Christopher W. Macomber, Chair of Robotic Surgery, Allina Health
With 2021 just getting underway, I found myself struggling with how to author a non-clinical article on “robotic surgery” that would interest someone in the midst of a pandemic and charged political climate. But as a surgeon,I couldn’t imagine anything more fun than discussing the economic and operational aspects of robotic surgery.
Given the enormity of this topic and the sheer amount ofcapital and resources robotic surgery encompasses, I thought it would be most beneficial to focus on a few key areas that my organization, a large Midwest health care system, and I, the chair of the robotics program, are looking at for the upcoming year:
Expansion of robotic surgery into the ambulatory surgical center (or ASC) market.
Enhancing data analytics and developing key performance indicators (or KPI’s) for robotic surgery—working towards determiningthe “value” of robotic surgery.
Developing methodology for the evaluation and incorporation of new robotic surgery and technology platforms coming to marketin the future.
As part of this article, I make two key assumptions around robotic surgery. First, I believe that most hospitals and health care systems have, at this point, recognized that robotics is a necessary component of their surgery service line offerings to patients. Second, based on personal experience and some available literature, many patients recognize the use of advanced technology such as robotics as a distinguishing factor when evaluating where to receive their health care and with what surgeon. With those assumptions in mind, I feel the above topics are three of the more critical areas that will need to be addressed in order to drive continued growth and innovation in robotics.
Shift to Ambulatory Surgery Centers (ASC)
Of the many forces impacting the ASC market, two, in particular, are accelerating interest in robotic surgery platforms at ASC’s: the pandemic and a majorshift to increased outpatient surgery by Centers for Medicare and Medicaid Services (CMS).
During the pandemic, hospitals were forced to decrease surgery volume, limiting access to main hospital operating rooms.Many hospitals and surgeons shifted cases to ASC’s, which felt safer to patients, away from COVID-19 units in hospitals, and helped reduce hospital resource utilization and staffing burdens (many ASC’s have separate staff and PPE supplies). As most surgical robots are installed at hospital operating rooms, not a free-standing ASC, this limited the number of robotic procedures that could be performed. Up to now, the cost of acquisition and higher per procedure cost has restricted the number of ASC’s with robots.
The second major driver is the upcoming shift in CMS policy regarding “inpatient only” procedures, with an expansion in the number of cases that can and will need to be done at ASC’s. There are several elements of this policy shift that can be beneficial; however, there is a nested cost-containment plan here, as outpatient procedures are typically reimbursed less than procedures performed at an inpatient operating room.
This shift in policy has highlighted limited surgeon access to ASC’s as well as limitations on what patients are healthy enough to receive surgery at an ASC. However, a large percent of current robotics cases can be safely performed at an ASC if the technology were more available.
Due to reduced reimbursement, this shift to ASC’s willresult in a drop in revenue for institutions. It will shift volume to the ASC without a clear incremental increase in surgical volume to fill the gap at the hospital operating rooms and could increase costs per procedure if it’s not deployed effectively.
We are working through this presently at my institution, but challenges include:
Physical size of the current robotic platforms
Per procedure costs
Procedural variability by surgeon, specialty, and complexity of the patient
Regardless of how you evaluate these two market forces, this will be a challenging business plan to write but will need to happen.
Data, Key Performance Indicators, and the Definition of Value
As amazing as “big data” in health care can be, a lot of these data and metrics are dependent on the quality of the information collected and the IT systems in place. In regards to “value”, even if you scour the surgical literature, you are hard-pressed to find a surgical association or surgical specialty that can agree on what defines value for a given surgery.
The surgical literature has been clear on one thing, the benefits of robotic surgery are very procedure specific. Therefore, defining value will need to be focused on not only improvements in clinical outcomes, but also patient satisfaction measures, opioid medication utilization (i.e., reduced pain), and its ability to offer surgery to more complicated and older patients. It is important for hospitals to generate their own robotic specific data at several levels, including surgeon, procedure, operational and financial. This will be necessary to justify offering not just robotic surgery but other technology as well.
I believe that “value-based” insurance contracts are going to expand, as will the shift to ASC’s and ensuing lower reimbursement. Add to this the always present cost pressure in the industry, and it’s clear that surgeons and hospitals will have to be at the tip of the spear in defining and demonstrating the value that we in the field all know robotic surgery offers.
New Robotic Surgery Technology and Platforms
Although there has been one dominant player in the field of robotic-assisted surgery for many years, the advent of competing platforms is perhaps one of the more exciting developments in recent memory. However, it is also going to be quite chaotic.
Every hospital in the country that offers robotic surgery built their robotics program around the same brand.In addition, surgeons have now spent years working with the same technology, learning its capabilities, understanding their outcomes, and knowing how to talk to their patients about the value of a robotic operation versus open or laparoscopic alternatives.
Surgeons will need to determine technology equivalency of a new platform and learn how to fit it into their practice. Hospitals will need to address platform-specific changes to their programs, including different surgeon and staff training, operating room designs and layouts, supply chain, sterile processing, data collection and reports, just to name a few.
Although cost is likely the number one issue for hospitals regarding robotic technology, available information indicates new platforms won’t be less costly. Combine a possibly equal or higher acquisition cost with the unknown technology equivalency of new platforms, and you have a rocky road to market.
I do believe it will be imperative for systems and hospital leaders to continue to have an open dialogue amongst each other to support these efforts. As the pandemic continues, insurance guidelines shift, and new systems hit the market, we will all be challenged with patient, surgeon, and industry demands for this technology, while simultaneously dealing with the ongoing financial and operational challenges it brings. For those of us who feel strongly about the role of robotics in medicine and surgery, it always comes down to ensuring the best patient care. and it will be critical that we are vocal, aggressive, and innovative in how we address these challenges to ensure we are meeting the needs of our patients.