REVIEW URRENT C OPINION
Cost-effectiveness of robotic surgery in gynecologic oncology Yue Xie
Purpose of review Robotically assisted surgeries have flourished in the United States, especially in gynecological procedures. Current robotic systems have high upfront and procedure costs that have led many in the medical community to question the new technology’s cost-effectiveness. Recent findings Recent research continues to find that robotically assisted gynecological cancer treatments have comparable outcomes to traditional laparoscopy and similar or better outcomes than that of laparotomy in the cases studied. However, robotic surgery costs remain higher than that of traditional laparoscopy. Summary Under the current reimbursement climate, practicing physicians and hospitals should collaborate on identifying cost-effective uses of robotic systems and pushing manufacturers to lower purchase and procedure costs to a level that may be accepted by all stakeholders. Keywords cost-effectiveness, costs, outcomes, reimbursement policy, robotic surgery
INTRODUCTION
OUTCOMES
Robotically assisted surgeries began in the 1980s and over the last three decades have expanded widely to various surgical specialties including gynecology [1]. Since the introduction of the da Vinci Surgical System in 1999, however, the number of robotically assisted procedures has increased rapidly. In 2013, there were approximately 422 000 procedures performed in the United States using the da Vinci system and 523 000 worldwide, representing an increase of more than 127% over 2010 and 554% over 2007 [2,3]. As a specialty, gynecology has become the system’s single largest user with approximately 240 000 performed procedures in the United States in 2013, 57% of all cases operated with the system and a 41% increase over 2011 [2]. Additionally, the manufacturer reported that the worldwide installation base for the da Vinci system had reached 2966 units by the end of 2013, a 197% increase over 2007 [2,3]. With the purchase cost of a da Vinci system currently running between $1 million and $2.3 million along with annual service contracts costing between $100 000 and $170 000, many in the medical community have questioned the cost-effectiveness of the system [3,4 ,5].
Cost-effectiveness, or value, has two components – costs and outcomes, with the equation defined as outcomes relative to costs [6]. The Society of Gynecologic Oncology’s Clinical Practice Robotics Task Force (Task Force) stated in 2012 that, based on the body of knowledge available at the time, robotically assisted oncologic procedures for cervical and ovarian cancers had similar performance outcomes to traditional laparoscopy, but offered advantages over laparotomy in less blood loss and shorter length of stay, whereas no differences were observed in oncologic outcomes among the three approaches [7 ]. In addition, the Task Force noted that the robotic and the laparoscopic approaches offered less operative complications for cervical cancer procedures,
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Department of Public Health, College of Health, The University of Southern Mississippi, Hattiesburg, Mississippi, USA Correspondence to Yue Xie, PhD, Health Policy and Administration, Department of Public Health, College of Health, The University of Southern Mississippi, 118 College Drive #5122, Hattiesburg, MS 39406, USA. Tel: +1 601 266 4180; fax: +1 601 266 5043; e-mail: [email protected] Curr Opin Obstet Gynecol 2015, 27:73–76 DOI:10.1097/GCO.0000000000000134
1040-872X Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.co-obgyn.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Gynecologic cancer
KEY POINTS Gynecologic robotically assisted surgery volume has increased significantly in recent years to lead all others by a wide margin. Current robotic systems have significant upfront and procedure costs. Studies show that robotically assisted surgeries have similar outcomes to traditional laparoscopy, but at a higher cost. Healthcare reimbursement climate is changing, and future payments may be based on episodes of care that bind physicians and facilities. Physicians and hospitals should collaborate on identifying cost-effective uses of robotic systems and pushing manufacturers to lower costs.
