Robots and health costs: Can either be tamed?

There are many reasons why the costs of delivering simple, uncomplicated health care in this country keep increasing while quality lags and value fails to keep pace with that of most major industrialized countries. But as a surgeon, I have a one-word answer for all that is wrong with health care: “robots.”

Surgical robots, costing an estimated 1.2 to 2.5 million dollars each with matching maintenance fees of $125,000 per year, are the latest luxury item on hospital shelves. It takes a lot of radical prostatectomies, hysterectomies and cholecystectomies, to justify buying a robot, but that’s not necessarily the issue. A surgical robot is a marketing tool and even if a hospital isn’t doing the hundreds of robot-assisted cases necessary to cover the expense of owning one, marketing surgical robots to consumers sends a message. If you want to know where the best hospital in town is, follow the robot.

I have no doubt that, in the right hands and for the right indications, surgical robots are superlative tools that help thousands of people but there is just one problem. No one seems to agree on what exactly the robot is adding and who can benefit most from its use.

Robot advocates believe that patients who undergo robotic surgery have smaller incisions and lose less blood and that these metrics translate into less pain, shorter hospital stays, and possibly an earlier return to work. But laparoscopic surgery, the dominant minimally invasive technique, offers those same benefits.

If you take a closer look, as several surgeons have recently, there is very little evidence that robotic surgery offers an advantage over laparoscopic surgery for the average patient. The most recent study, a randomized clinical trial published in the New England Journal of Medicine, from Memorial Sloan Kettering Cancer Center, found no appreciable benefit in reducing surgical complications or hospital stays.

In an earlier retrospective study, researchers from Columbia University examined the records of 264,758 women who had undergone either robotic or laparoscopic hysterectomy for benign conditions from 2007 to 2010, a time during which robotic surgery rose from 0.5 percent to nearly 10 percent of all hysterectomies. The complication rate again was the same for both groups.

The authors of both studies concluded that further evaluation of new surgical technologies is warranted before widespread adoption takes place.

“More technology doesn’t necessarily mean better health care,” Dr. Martin Makary of Johns Hopkins University School of Medicine has said regarding the potential complications of robotic surgery. Dr. Makary was expressing a concern that many surgeons have. A robot cannot feel a patient’s tissue and that loss of tactile input as a surgeon performs delicate maneuvers might cause organs to be inadvertently injured. Dr. Makary undertook a study published in 2013 in the Journal of Healthcare Quality that found several incidents of robotic complications that appeared in the media were not reported to the FDA until after the stories appeared in the press. With incomplete and inaccurate data regarding robot performance, it is difficult to judge the safety of robotic surgery.

We know robots are adding cost.  In the Columbia University study, for example, the average cost to the hospital for robotic hysterectomy was $8,868 vs. $6,679 compared to a laparoscopic procedure.

“We did not develop the robot to compete with laparoscopic surgery,” Dr. Myriam Curet, chief medical adviser for Intuitive Surgical, has said in reference to the hysterectomy study.

But if it is true that the robot was not intended to compete with laparoscopic surgery why is it now being marketed for gallbladder removal, one of the most common laparoscopic operations in the United States (750,000 per year) that most experienced surgeons can perform in 45 minutes or less? Who decides what procedures should be performed if one costs at least a third more and has not been sufficiently studied to define the benefits versus the risks?

I am not anti-technology. I’ve seen some amazing new medical devices in the past ten years, but the robot controversy demonstrates what I believe is wrong with our health care system.  We, doctors and hospitals, embrace the most expensive technology available, not because it will make a measurable difference in a patient’s outcome, but because it will bring us more business and make us more money.

How will we ever tame health care costs in this country? By tracking down all the robots in our system and taming them too.

Catherine Musemeche is a pediatric surgeon and the author of Small: Life and Death on the Front Lines of Pediatric Surgery.

Comments are moderated before they are published. Please read the comment policy.

  • doc99

    Steve Jobs struck out with the Lisa but without the Lisa, there would be no Mac.

    • QQQ

      The Apple II was my favorite about of all of Apples past and current models! Had lots of fun playing “The Oregon Trail” and Hollywood Squares!

      But the Commodore computers were the BEST out of all for me! The C64 and Amiga series were awesome!

