The Bottom Line

It’s cool. So cool, that President Obama used one. So cool, it’s been on the cover of Newsweek. It’s been in multiple television commercials, radio advertisements, highway billboards, and was even coined one of the top 14 medical breakthroughs of 2011 by Boston Magazine, a city teeming with medical innovation. Yet surgeons and health economists are unable to explain the fascinating rise of robotic-assisted surgery.

Currently, a single company manufactures and distributes the robot, a line of surgical equipment used to conduct robotic-assisted surgery. The robotic system consists of a surgeon’s console with 3-dimensional high definition vision and a patient-side cart featuring robotic arms with proprietary wristed instruments. The system translates the surgeon’s natural hand movements on instrument controls into corresponding movements of instruments inside the patient, giving the surgeon control, range of motion, and depth of vision similar to open surgery.

The sole manufacturer hopes to establish the robot as the standard for surgical procedures by encouraging surgeons and hospitals to adapt the technique while marketing aggressively to patients about the benefits of robotic surgery. As of June 2011, the manufacturer had installed 1,933 robotic systems. They estimate that 278,000 robotic-assisted surgical procedures were performed in 2010, up 35% from 2009, and aims to achieve one million annual procedures in the United States over the next few years (Invester Report 2011). To achieve this goal, the manufacturer strategically markets to smaller hospitals and surgeons who may not be skilled at conventional laparoscopy to give them an edge for attracting patients.

The robotic systems are sold to hospitals for a cost of $1.0 – $2.3 million, depending on the version. Mandatory annual service agreements range from $100,000 to $170,000 per year. These prices are paying off for the manufacturer. In 2010, the company reported revenues of over $1.4 billion from the sale of systems, and most recently, a 38% increase in instrument sales and 25% growth on systems revenues for the third quarter of 2011 (S&P stock report 2011). Since 2006, the company reports gross profits at 66%-73% of revenue.

Who regulates these costs? Only the sole manufacturer does. The robotic surgical system is the only FDA-approved robotic system on the market. In addition, the manufacturer owns or has exclusive rights to over 2000 patents and patent applications, derived from the acquisition of other robotic devices and companies. Extensive regulations administered by the FDA act as a barrier to entry by other competitors, and since the manufacturer’s acquisition of its major competitor in 2003, there are no direct commercial competitors in the robotic-assisted surgery market. Without competition, a single company runs the robotic market without any regulation.

Shareholders are thrilled. The stock value continues to rise in a recession and has just joined the passed the $500 per share mark. Patients want it. Hospitals are buying it. So why isn’t everyone excited about robotic-assisted surgery?
Unfortunately, the exuberant and rapid adoption of robotic-assisted surgery has occurred in the absence of randomized trial evidence validating its use. Instead, marketing by the manufacturer accounts for the exponential use of robotic surgery over the past five years rather than clinical evidence.

In fact, researchers from Johns Hopkins found that hospital websites, using manufacturer-provided content, misled patients with clinical claims that have not been substantiated (1). The researchers found approximately 4 in 10 hospital websites in the United States publicize the use of robotic surgery. What was most concerning was that 89% of these hospital websites made a statement of clinical superiority over conventional surgeries, the most common being less pain, shorter recovery, less scaring, and less blood loss. 32% made a statement of improved cancer outcome, and none mentioned any risks or costs.

The evidence is just beginning to emerge to the contrary. Literature has shown that while clinical outcomes are similar to or no better than conventional surgery, the robotic technique is more expensive than conventional laparoscopy for a number of surgeries including cholecystectomy (2) and hysterectomy for endometrial cancer (3). For some procedures, including benign hysterectomy, sacrocolpopexy (4), and myomectomy (5), the robotic technique is even more expensive than conventional laparoscopy and laparotomy. Despite the large number of robotic prostatectomies performed to date, evidence has yet to show improved clinical, cancer, or cost outcomes for robotic prostatectomy (6). In addition, studies show that robotic-assisted surgery is consistently $1600-$3000 more than conventional laparoscopy or open surgery (7,8). Our institutional data for hysterectomy showed that robotic-assisted surgery translated into a $6000-$10,000 increase in expenses to the patient over all other methods of hysterectomy. If the 600,000 hysterectomies performed in the United States each year were all converted to robotic-assisted hysterectomies, this would represent a $3.6 billion to $6 billion increase in patient costs. An increase in patient costs for no clinical benefit.

