It’s no secret that financial analysis comparing the costs of surgery performed via different approaches has shown that robotic surgery is more expensive. Some healthcare systems even report a net negative margin for robotic procedures when compared with open and laparoscopic approaches. While we expect to have winners and losers in the world of healthcare economics, the prospect of losing money on a surgical approach that continues to increase in volume and popularity is unsustainable.
My background as a gynecologist turns my focus to use in hysterectomy, the second most common gynecologic surgical procedure.
My initial reaction is to question the data comparing the costs of surgery by approach.
Robotic gynecologic surgeons anecdotally report that they are being funneled more challenging cases from their non-robotic surgeon colleagues. As a former high-volume robotic gyn surgeon myself, I can attest to being on the receiving end of referrals from my non-robotic surgeon colleagues to operate on patients with high body mass index, large uterine size, severe endometriosis, and history of multiple abdominal surgeries — all characteristics that can lead to longer case times and higher costs.
My second reaction is one of fear.
Mass exodus of surgeons or recruitment challenges are a risk if robots are restricted or removed from facilities. A 2011 study from the Journal of Minimally Invasive Gynecology demonstrated that 58% of ob-gyn residency programs were training their residents in robotics. As a physician leader tasked with hiring a physician workforce, my observation is that new surgeon graduates are making career choices based on their ability to access the tool, a situation also reported in this 2014 article.
Trying to “force” the existing active robotic surgeons to use an alternative approach to hysterectomy wouldn’t go over well, either, especially when many of our active robotic surgeons now lack the confidence and skills to perform complex hysterectomy via alternative approaches.
I can attest to that evolution. Fresh out of training, I performed all my hysterectomies laparoscopically and vaginally, because that was how I was trained. Living the “straight stick” life was fun for a few years.
Eventually, I demoed the Intuitive Surgical da Vinci robot console. Ten minutes into my demo and the Intuitive rep had me booked for a training session in Sunnyvale, California. There I got my chops operating on a pig, and I never looked back.
Laparoscopic surgery was a gateway drug. Robotic surgery was hardcore. Four years later, my advanced laparoscopic and vaginal surgery skills had atrophied and were rusty, at best.
My story is typical. I have a distinct memory circa 2014 of sitting in the surgeon lounge with a group of my other gyn-robotic colleagues and listening to them marvel about the robot.
One surgeon reported that the robot extended her career as her back and hip no longer bother her as they did with laparoscopic cases, a finding that was validated in this study.
Another surgeon shared how she was able to operate up to her due date for her current pregnancy, all because of the robot. A third surgeon compared the robot to driving a Ferrari versus the laparoscopic ’57 Chevy.
Here we are in 2020, and an entire generation of gyn surgeons have adopted and trained on the da Vinci. Robotic surgery now generates an annual $3 billion dollars in revenue and is expected to grow by 15% per year until 2022.
The deeper question for health systems is how to address the economics of the situation.
Below is a stakeholder assessment and proposed contributions to forge a path to a high-value hysterectomy clinical pathway.
Healthcare Systems and Surgeons
Healthcare systems are bearing the brunt of the economic loss and expense related to the explosion of robotic surgery. Surgeons often lack awareness and understanding of what we can do to reduce costs.
I recall a dialogue with my colleagues several years ago in which we compared the costs of various hemostatic agents we routinely used in the operating room. We were surprised to learn that the cost varied from $13 to $250 per case. This discussion pushed us to create an equipment and supply scorecard that compared our supply chain patterns with a focus on value, best practices, and evidence-based medicine.
The concept of a surgeon scorecard is not unique and has been well documented as an effective intervention in a recent JAMA article in which a 7.4% cost reduction was realized.
Another article highlighting a similar intervention for orthopedic procedures demonstrated an 8.7% reduction in cost when surgeons were given a monthly “Surgeon Value Scorecard” over a 9-month period.
In order to support opportunities like these, health systems need to invest in technology and analytic solutions to engage and influence physician behaviors that offer real-time feedback and empower physician leaders with the tools and resources they need to make value-based choices in the operating room.
Approaching a high-value hysterectomy clinical pathway by focusing on four areas of opportunity in a continuous fashion — supply costs, length of stay, surgeon efficiency, and route selection — is a great starting point. Individual surgeon and institutional scorecards that drill down into these factors can be leveraged to identify mentorship opportunities, potential behavior changes, and most importantly, best practices.
Intuitive Surgical and Device Manufacturers
Aligned incentives between medical device representatives is critical to our success. As we introduce technology solutions into our healthcare systems, we need to ensure that a value prospect is included in the contracting process.
In my experience, the Intuitive reps often encourage trainees to switch out instruments and select higher-cost instruments as they are incentivized to maximize surgeon utilization.
A 2010 ACOG Green Journal article identified disposable equipment cost opportunities in robotic surgery. Healthcare systems and training programs should demand that device manufacturers develop the highest value training program for adoption of their device and respect the clinical pathways and best practices within an institution for utilization of the device.
Residency Training Programs
Non-academic health systems should work collaboratively with graduate medical education programs, sharing their challenges, and influencing curriculum and training that promotes value in surgeon development. A 2013 AJOG article emphasized the importance of surgeon efficiency in robotic surgery cost management.
Integrating an efficiency assessment and cost management into surgical training is described in this article as part of the robotic credentialing pathway.
Academies and Society Consensus Statements
In 2009, ACOG reinforced their recommendation that vaginal hysterectomy was the preferred route of hysterectomy via a Committee Opinion, yet despite this statement, vaginal hysterectomy rates continued to decline. This is a testament to the fact that an academy, college, or society statement alone cannot influence the tide of change.
That being said, they can lead the charge in engaging the above stakeholders to develop high-value clinical pathways that incorporate emerging technologies.
In conclusion, the impact of the COVID-19 global pandemic has placed significant financial pressure on healthcare systems, making opportunities to identify value in care delivery ever more relevant and urgent.
The use of a high-value hysterectomy clinical pathway that provides real-time and transparent feedback to surgeons is an approach that can address factors related to cost and quality and integrate value into surgical care.
Eve Cunningham, MD, is the chief medical officer of Providence Medical Group.