whereas robotic surgery showed advantages over laparoscopy in managing obese patients with endometrial cancers [7 ]. However, the Task Force cautioned that these findings are based on retrospective studies with sequential time comparisons or single-surgeon experiences that may be affected by selection bias. More recent studies, nevertheless, continue to show robotically assisted surgical outcomes to be comparable to that of traditional laparoscopy and superior to laparotomy, while expanding its reach to transperitoneal infrarenal paraaortic lymphadenectomy (TIPAL), elderly and medically ill patients, and patients with advanced cervical cancer [8–11]. With regard to ovarian cancer, however, the Task Force noted that data were too limited to provide any conclusive guidance, except that robotic surgery may be more suited for early-stage or small volume disease than more advanced disease [7 ]. More recent studies on the subject continue to show limited use of robotics in ovarian cancer surgeries. Nevertheless, Escobar et al. [12] reported in a retrospective, multiinstitutional study that, from 2006 to 2012, 48 robotically assisted surgeries were performed on patients who had recurrent ovarian cancers with masses isolated to one anatomic region. Of the study group, four cases (8.3%) were converted to laparotomy, whereas the remaining had mean operative time of 179.5 min, estimated blood loss of 50 ml, and 1 day postoperative stay. Finger and Nezhat [13] further reported that robotically assisted fertility-sparing surgeries were successfully performed on two women of ages 29 and 31 with early ovarian cancer. Both women were eventually able to conceive and were disease-free at 46 months and 19 months postoperative, respectively [13]. &&
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Neither study, however, compared results with that of the traditional laparoscopic or laparotomy approaches. One retrospective study by Feuer et al. [14] did compare single surgeon robotically assisted management of epithelial ovarian cancer with that of laparotomy. The results showed that robotic surgery (63 cases) required longer operative time, but had reduced blood loss, shorter length of stay, and survival rates similar to that of laparotomy (26 cases) at 1 year [14].
COSTS Although consensus that robotically assisted surgeries have similar outcomes to that of traditional laparoscopy and better outcomes than laparotomy may be emerging, the costs side of the value equation is still being debated. The Task Force noted in 2012 that studies have shown robotic technology to be of higher cost than traditional laparoscopy, but less expensive than traditional laparotomy in the management of endometrial cancer [7 ]. Where robotic surgery had demonstrated advantages were the shorter length of stay and quicker recovery to normal level of activity. However, robotically assisted surgeries incurred much higher upfront purchase costs and maintenance costs along with increased disposable instrument costs. Another observed cost differentiator commented by the Task Force was the increased operating room time associated with robotic surgery, but it postulated that with more experience this may potentially decrease over time. More recent studies indeed demonstrate that robotic surgery efficiencies improve over time and one study showed that it may have a faster learning curve than traditional laparoscopy. Reynisson and Persson [15 ] reported that, for radical hysterectomy and pelvic lymphadenectomy, robot-assisted laparoscopy was able to decrease operating room time from 406 min to 277 (22 min less than laparotomy) and bring down costs to the level of laparotomy after approximately 90 procedures. Lim et al. [16 ] further noted that, performing hysterectomy with lymphadenectomy, proficiency was reached by the 24th case for the robotically assisted approach as compared with the 49th case for the traditional laparoscopic method. Other studies continue to report that traditional laparoscopy is less expensive than robotic surgery, but robot-assisted approaches may be less costly than laparotomy given sufficient volume and decreased length of stay [9,17,18 ,19]. &&
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STAKEHOLDER VIEWS AND IMPLICATIONS Cost-effectiveness, however, is in the eye of the beholder and different stakeholders may base Volume 27 Number 1 February 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Cost-effectiveness of robotic surgery in gynecologic oncology Xie