What does the literature show? High-volume subspecialty surgeons have better patient outcomes and use less hospital resources and health-care dollars than low-volume, less-skilled surgeons (9). In fact, a hospital’s investment into a moderately priced robotic system over 5 years would provide an average salary for a fellowship-trained minimally invasive surgical subspecialist (conventional laparoscopist) for 10 years. Instead of investing in a marketing technique, hospitals should invest in and develop talented high-volume surgeons because the clinical benefit is proven.

In a time where medical bills are the leading cause of personal bankruptcy in the United States and health care spending is nearly 18% of the GDP, why are patients paying more for a technique without any proven benefits over conventional therapies? Why are hospitals marketing robotic-assisted surgery to patients without reviewing the manufacturer’s claims? Why are we allowing a single company’s bottom line to increase while insurance premiums and out-of-pocket spending for patients increase every year? We have to stop pursuing things because they are marketed to us. In medicine, there are always procedures that are feasible, but they are not always the right clinical choice; similarly, they are not always the cost-effective choice. In the case of robotic-assisted surgery, it shows neither improved clinical outcomes nor lowered costs.

Dr. Kelly Wright is a minimally invasive gynecologic surgery fellow in the Boston area. This post appeared on Costs of Care.

10 replies »

  1. In reply to dr Steve Dudley

    a) “Surgeons are not flocking to the robot in order to make more money”

    Wrong – European Urologists are flocking to a an “Island-Country” in Southern Europe, where they IN A WEEKEND can make 8-10 prostatectomies in two well-known private centres. Each surgeon receives approx. 2000 Euro upfront and Cash PER PATIENT without appropriate taxation in their respective homecountries. That is organized tax-evasion, Sir!
    [I did not mention the additional problem of bringing that countries documented MRSA and VRE to and fro over the continent…some kind of inverted bonus ?]

    b) If you are lured into a Prostatectomy having only 1-2 mm of Cancer after 12 biopsies and the Gleason score is at most 6 – but most often much less – and then you find yourself impotent and incontinent and start reading American and European literature on what is recommended, then you will certainly not have only back and neck-pain, but also pain in your gut.

    c) Your concerns on the drug costs are motivated, but be sure, once Canada has as much Robots as the USA, people will have to turn south to Mexico to have the right prices. Because, the Robots add to the general rise in costs.

    One more thing – please do not try to rub the nose of dr Wright because she is young and you are 61. That is more or less an adolescent way of proving ones point.

    Have a nice day !

  2. Dr. Wright,

    Your idealism is painfully attractive to me.

    However, as a 61 year old gynecologic oncologist, I would like to point out what you don’t know or haven’t considered. By seeing my own experience, listening to hospital executives, and sharing with my colleagues, I can state:

    1. The real “cost” of robotic surgery is being shouldered by the hospitals, not the patients. Insurance plans do not recognize the robot as a billable item and reimburse as per traditional laparoscopic surgery. Hence, the “expense” is merely a line item in a hospital bill that has to be written off because of contractual agreements. It is not passed on to the patients or the insurance companies. It is a real expense, nonetheless, and the difficulty making a profit in robotic surgery has created a bottleneck in that hospitals cannot afford to buy enough robots to keep up with the demand. My own hospital is in just this position right now. What robots we do have, we have because the manufacturer has indeed done a good job convincing the hospitals that they will lose market share if they don’t have one, which is true.

    2. Surgeons are not flocking to the robot in order to make more money. I get reimbursed the same amount (there is no CPT code for robotic hysterectomy) whether I do a hysterectomy by robotic or traditional laparoscopy. In many cases, I would make much more by doing the case open as I could do it more quickly and the CPT code for open cases pays more. But with my 30 years of experience, I have been put into a state of awe at what I can do with the device and I believe it is what is best for now the majority of my patients.

    3. What you and so many others have failed to acknowledge, is that robotic surgery is much easier to learn than advanced laparoscopic surgery and there are many difficult ureteral dissections that most of us simply cannot perform with rigid sticks. I can attest to the fact that the robot prevented conversion to an open case many times over the past year. The successful preservation of a minimally invasive case resulted in the patient getting back to work much more quickly than if I had capitulated and opened, which I would have done without the robot. Even with your skillful and youthful hands, I would wager that the wristed instruments enhance your efficiency in dissection. The rise is supracervical hysterectomies has occurred because it is so much easier and pays almost the same as a complete hysterectomy.

