this series where we will wrestle with the complexities of determining the value of genetic-altering treatments for blood disorders.