evaluations on divergent parameters. For a practicing physician, surgical outcome, ergonomics, procedure volume and reimbursement may be important. For a hospital or surgical center administrator, outcome, profitability, cost, reimbursement, and the ability to attract physicians and patients may be paramount. Yet, what about the health system and those who influence system level policies such as reimbursement rules? For health systems, the primary policy concerns are related to cost, quality, and access. The Affordable Care Act (ACA) prominently promotes access, but subtly also addresses cost and quality by binding reimbursement to outcomes. In the United States, the policy makers are especially concerned with the fast pace of healthcare cost growth as the total health system expenditures reached 17.9% of Gross Domestic Product (GDP) in 2011 [20]. The federal government being a payer of healthcare services and responsible for 26% of national healthcare expenditures while facing an aging population has a policy mandate to control the pace of cost growth [21]. Previous studies have suggested that about half of the long-term increases in healthcare costs may be attributed to the introduction of new medical technologies [22]. Robotically assisted surgery, more specifically the da Vinci system, although introduced over 15 years ago, is not yet recognized as a separate procedure requiring increased reimbursement. Currently, robotic surgeries receive the same reimbursement as traditional laparoscopy. In light of Wright et al. [4 ] reporting that outcomes for robotically assisted hysterectomy for benign gynecologic disease were comparable to laparoscopy while costing $2189 more per case, it is not likely reimbursement policy would change soon; especially when 191 000 hysterectomies were performed robotically in 2013 [2], potentially adding another $418 million in annual costs to the health system. Hospitals on the contrary have very different interests from that of the health system. The bottom-line for any hospital is to generate a profit and sustain operations, or ‘No Margin, No Mission’ as championed by Sister Irene Kraus, the one-time President of the 80-hospital Daughters of Charity National Health System [23]. There are exceptions such as a hospital stays open for the benefit of a community while operating at a loss, but such business model cannot be sustained in the long run. Each year a significant number of hospitals operate with negative margins and are likely to face closure. The latest data available from the American Hospital Association show that 25.9% of the 5723 US hospitals in 2012 had negative operating margins, whereas 21.3% had negative total margins – both are improved performances over prior years &
[24,25]. Ideally then, choosing among robotic surgery, traditional laparoscopy and laparotomy, a hospital would want to select the most profitable method or at a minimum the most cost-effective method. Current research on robotic surgery, nevertheless, remains focused on cost comparisons rather than profitability. A single retrospective study by Geller and Matthews [26 ] did present that robotic surgery was progressively more profitable over time at their institution. A shortcoming of this study is that the facility involved is a large academic medical center with extensive market share in its region, and therefore would have commanded much higher managed care reimbursement rates than the many smaller community or rural hospitals that have entered the robotic surgery market [27–29]. Are these smaller hospitals being prudent? Or maybe they are contributing to the body of evidence that shows that hospitals are more or less in a medical ‘arms race’ when making robotic system purchasing decisions [1] – instead of acquisition based on profitability and cost-effectiveness analysis, robotic technology is used to attract patients and surgeons, and increase market share. Historically, the interests of the practicing physicians are much more aligned with the facilities than that of the overall health system. Like hospitals, physicians want to see good surgical outcomes, greater volume, and higher reimbursements. Unlike hospitals, however, physicians are not as concerned with equipment and procedure costs because these have been the responsibility of the facilities. This dynamic, nevertheless, is changing. Medicare, using its position as the largest healthcare payer, is driving forward episode-based payment reforms that would ultimately bind physician and facility services into one single payment for an entire patient-care episode from preadmission to readmission [30 ,31]. Furthermore, traditionally when Medicare makes a paradigm shift in reimbursement strategy the commercial insurances have quickly followed [32]. Therefore, it is possible that within the next 10–15 years the entire healthcare reimbursement landscape would be dramatically different and physicians would then be responsible for not only outcomes, but also costs. Robotic surgery in gynecologic oncology has generally demonstrated outcomes comparable to that of the traditional laparoscopy for the procedures studied, but at a higher cost. Unless costs drop in the foreseeable future, where robotic surgery has shown potential advantages, then, is perhaps in cases involving high body mass patients or when a surgeon is not proficient or no longer able to perform procedures using traditional laparoscopy. Another opportunity may lie with the replacement of certain costly
1040-872X Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
&
&
www.co-obgyn.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Gynecologic cancer
laparotomy procedures if traditional laparoscopy is not an option.