    • SteveCaley

      Realize perhaps they were no different – Jobs’s idea was incompletely formed in the Lisa, but formed in the Mac. Without Jobs, there would be neither.
      In a philosophical sense, tools only deserve the measure of whether they are instrumentally effective. They must perform an action, and the traditional method of craftsmanship states that the operator/craftsman should be the authority and principle architect of the measures of quality.
      Taylorism (and Fordism) states that the operator is a carbon-based machine that in turn operates one of several ancillary machines. For the operator to mentate during working hours is an impediment to quality.
      “Robot surgery” is a terrible term – “smart scalpels” is far more correct. The Taylorist resurgence in medicine is not helping anyone.

  • DeceasedMD

    it astounds me to no end, how physicians have to prove their worth with evidence based medicine. Treatment is challenged if it is not “evidence based”. yET for hospitals and marketers, they have taken over and are allowed to market things that sound innovative and exciting that in the end could be dangerous. And people believe them. And Doctors don’t refuse for unclear reasons-perhaps to keep their job.The problem is if anything goes wrong, then they are the fall guy.

    • Dr. Kate Musemeche

      Sad but true.

  • Joe

    Physicians are to blame for this as well. When our medical staff was assisting with the recruitment of a urologist, it was amazing how many simply would not go to a place unless there was a robot. It was a deal-breaker demand.

    • DeceasedMD

      Is that still the case?A local well known gyn near me stays away from robotic surgery after a lawsuit. At the very least aren’t they concerned about their license after all this?

      • Joe

        That never came up. All I can tell you is that they cycled through I don’t know how many prospectives (young and old alike), and this was a pretty standard thing. My understanding is that a lot of the younger ones had trained almost exclusively on robotics. That’s second hand, though, so it might be an exaggeration.

        • Patient Kit

          My surgeon is young — about 40 — but he was clear that his intention was to do my surgery robotically but there was a chance that he might need to convert to laparoscopic or even traditional open surgery. (My surgery was GYN for OVCA). Thankfully, he was able to stay with the robot. He might prefer the robot, but it’s not the only kind of surgery he does.

        • DeceasedMD

          Thanks. Now that’s frightening. Hope the younger ones still have the memory of how to operate without robotics.

    • Dr. Kate Musemeche

      Thank you for pointing out this interesting perspective on using the robot as a recruitment tool.

  • Patient Kit

    I had robotic surgery 1.5 years ago for OVCA. I didn’t push for the robot. I didn’t ask for the robot. I, in fact, had not even heard of the DaVinci robot before my dx. And going in, my doc made sure I was prepared for the possibility that we — well, he — might have to convert to conventional surgery. He didn’t have to, my robotic surgery went well, with zero complications and an easy recovery.

    Medicaid covered my robotic surgery with no hassle on my end. I don’t know whether my doc had to fight with them to cover it. When I started doing research on robotic surgery after it had. been recommended and scheduled, I know that I read somewhere that most insurances were reimbursing robotic surgery at the same rate as.laproscopic surgery. I don’t know whether that was or is still true or not but I think it was a reputable news source where I read that. I remember wondering why hospitals wanted to use the robot so much if they don’t get reimbursed more for it’s use by insurance. I thought maybe it was a pure marketing tool to draw more patients. The competition by hospitals in NYC for patients is pretty intense.

    Anyway, I’m neither a robotic surgery advocate or foe. I am a patient who had successful robotic surgery. But that doesn’t mean I couldn’t have had successful laproscopic surgery. I am a fan of minimally invasive surgery. Very glad I didn’t need traditional open surgery.

    • Dr. Kate Musemeche

      Thank you for sharing your perspective as a patient and your good outcome. Insurance companies do seem to be reimbursing robotic at the same rate as laparoscopic which might suggest something about the value assigned to the procedure.

      • Patient Kit

        Thank you for confirming what I knew I read — that robotic surgery is being reimbursed at the same rate as laparoscopic. My experience with robotic surgery was very good but I have a really good surgeon. Not only is he skillful and smart but he is compassionate and communicative. I credit my human surgeon far more than the robot. But he seems to like the robot.

  • Patient Kit

    I had open surgery for a pathologic fractured femur 15 years ago and minimally invasive robotic GYN surgery for OVCA last year. And, as a patient, I think minimally invasive surgery, when possible, is a million times better than traditional open surgery. This is one of the truly amazing and awesome advances in medicine — minimally invasive surgery.

Most Popular