Insurers should stop paying for robotic hysterectomies

A new study confirms what previous studies tell us. That a robotic hysterectomy is not a safer or a more efficient way to remove a uterus for non-cancerous (benign) surgery than a traditional laparoscopic approach. This study indicates that there is little difference between the two types of surgery with one glaring exception, a robotic hysterectomy was $2,489 more expensive than a laparoscopic hysterectomy.

Several months ago the American Congress of Obstetricians and Gynecologists (ACOG) issued these statements:

Robotic surgery is not the only or the best minimally invasive approach for hysterectomy. Nor is it the most cost-efficient. It is important to separate the marketing hype from the reality when considering the best surgical approach for hysterectomies.

And,

there is no good data proving that robotic hysterectomy is even as good as—let alone better—than existing, and far less costly, minimally invasive alternatives.

Robotic hysterectomies for benign disease provide nothing additional from a medical perspective although they are a welcome marketing ploy for doctors and hospitals (Hey, we have a robot! Come see us! That’s so cool!). Some hospitals and GYN practices have literally built their marketing around the robot. And obviously the more robotic hysterectomies performed the greater the profits for the makers of the da Vinci robot.

There is enough data for insurance companies to say, “We won’t pay the price difference.” If insurance companies capped hysterectomy fees at the cost of a laparoscopic procedure then if hospitals and doctors wanted to eat the price difference or pass that price difference along to their patients, so be it.

Wasting money on a procedure that offers nothing over a less expensive alternative is an outrage. As an aside, this is the biggest issue I have with Obamacare. We should all be insured, but doctors, hospitals, and medical device companies should not be allowed to take advantage of that. The need to curtail egregious expenses is urgent. A robotic hysterectomy does offer advantageous for cancer surgery, so I’m all over that, but isn’t it better to channel the money to where it can actually improve outcomes?

And so my plea is to insurance companies. Whether procedures and drugs are covered or not depends in a large part on the body of medical literature and recommendations by professional organizations (like ACOG). There is not one study that shows the benefit of robotic hysterectomy over a traditional laparoscopic approach. Since the doctors and hospitals that push robotic hysterectomies don’t have the ethics to police themselves, insurance companies must step in and stop the madness. Insurance companies can either flat-out deny robotic hysterectomies or simply cap what they will pay at the cost of a traditional laparoscopic procedure. If there were a $2,489 co-payment for a robotic hysterectomy versus a $200 co-payment for a laparoscopic hysterectomy, given they have similar outcomes, which do you think would be more popular?

It is wrong to pass the additional cost of a more expensive and non medically advantageous procedure along to other purchasers of the same insurance. I don’t want my premiums to go for medically unindicated expenses and I certainly don’t want my premiums paying for corporate perks at Intuitive Surgical (makers of the da Vinci, and who are, by the way, laughing all the way to the bank).

Given that we are all curators of the health care system it is unethical to recommend robotic hysterectomies for benign disease. If doctors and hospitals refuse to read the literature (never mind reducing the waste in the system) then they should not be surprised at all when a third party steps in to do it for them.

Someone has to help stop the madness.

Jennifer Gunter is an obstetrician-gynecologist and author of The Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.

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  • Shirie Leng, MD

    Yes Yes Yes! I’m so proud of the ACOG for taking a stand on this. My institution has two (!) robots, resulting in nothing but longer and more expensive cases. We need more physicians organizations taking a similar stand.

  • southerndoc1

    Does anyone know if Medicare also pays more when the robot is used?

  • May Wright

    The blogger “Skeptical Scalpel” had a post on this last year, where he looked at a report on robotic surgery, which had this amazing point:
    * * * * *
    “Here is the most interesting part of the report. The lead author said,
    “The robotic hysterectomy does … offer lower rates of conversion to
    laparotomy but does cause higher facility and total charges, as well as
    higher reimbursement rates.” The mean total hospital charge for robotic
    hysterectomy was $44,700 versus $25,557
    , a statistically significant
    difference. The average charge for the robotic instruments was $8,322
    compared to $3,762 for standard laparoscopy equipment, also a
    significant difference. In response to a question about why there was
    such a disparity, the lead author said: “The charges are likely to
    recoup the cost of the robot purchase.
    We have multiple robots … four
    at our main institution and several others at other sites.”