CONCLUSION Robotically assisted surgeries in gynecologic oncology have demonstrated comparable outcomes to that of traditional laparoscopy and better outcomes than laparotomy in many procedures. However, these outcomes are often associated with increased costs. Under the current reimbursement climate, physicians and hospitals should collaborate on identifying cost-effective use of the robotic system and pushing manufacturers to lower purchase and procedure costs to a level that may be accepted by all stakeholders. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest None.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Garber S, Gates SM, Keeler EB, et al. Redirecting innovation in U.S healthcare: options to decrease spending and increase value. Santa Monica: RAND Corporation 2014. 2. Intuitive Surgical, Inc. Annual Report 2013. http://phx.corporate-ir.net/Exter nal.File?item=UGFyZW50SUQ9MjIzOTk3fENoaWxkSUQ9LTF8VHlwZT0z& t=1. [Accessed 6 September 2014] 3. Barbash GI, Glied SA. New technology and healthcare costs: the case of robot-assisted surgery. N Engl J Med 2010; 363:701–704. 4. Wright JD, Ananth CV, Lewin SN, et al. Robotically assisted vs laparoscopic & hysterectomy among women with benign gynecologic disease. JAMA 2013; 309:689–698. Most cited recent journal article in the discussions related to cost-effectiveness of robotically assisted surgery. 5. Statement on robotic surgery by ACOG President James T. Breeden, MD. The American Congress of Obstetricians and Gynecologists. http://www. acog.org/About_ACOG/News_Room/News_Releases/2013/Statement_on_ Robotic_Surgery?p=1. [Accessed 6 September 2014] 6. Porter ME. What is value in healthcare? N Engl J Med 2010; 363:2477– 2481. 7. Society of Gynecologic Oncology’ Clinical Practice Robotics Task, Force. && Robotic-assisted surgery in gynecologic oncology: a society of Gynecologic Oncology consensus statement. Gynecol Oncol 2012; 124:180–184. The Task Force’s conclusions reached in 2012 continue to be highly relevant with regard to robotically assisted surgeries in gynecologic oncology. 8. Lavoue V, Zeng X, Lau S, et al. Impact of robotics on the outcome of elderly patients with endometrial cancer. Gynecol Oncol 2014; 133:556–562. 9. Coronado PJ, Fasero M, Magrina JF, et al. Comparison of perioperative outcomes and cost between robotic-assisted and conventional laparoscopy for transperitoneal infrarenal para-aortic lymphadenectomy (TIPAL). J Minim Invasive Gynecol 2014; 21:674–681. 10. Sieston G, Ornaghi S, Ieda N, et al. Robotic surgical staging for endometrial and cervical cancers in medically ill patients. Gynecol Oncol 2013; 129:593– 597.
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11. Vizza E, Corrado G, Mancini E, et al. Laparoscopic versus robotic radical hysterectomy after neoadjuvant chemotherapy in locally advanced cervical cancer: a case control study. Eur J Surg Oncol;2013. http://dx.doi.org/ 10.1016/j.ejso.2013.08.018. [Epub ahead of print] [Accessed 6 September 2014] 12. Escobar PF, Levinson KL, Magrina J, et al. Feasibility and perioperative outcomes of robotic-assisted surgery in the management of recurrent ovarian cancer: a multiinstitutional study. Gynecol Oncol 2014; 134:253–256. 13. Finger TN, Nezhat FR. Robotic-assisted fertility-sparing surgery for early ovarian cancer. JSLS 2014; 18:308–313. 14. Feuer GA, Lakhi N, Parker J, et al. Perioperative and clinical outcomes in the management of epithelial ovarian cancer using a robotic or abdominal approach. Gynecol Oncol 2013; 131:520–524. 15. Reynisson P, Persson J. Hospital costs for robot-assisted laparoscopic & radical hysterectomy and pelvic lymphadenectomy. Gynecol Oncol 2013; 130:95–99. Study shows that cost efficiency of robotically assisted surgeries improves over time and at least 90 procedures may be required to reach this level of efficiency. 