    4. Fatigue is delayed by sitting at the robotic console. That probably is not very important to you, but I assure you as you get older and busier it will be. Whereas for the last few years I have considered myself to be optimal for only two major cases a day, I can now easily perform three major cases a day if only two of them are robotic. Thus, the robot can increase productivity by the given surgeon and quite probably prolong his/her career.

    5. Surgeon injuries (back and neck) I predict will decline with robotic surgery.

    The real challenge, then, is how to research and prove these claims which most of us already know to be true. Perhaps you could be on the forefront of that movement. For starters, lets’ find out how many cases according to surgeons’ judgements would have had to be converted to open cases ( or would never have been attempted by traditional laparoscopy by most of the gyn surgeons in the land) in the absence of a robot and then calculate the lost wages from extended recovery times. I strongly believe that it is here where your financial concerns will be thoroughly nullified. Don’t forget that ALL robotic prostatectomies will qualify as there is no traditional laparoscopic equivalent. And let’s not forget the pain and suffering, apart from the disability, that conversion to an open case entails. I can assure you, knowing full well that the cancer, impotence, and incontinence outcomes are really no different, I will definitely want my radical prostatectomy done robotically.

    I salute your concern about the economics of medicine. Please direct a good portion toward what I have called the “last pirates of the health care system”, the pharmaceutical companies. Why are drugs cheaper everywhere else in the world and U. S. citizens flock to Canada to buy their drugs. Now that’s eggregious. I am furious about the cost of Avastin, nearly $10,000 a treatment, , and knowing how much clean water and how many life saving vaccinations that money would buy elsewhere in the world, to spend it for four extra months of life is immoral and unethical in my opinion. I would be pleased to hear your opinion about it.

  3. It’s the newest & hip-est thing to come along and as Dr. Reece said we love new technology. A hospital can offer the newest, hip-est thing a look like they’re on the cutting edge of technology

  4. This has been the story of American health care since 1935. Dont expect it to stop now because of a few studies. Remember the huge COURAGE study that showed that stents are less effective than medical management for heart disease? Since then stent use has gone UP!

  5. yes! as soon as this stops, so will the hospitals desire to lose money on every case. imagine being recruited to do open surgery because it saves the health system money ! —- as far as new surgeons are concerned – “no one ever took a weekend course to learn how to do traditional surgery””

  6. Excellent article. Some bias exists, even when a gyn fellow talks about sacrocolpopexy? A traditional sacrospinous repair can be done with the cost of a few sutures, without even a laparoscope. Evidence-based medicine (in spite of the lack of evidence to support 98% percent of what is done in the OR) is temptiing, but we tend to prefer evidence only when it can be twisted to support our positions. Keep it up – do more research here …

  7. I want to congratulate Dr. Wright on raising the important underlying issues of clinical improvement and cost. Indeed while those comment on the “robo-love” of the patient and surgeons, once again it is a costly technology with perhaps not so much benefit and thus we again fail as stewards of our profession.

    I am all about advancement and technology, but as Dr. Wright notes, this may be an example of false technology promulgated by the DaVinci folks more than by better patient care.

    Dr. Reece, while theoretically I agree that the ‘market’ should figure this out, there is little to support this traditional economic behavior in medicine. Take for example the explosion and persistent use of coronary stenting for angina which has little to no improvement in patient outcomes..no failure in the market there.

    Admittedly I am not well versed in the outcomes data for robotic procedures, but am encouraged to see that emerging physicians like Dr. Wright are asking the correct questions.

  8. Are insurers, including Medicare, paying more for surgery done with a robot than when not?

  9. Dr. Wright,

    It is not your money to reallocate.

    Why do people upgrade from the past? They see something they want and are willing to pay for and have the means to do it.

    Turning surgery into a video game will create a lot of surgeons.

  10. Doctor Wright; Don’t get your hopes up. Americans love technology and its promises. Hospitals want to enhance their bottom lines. Robots are made for marketing. Hospitals want to attract surgeons. Surgeons love the latest in high tech. If CTS or MRIs are an example and if Robots prove to be a superior technology, which they might, robotic surgery will proliferate, no matter what the government says about technology assessment before you go to market. If robotic results fail to measure up, they will fail in the market, as they should.