    “The reimbursement actually received for robotic hysterectomy was $19,000 and for standard laparoscopic, a mere $8,000.”
    * * * * *

    This is why your insurance is so expensive. You are buying expensive toys. And as usual, cash payors get socked the worst.

  • PrimaryCareDoc

    The robot has become a solution in search of a problem. Hospitals can’t recoup their investment in the robot by prostatectomy alone, so now they are pushing robot assisted hysterectomy and cholecystectomy. No outcome advantage, but longer time under anesthesia, higher cost, and higher complication rate.

  • buzzkillerjsmith

    A plea to insurance companies? Wow.

    But you are correct that the DaVinci stuff is mostly a scam. Another unproven technology–like EHRs. The money is to be made, but not by the likes of us.

    On the positive side, you do have to admit that robots are cool. “Lost in Space” from the ’60s. Crow T. Robot on MST3k. Robots rock. Bows and arrows are also cool, but I digress….

    • Suzi Q 38

      Maybe you can try it out for yourself….take a chance, Buzz.

  • Suzi Q 38

    Having had a poor outcome after my di Vinci hysterectomy (for pre-cancer) I AGREE.
    That machine should be a “dinosaur” if I have anything to say about it.
    If a gyn wants to use this machine on you, “RUN for the hills.”
    I have nerve damage, we are not sure why. I walked into the surgery without it.
    Also, the surgery itself took 5 hours. No cancer, just pre-cancer.
    Not a complicated tumor or anything.
    My recovery time was not bad, but I still had healing problems after.

    I think that this machine is the biggest rip-off ever.
    The surgeons are given minimum training, and it is NOT enough, IMHO.
    Sometimes the sales reps help instruct the surgeons…..imagine that??

    Hospitals have spent so much on these machines that they pressure the doctors to find other surgeries to use it on.

    It costs MORE to use the machine then other conventional methods.

    The maintenance costs are close to $100K a year for each machine.

    Some of the doctors who swear by this machine are paid honorariums by Intuit.

    I asked my hospital to report my poor outcome to the FDA, but the CMO has not gotten back to me on that one.

    I am not surprised.

    • querywoman

      Suzi Q, I remembered that you had a lousy outcome. Do you think it was from the machine or that you had an unnecessary hysterectomy? Or both?
      Everyone knows a surgeon can help you heal or maim you horribly with surgery. A good surgeon has a pair of highly skilled hands. I find it difficult to believe that any kind of machine is as good as a trained surgeon’s hands.
      We don’t always need progress. I never had robotic surgery, but I thought it bizarre. Human parts don’t follow consistent patterns, and only human hands and fingers can adequately explore the hills, bumps, and creases of a human.
      These, and other medical machines, are often paid for by the business community through private insurance.
      I doubt you could get the insurance company not to pay.
      The federal government has realized that we need more human touch and talk in medical care, and has found that home visits are an effective way to reduce cost.

      • Suzi Q 38

        Suzi Q, I remembered that you had a lousy outcome. Do you think it was from the machine or that you had an unnecessary hysterectomy? Or both?

        I can only say what I think is the cause. Who knows what is truly the cause. All I know is, I walked onto the table without any nerve problems, and had leg weakness that persisted and got worse after the diVinci hysterectomy. I figured I was on that table, slightly upside down, for about 5 hours. That could not have been good for my c-spine stenosis. The anesthesia is longer, too.

        As far as whether or not I needed the surgery, I would like to think that I made the right decision in allowing it.
        I was having severe symptoms for about 8 months or longer before the surgery, and I had complex atypical hyperplasia. The main symptom was excessive bleeding for 3 weeks out of every month. When they removed my uterus and ovaries, there was no cancer. There was a borderline tumor in my left ovary. Yes, it was good to get that one out, but it was so small that I wonder how long it would have taken to grow to a point of doing any damage.

        I had 2 separate pathologists and a gyn oncologist who recommended hysterectomy. My own gyn was “on the fence.” He said it was up to me and so I decided to do it. My surgeon did not disclose what could go wrong. I think that surgeons should do a better job of that.

        In the end, it was my decision. I was tired of the bleeding and fearful of the threat of my complex atypical cells changing to cancer. The tumor in my ovary also surprised me.

        I read later that if the problem is in the uterus (which mine was) that a more “open approach” is better, anyway. This is another reason why I question this machine for my type of surgery.