16. Lim PC, Kang E, Park DH. A comparative detail analysis of the learning curve & and surgical outcome for robotic hysterectomy with lymphadenectomy versus laparoscopic hysterectomy with lymphadenectomy in treatment of endometrial cancer: a case-matched controlled study of the first one hundred twenty two patients. Gynecol Oncol 2011; 120:413–418. This study shows that robotically assisted surgeries may have a faster learning curve than traditional laparoscopy. 17. Elliott CS, Hsieh MH, Sokol ER, et al. Robot-assisted versus open sacrocolpopexy: a cost-minimization analysis. J Urol 2012; 187:638–643. 18. Venkat P, Chen LM, Young-Lin N, et al. An economic analysis of robotic versus & laparoscopic surgery for endometrial cancer: costs, charges and reimbursements to hospitals and professionals. Gynecol Oncol 2012; 125:237–240. This study shows that robotically assisted procedures cost more than traditional laparoscopic procedures, but no difference in reimbursement. 19. Leitao MM, Bartashnik A, Wagner I, et al. Cost-effectiveness analysis of robotically assisted laparoscopy for newly diagnosed uterine cancers. Obstet Gynecol 2014; 123:1031–1037. 20. Fuchs V. The gross domestic product and healthcare spending. N Engl J Med 2013; 369:107–109. 21. NHE Fact Sheet: Historical NHE, 2012. Center for Medicare & Medicaid Services. 2014. http://www.cms.gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet. html. [Accessed 8 September 2014] 22. Congressional Budget Office. CBO testimony: growth in healthcare costs. http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/89xx/doc8948/01-31healthtestimony.pdf. [Accessed 8 September 2014] 23. Manning M. Health chain in spotlight: Wall street journal scrutinizes Daughters of Charity. St. Louis Business Journal; 1998. http://www.bizjournals.com/ stlouis/stories/1998/01/12/story3.html?page=all. [Accessed 8 September 2014] 24. American Hospital Association. Chartbook: trends affecting hospitals and health systems. American Hospital Association. http://www.aha.org/re search/reports/tw/chartbook/ch4.shtml. [Accessed 8 September 2014] 25. American Hospital Association. Fast facts on US hospitals. American Hospital Association. http://www.aha.org/research/rc/stat-studies/101207fastfacts. pdf. [Accessed 8 September 2014] 26. Geller EJ, Matthews CA. Impact of robotic operative efficiency on profitability. & Am J Obstet Gynecol 2013; 209:20.e1-5. This study shows that for a large academic medical center with a dominant market share robotically assisted surgeries may be profitable. 27. White C, Bond AM, Reschovsky JD. Research brief: high and varying prices for privately insured patients underscore hospital market power. Washington DC: Center for Studying Health System Change; Number 27; September 2013. 28. Ginsburg PB. Research Brief: wide variation in hospital and physician payment rates evidence of provider market power. Washington DC: Center for Studying Health System Change; Number 16; November 2010. 29. Lee J. Surgical-robot costs put small hospitals in a bind. Modern Healthcare. http://www.modernhealthcare.com/article/20140419/MAGAZINE/ 304199985. [Accessed 8 September 2014] 30. Paths to healthcare payment reform. Center for Healthcare Quality & Payment & Reform. http://www.chqpr.org/downloads/TransitioningtoEpisodes.pdf. [Accessed 9 September 2014] This is a fact sheet explaining episode-based payment reform. 31. Mechanic RE, Altman SH. Payment reform options: episode payment is a good place to start. Health Aff (Millwood) 2009; 28:w262–w271. 32. Clemens J, Gottlieb JD. Bargaining in the shadow of a giant: Medicare’s influence on private payment systems. Working paper 19503. National Bureau of Economic Research. October 2013. http://www.nber.org/papers/ w19503. [Accessed 6 September 2014]
Volume 27 Number 1 February 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Cost-effectiveness of robotic surgery in gynecologic oncology Yue Xie
