Along with all the hype about robotic surgery, we finally get some credible data and a useful proposal.
In the February 2013 issue of the Journal of the American Medical Association, Jason Wright and his colleagues from Columbia University compared the outcomes of performing robotically assisted benign hysterectomies with other methods. The most meaningful comparison is with laparoscopic surgery performed without the assistance of a robot. They found that there was no significant advantage to performing the procedure with the assistance of a robot, but that the method carried an additional (incremental) cost of about $2,000. Despite this apparent disadvantage, the authors report that the adoption of robotically-assisted surgery for benign hysterectomies is rising more rapidly than “standard” laparoscopic surgery.
The article was accompanied by an editorial, drawing attention to the impact of direct-to-consumer marketing of robotic surgery and its likely role in driving demand, thus fueling “unnecessary utilization.” The authors of the editorial, Joel Weissman and Michael Zinner from Brigham and Women’s Hospital in Boston, went further: They pointed out that, since reimbursement for laparoscopic benign hysterectomy is the same whether robotically assisted or not, patients and hospitals do not have an incentive to use the less expensive option. To stimulate the right behavior – in this particular case, where the outcomes are effectively the same – Weissman and Zinner suggest that, when the patient requests robotically assisted surgery, a copayment equal to the additional cost be imposed. If physicians and hospitals are driving the demand, they suggest that they be asked to justify their recommendation. (In the interest of brevity, I’ve simplified things a bit; for the details, please consult the editorial).
The opportunity cost
Although it was not mentioned in the article by Wright and his colleagues, robotically assisted benign hysterectomy consumes more OR time than the “standard” laparoscopic method. Thus, when estimating the copayment, a premium should be added to account for the opportunity cost associated with reimbursement that would have been received by fitting a greater number of standard laparoscopic procedures into the available OR time.
The estimate of the opportunity cost
How large should this premium be? In our paper, “Calculating the true cost of robotic hysterectomy,” which appears in the August issue of Healthcare Financial Management, Vikram Tiwari, Warren Sandberg and I provide the answer. We employ a simulation model to estimate the number of robotically assisted and standard laparoscopic procedures that can be performed in one month in a dedicated OR, and then calculate the resulting difference in a hospital’s cash flow. For a range of reasonable values of the important parameters, we find that, when the premium is taken into account, the appropriate copayment could be at least three times as large as proposed by Weissman and Zinner. As we point out in our article, the total copayment represents 7 to 9 percent of the median income of a family of four in the United States. Translation: It’s a big deal!
If transparency were introduced, with prospective patients regularly presented with outcome data for the two non-invasive methods along with what they would have to pay for the privilege of the robotically assisted method, it is likely that a majority of patients would forgo the robot.
So, what’s the really big lesson here? We need more transparency; more researchers like Jason Wright and his colleagues to collect and carefully analyze masses of data; and more highly regarded influencers like Joel Weissman and Michael Zinner to call ‘em as they sees ’em.
 Wright, J.D., Ananth C.V., Lewin, S.N., et al., “Robotically Assisted Vs. Laparoscopic Hysterectomy Among Women with Benign Gynecologic Disease,” Journal of the American Medical Association, February 2013.
 Weissman, J.S., and Zinner M., “Comparative Effectiveness Research on Robotic Surgery,” Journal of the American Medical Association,February 2013.