        To answer your question, I do not know. It is just odd to be able to walk well before the surgery, and have nerve sensations and leg weakness after the surgery.

  • Suzi Q 38

    Thanks,
    Of course, I wished I had talked to you before my surgery. If I had, I would not have had it done with a Da Vinci robot machine.

    • webmisdris

      As an RN in an OR with the DaVinci I can tell you that it does offer the surgeon additional mobility and flexability. A huge concern from The OR RN is the positioning of the patient and padding the nerves. As you are generally placed in stirrups and ina steep trendelenburg position. Cervical stenosis is not an issue with only lower extremity issues. That sounds like anywhere from lumbar spine, to nerves in the legs (the peroneal nerve that runs behind the knee can be compressed in stirrups depending on positioning). Of course I have not had medical training so medical diagnoses are out of my scope of practice, but with my nursing knowledge and knowledge of the OR I would hope that you have had an MRI of the spine to rule out causes. My GUESS would be that you may have bad genetics when i comes to your spine and may have had some stenosis or disc bulging prior to the surgery and positioning may have irritated the situation or worsened it. My fiance is a young man with bad genes for the spine. He has had 3 back surgeries before turning 40. And again these are simply my opinions and guesses but I don’t think that anything they were doing surgically would be near any anatomical structures that would cause these sypmtoms. And typically the Or staff does a phenominal job at padding and protecting nerves during surgery. Not to say that errors don’t happen. But I do agree that physicians could do a better job of explaining risks benefits and alternatives in surgery. I am not necessarily for or against the robot. One thing that I find to be true is that these patients are typically under anesthesia for much longer than a laparoscopic or open approach and that increases surgical risk for adverse events related to anesthesia. I hope I was able to provide some insight. Ad if for some reason you have not had an MRI then advocate for yourself until you do. Unfortunately as healthcare consumers we are ignorant and generally do not advocate for ourselves. I am including myself. It wasn’t until I became a nurse that I realized just how blindly we accept whatever the person who has MD attached to their name says. But while they have the degree they don’t always have the experience to lead them in the right direction or the ability to recognize when it is above and beyond their knowledge. As a patient you have to educate yourself and trust your instincts. We know when something is wrong and we are not improving with treatment that has been ordered. That said there is also a level of trust that you have to give your MD. I have to say that I work in a community hospital with some of the best docs around, who def. are not afraid to refer a pt somewhere else. I have also worked with a couple who didn’t last long here or anywhere else that I used to think how in the heck did they get this far in medicine! Trust your insincts, educate yourself and advocate for yourself! My finace almost was denied his last back surgery by the orthopedica doc who said because he could not see changes on the MRI it must be in his head (he could not sit upright without being in excruciating pain). If it were not for his neurosurgeon advocating for him he may be paralyzed right now. And the ortho doc said to me humbley after surgery that there was more pathology than what he could see on the MRI. X-rays,etc…are just tools; you know how you feel, so keep advocating for yourself!

      • Suzi Q 38

        Thank you for your insightful and kind reply.
        Unfortunately, I had tingling and numbing sensations in my hands as well as my legs.
        I think, and it is only a bunch of thoughts, that I had a prior condition in my c-spine that no one was aware of, and it got far worse after the surgery.
        The problem was that I needed help. My doctor hand me convinced that it could not be his surgery in any form and that all of what I was feeling would probably just go away with time.
        He was basically buying time and wishing that all would magically disappear.
        It took him 4-5 months to write me a referral to a neurologist, who was his friend, and didn’t want anything to truly be wrong, either.
        The PT department came back with a suspected diagnosis of cauda equina, which is fairly serious. This was not investigated further and dismissed by the neurologist as not plausible. My tingling in my hands and feet were dismissed as diabetes, as my A1C was 7.0.

        I was a fool to trust and believe in them for the year that they “put me off” and delayed my care.

        It got really bad when I started getting more and more troubling symptoms: urinary, bowel, and general pain and numbing sensations.

        I wrote a heartfelt letter sent to him (my gyn/oncologist, who was considered my primary at the cancer hospital) by email detailing my new, troubling symptoms. For example, when I bent over to try to pick something up, I felt a bilateral “pull” under both arms. Clearly c-spine, only I did not know it.