Purpose of review Robotically assisted surgeries have flourished in the United States, especially in gynecological procedures. Current robotic systems have high upfront and procedure costs that have led many in the medical community to question the new technology’s cost-effectiveness. Recent findings Recent research continues to find that robotically assisted gynecological cancer treatments have comparable outcomes to traditional laparoscopy and similar or better outcomes than that of laparotomy in the cases studied. However, robotic surgery costs remain higher than that of traditional laparoscopy. Summary Under the current reimbursement climate, practicing physicians and hospitals should collaborate on identifying cost-effective uses of robotic systems and pushing manufacturers to lower purchase and procedure costs to a level that may be accepted by all stakeholders. Keywords cost-effectiveness, costs, outcomes, reimbursement policy, robotic surgery
INTRODUCTION
OUTCOMES
Robotically assisted surgeries began in the 1980s and over the last three decades have expanded widely to various surgical specialties including gynecology [1]. Since the introduction of the da Vinci Surgical System in 1999, however, the number of robotically assisted procedures has increased rapidly. In 2013, there were approximately 422 000 procedures performed in the United States using the da Vinci system and 523 000 worldwide, representing an increase of more than 127% over 2010 and 554% over 2007 [2,3]. As a specialty, gynecology has become the system’s single largest user with approximately 240 000 performed procedures in the United States in 2013, 57% of all cases operated with the system and a 41% increase over 2011 [2]. Additionally, the manufacturer reported that the worldwide installation base for the da Vinci system had reached 2966 units by the end of 2013, a 197% increase over 2007 [2,3]. With the purchase cost of a da Vinci system currently running between $1 million and $2.3 million along with annual service contracts costing between $100 000 and $170 000, many in the medical community have questioned the cost-effectiveness of the system [3,4 ,5].
Cost-effectiveness, or value, has two components – costs and outcomes, with the equation defined as outcomes relative to costs [6]. The Society of Gynecologic Oncology’s Clinical Practice Robotics Task Force (Task Force) stated in 2012 that, based on the body of knowledge available at the time, robotically assisted oncologic procedures for cervical and ovarian cancers had similar performance outcomes to traditional laparoscopy, but offered advantages over laparotomy in less blood loss and shorter length of stay, whereas no differences were observed in oncologic outcomes among the three approaches [7 ]. In addition, the Task Force noted that the robotic and the laparoscopic approaches offered less operative complications for cervical cancer procedures,
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Department of Public Health, College of Health, The University of Southern Mississippi, Hattiesburg, Mississippi, USA Correspondence to Yue Xie, PhD, Health Policy and Administration, Department of Public Health, College of Health, The University of Southern Mississippi, 118 College Drive #5122, Hattiesburg, MS 39406, USA. Tel: +1 601 266 4180; fax: +1 601 266 5043; e-mail: [email protected] Curr Opin Obstet Gynecol 2015, 27:73–76 DOI:10.1097/GCO.0000000000000134
1040-872X Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.co-obgyn.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Gynecologic cancer
KEY POINTS Gynecologic robotically assisted surgery volume has increased significantly in recent years to lead all others by a wide margin. Current robotic systems have significant upfront and procedure costs. Studies show that robotically assisted surgeries have similar outcomes to traditional laparoscopy, but at a higher cost. Healthcare reimbursement climate is changing, and future payments may be based on episodes of care that bind physicians and facilities. Physicians and hospitals should collaborate on identifying cost-effective uses of robotic systems and pushing manufacturers to lower costs.
