I’m a big fan of science fiction. In some of my favorite movies, machines scan the site of surgery and perform complex procedures on humans in a manner that mirrors the inhuman speed and surety of assembly line robots in a car factory. Unfortunately, the technology is not quite there just yet, and detractors argue that patients might be inclined to falsely believe that navigated surgery, or robotic surgery, is necessarily ‘better’ than more traditional laparoscopic, or open surgical techniques. The truth, as usual, is more nuanced.
Let’s start with ‘better.’ The most popular robotic surgical system, Intuitive Surgical’s da Vinci, is the oldest and most successful product in the robotic surgery market space. Despite this history, a quick Google search would have you believe that the expensive robot has drunkenly stumbled from procedure to procedure in search of one where it can perform significantly better than a surgeon performing open or laparoscopic surgery. Unfortunately for companies selling them, surgical robots have had a mixed history in the US healthcare system. While reality is certainly not bleak for Intuitive Surgical, there is unfortunately some truth to perceptions that outcomes from robotic surgery—as of now—do not always justify its cost. Take, for example, the following from James Breeden, President of the American Congress of Obstetricians and Gynecologists (ACOG), who stated that,
“If most women undergoing hysterectomy for benign conditions each year chose a vaginal or laparoscopic procedure—rather than TAH or robotic hysterectomy—performed by skilled and experienced surgeons, pain and recovery times would be reduced while providing dramatic savings to our health care system. Conversely, an estimated $960 million to $1.9 billion will be added to the health care system if robotic surgery is used for all hysterectomies each year.”
In this situation, robotic and navigated surgery are not necessarily significantly better than traditional surgical methods if we take ‘better’ to mean improved patient outcomes or reduced costs for the same outcomes. In other words, both systems start to lose some of their luster if we think about them in the following terms:
When I was at the American Academy of Orthopaedic Surgeons (AAOS) conference this year, companies were competing to show off their attempts at bringing surgical navigation and robotics to orthopedics in order to push the nascent market towards growth. This push is supported by a straightforward argument: that with the use of navigation, or with the use of robots, we can better position implants or be less invasive. But this has not always been the case in practice. Some clinicians that I spoke to at AAOS complained that the increased amount of planning and operative time required for a navigated procedure did not translate to significantly better, or even proportionately better, outcomes.
Others said that although they are not yet necessarily fans of robotic or navigation systems themselves, they have an increasing number of patients specifically asking about robotic and navigated surgery. Many patients simply feel better knowing that their surgeon uses the latest and greatest medical technology. However, as cost saving measures in the Affordable Care Act begin to be felt across the industry, the increased cost of these devices will come under increased scrutiny. If the costs remain out of proportion to benefits, then continued use is hard to justify.
To successfully capture a larger portion of the orthopedic surgery market, navigation systems and robotic surgery systems need to demonstrate value and, perhaps more importantly, prevent provoking the ire of regulators and reimbursers. To start with, costs per procedure need to decrease such that they are proportionate to the benefits that patients can reasonably expect to receive. Ease-of-use of systems should be a focus for improvement; if planning, setup, operating, and room turnover times for navigation and robotic surgery can be significantly reduced, then making a case for expanding their use in orthopedics becomes much simpler.
Episode-of-Care Payments: The Manufacturer Strikes Back
Nonetheless, I’m an optimist, and I think the long-term prospects are positive. I think there is huge potential for robotic systems in orthopedics, especially given the fact that through the BCPI initiative, orthopedic procedures are starting to be reimbursed on an episode-based basis. Episode-based reimbursement generally revolves around a common, lump sum awarded per patient from which each part of care is reimbursed. That means that the entire length of care, from pre-admission through to readmission, must draw from this single reimbursed sum. As a result, efficiency, preventing complications, and preventing readmissions becomes important in ensuring that all involved care providers are acceptably compensated.
With bundled episode-based reimbursement, it easier for manufacturers to make a case for the value of these technologies to more facilities. When minimizing readmissions and adverse events is linked to reimbursement, then the precision and reproducibility of a navigated or robotic system becomes very attractive.
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