        I didn’t hear from my surgeon at all and I told him I really needed to as I was going on a 30th anniversary cruise to Europe in a couple of months. No answer. I emailed his nurse to see if he had received the letter. She wrote back and said that he had. I was hurt, but decided that it must not be all that bad if he didn’t answer, so I decided to go on vacation anyway.

        Two days before, I saw my gastro (who was chief of staff at the time) and he figured it all out. It was as if a huge lighbulb went off and he told me that I probably needed c-spine surgery.
        I didn’t know what that was or how serious or risky it was. No one explained that to me.
        I did get in to see my neurologist, who finally ordered all of the MRI’s that I had been requesting a couple of times in the last year.
        He did it because the gastro told me to tell him (the neuro) that “He said so.”
        The neuro finally came alive.
        I did not get a chance to get my tests before my trip, or I would not have gone or I would at lest have been very careful.
        Instead, as usual, I signed up for tour after tour, which involved a lot of walking. I was in severe pain in both legs night after night. I needed ice packs every night.
        Anyway, by the time I got back, I needed a wheelchair for longer distances, like from the parking lot to the doctor’s office.
        I finally got my tests, and it showed severe spinal stenosis. I listened to a talk a neuroradiologist gave at Stanford and she said “When you see neuropathies in hands and feet, do not only think lumbar spine, think t-spine and c-spine as well.”
        I could have become a quadriplegic at anytime during my trip. My jump into the huge, twisting, water slide and into the swimming pool on the cruise could have been my last act of mobility.

        When I came back I finally saw the neurosurgeon at that hospital. He was a good person and intently listened to my story. He was so livid his face turned red and he had to leave the room for a few minutes. You know home intense some surgeons get.

        Apparently, he called my gyn-surgeon immediately after our visit. I wish I was a fly on the wall for that conversation on his end.
        I told him about the letter two months prior, and that I still had a copy of it.

        I trusted a couple of doctors way too much until the last two months because my symptoms, while troubling, were not intense, but came and went.

        I now do not trust just any doctor as readily, and that is sad.

  • EE Smith

    I am a little bit confused as to whether insurers actually reimburse at a higher level for DaVinci surgery.

    http://capsules.kaiserhealthnews.org/index.php/2012/03/why-are-health-costs-so-high-the-robot-knows/?referrer=search

    From March 2012, Kaiser Health News:

    “But insurers typically won’t pay more for a robotic surgery, or for the newest kind of MRI or CAT scan. So instead hospitals recoup their costs by charging insurance companies more for everything. And that contributes to $20 aspirin pills and the world’s highest health insurance costs”.

    The conclusion would be the same: that this is why our health insurance rates are so high. But your solution that “Insurance companies can [...] simply cap what they will pay at the cost of a traditional laparoscopic procedure” won’t work if the insurers already pay the same for each procedure, and the hospitals which are eating the extra expense are simply charging more for everything else to make up for it.

    Does anyone know what the true situation is?

    • southerndoc1

      I’ve been trying to get accurate answers to this question also.

    • Judgeforyourself37

      We could have a Medicare for All type of health care. Medicare has a 3% profit margin, whereas insurance companies were recently told that they could “only” have a 20% profit margin. If we had Medicare for All, the government would soon put a stop to hospital over charging, as the hospital would not get paid and they could not balance bill the patient. Perhaps then hospitalists would disappear, as would da Vinci robotics used unnecessarily, for the sake of more money for the institution?

      • EE Smith

        So are you claiming that Medicare doesn’t cover DaVinci surgery? Could you provide a link?

        And also, are you aware that many doctors and even more NPs will not accept Medicare? What good would it be giving everyone “insurance” that half the practitioners out there would not accept?

  • Suzi Q 38

    So what.
    Maybe it is good for them and not for us patients, especially for hysterectomies. Leave it to the urologists for prostate surgery.
    There are so many complaints, and some physicians/hospitals do not report all of them to the FDA like they should.
    I am sure there are pros and cons just like anything else, but this one has not proven to be markedly better for the price tag of the machine plus all of its maintenance costs.

  • Suzi Q 38

    “…. (although, the robot provides real ergonomic benefits to the surgeon, not to the patient.)”

    Yes, I was almost upside down for about 5 hours during my hysterectomy.
    This could not have been good for my c-spine.