whereas robotic surgery showed advantages over laparoscopy in managing obese patients with endometrial cancers [7 ]. However, the Task Force cautioned that these findings are based on retrospective studies with sequential time comparisons or single-surgeon experiences that may be affected by selection bias. More recent studies, nevertheless, continue to show robotically assisted surgical outcomes to be comparable to that of traditional laparoscopy and superior to laparotomy, while expanding its reach to transperitoneal infrarenal paraaortic lymphadenectomy (TIPAL), elderly and medically ill patients, and patients with advanced cervical cancer [8–11]. With regard to ovarian cancer, however, the Task Force noted that data were too limited to provide any conclusive guidance, except that robotic surgery may be more suited for early-stage or small volume disease than more advanced disease [7 ]. More recent studies on the subject continue to show limited use of robotics in ovarian cancer surgeries. Nevertheless, Escobar et al. [12] reported in a retrospective, multiinstitutional study that, from 2006 to 2012, 48 robotically assisted surgeries were performed on patients who had recurrent ovarian cancers with masses isolated to one anatomic region. Of the study group, four cases (8.3%) were converted to laparotomy, whereas the remaining had mean operative time of 179.5 min, estimated blood loss of 50 ml, and 1 day postoperative stay. Finger and Nezhat [13] further reported that robotically assisted fertility-sparing surgeries were successfully performed on two women of ages 29 and 31 with early ovarian cancer. Both women were eventually able to conceive and were disease-free at 46 months and 19 months postoperative, respectively [13]. &&
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Neither study, however, compared results with that of the traditional laparoscopic or laparotomy approaches. One retrospective study by Feuer et al. [14] did compare single surgeon robotically assisted management of epithelial ovarian cancer with that of laparotomy. The results showed that robotic surgery (63 cases) required longer operative time, but had reduced blood loss, shorter length of stay, and survival rates similar to that of laparotomy (26 cases) at 1 year [14].
COSTS Although consensus that robotically assisted surgeries have similar outcomes to that of traditional laparoscopy and better outcomes than laparotomy may be emerging, the costs side of the value equation is still being debated. The Task Force noted in 2012 that studies have shown robotic technology to be of higher cost than traditional laparoscopy, but less expensive than traditional laparotomy in the management of endometrial cancer [7 ]. Where robotic surgery had demonstrated advantages were the shorter length of stay and quicker recovery to normal level of activity. However, robotically assisted surgeries incurred much higher upfront purchase costs and maintenance costs along with increased disposable instrument costs. Another observed cost differentiator commented by the Task Force was the increased operating room time associated with robotic surgery, but it postulated that with more experience this may potentially decrease over time. More recent studies indeed demonstrate that robotic surgery efficiencies improve over time and one study showed that it may have a faster learning curve than traditional laparoscopy. Reynisson and Persson [15 ] reported that, for radical hysterectomy and pelvic lymphadenectomy, robot-assisted laparoscopy was able to decrease operating room time from 406 min to 277 (22 min less than laparotomy) and bring down costs to the level of laparotomy after approximately 90 procedures. Lim et al. [16 ] further noted that, performing hysterectomy with lymphadenectomy, proficiency was reached by the 24th case for the robotically assisted approach as compared with the 49th case for the traditional laparoscopic method. Other studies continue to report that traditional laparoscopy is less expensive than robotic surgery, but robot-assisted approaches may be less costly than laparotomy given sufficient volume and decreased length of stay [9,17,18 ,19]. &&
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STAKEHOLDER VIEWS AND IMPLICATIONS Cost-effectiveness, however, is in the eye of the beholder and different stakeholders may base Volume 27 Number 1 February 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Cost-effectiveness of robotic surgery in gynecologic oncology Xie
evaluations on divergent parameters. For a practicing physician, surgical outcome, ergonomics, procedure volume and reimbursement may be important. For a hospital or surgical center administrator, outcome, profitability, cost, reimbursement, and the ability to attract physicians and patients may be paramount. Yet, what about the health system and those who influence system level policies such as reimbursement rules? For health systems, the primary policy concerns are related to cost, quality, and access. The Affordable Care Act (ACA) prominently promotes access, but subtly also addresses cost and quality by binding reimbursement to outcomes. In the United States, the policy makers are especially concerned with the fast pace of healthcare cost growth as the total health system expenditures reached 17.9% of Gross Domestic Product (GDP) in 2011 [20]. The federal government being a payer of healthcare services and responsible for 26% of national healthcare expenditures while facing an aging population has a policy mandate to control the pace of cost growth [21]. Previous studies have suggested that about half of the long-term increases in healthcare costs may be attributed to the introduction of new medical technologies [22]. Robotically assisted surgery, more specifically the da Vinci system, although introduced over 15 years ago, is not yet recognized as a separate procedure requiring increased reimbursement. Currently, robotic surgeries receive the same reimbursement as traditional laparoscopy. In light of Wright et al. [4 ] reporting that outcomes for robotically assisted hysterectomy for benign gynecologic disease were comparable to laparoscopy while costing $2189 more per case, it is not likely reimbursement policy would change soon; especially when 191 000 hysterectomies were performed robotically in 2013 [2], potentially adding another $418 million in annual costs to the health system. Hospitals on the contrary have very different interests from that of the health system. The bottom-line for any hospital is to generate a profit and sustain operations, or ‘No Margin, No Mission’ as championed by Sister Irene Kraus, the one-time President of the 80-hospital Daughters of Charity National Health System [23]. There are exceptions such as a hospital stays open for the benefit of a community while operating at a loss, but such business model cannot be sustained in the long run. Each year a significant number of hospitals operate with negative margins and are likely to face closure. The latest data available from the American Hospital Association show that 25.9% of the 5723 US hospitals in 2012 had negative operating margins, whereas 21.3% had negative total margins – both are improved performances over prior years &
[24,25]. Ideally then, choosing among robotic surgery, traditional laparoscopy and laparotomy, a hospital would want to select the most profitable method or at a minimum the most cost-effective method. Current research on robotic surgery, nevertheless, remains focused on cost comparisons rather than profitability. A single retrospective study by Geller and Matthews [26 ] did present that robotic surgery was progressively more profitable over time at their institution. A shortcoming of this study is that the facility involved is a large academic medical center with extensive market share in its region, and therefore would have commanded much higher managed care reimbursement rates than the many smaller community or rural hospitals that have entered the robotic surgery market [27–29]. Are these smaller hospitals being prudent? Or maybe they are contributing to the body of evidence that shows that hospitals are more or less in a medical ‘arms race’ when making robotic system purchasing decisions [1] – instead of acquisition based on profitability and cost-effectiveness analysis, robotic technology is used to attract patients and surgeons, and increase market share. Historically, the interests of the practicing physicians are much more aligned with the facilities than that of the overall health system. Like hospitals, physicians want to see good surgical outcomes, greater volume, and higher reimbursements. Unlike hospitals, however, physicians are not as concerned with equipment and procedure costs because these have been the responsibility of the facilities. This dynamic, nevertheless, is changing. Medicare, using its position as the largest healthcare payer, is driving forward episode-based payment reforms that would ultimately bind physician and facility services into one single payment for an entire patient-care episode from preadmission to readmission [30 ,31]. Furthermore, traditionally when Medicare makes a paradigm shift in reimbursement strategy the commercial insurances have quickly followed [32]. Therefore, it is possible that within the next 10–15 years the entire healthcare reimbursement landscape would be dramatically different and physicians would then be responsible for not only outcomes, but also costs. Robotic surgery in gynecologic oncology has generally demonstrated outcomes comparable to that of the traditional laparoscopy for the procedures studied, but at a higher cost. Unless costs drop in the foreseeable future, where robotic surgery has shown potential advantages, then, is perhaps in cases involving high body mass patients or when a surgeon is not proficient or no longer able to perform procedures using traditional laparoscopy. Another opportunity may lie with the replacement of certain costly
1040-872X Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
&
&
www.co-obgyn.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
75
Gynecologic cancer
laparotomy procedures if traditional laparoscopy is not an option.
CONCLUSION Robotically assisted surgeries in gynecologic oncology have demonstrated comparable outcomes to that of traditional laparoscopy and better outcomes than laparotomy in many procedures. However, these outcomes are often associated with increased costs. Under the current reimbursement climate, physicians and hospitals should collaborate on identifying cost-effective use of the robotic system and pushing manufacturers to lower purchase and procedure costs to a level that may be accepted by all stakeholders. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest None.
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Volume 27 Number 1 February 2015
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