Robotic Surgery and Hospital Reimbursement

Abstract

The field of plastic surgery remains at the forefront of technological and surgical innovation. However, the promising applications of robotics in plastic surgery must be thoughtfully balanced with hospital finances and reimbursements. Robotic systems have been studied extensively across multiple surgical disciplines and across diverse health care systems. The results show that there may be equal or better patient outcomes than alternatives. In an era where fiscal responsibility in health care is a top priority, thoughtful budgeting and spending must be considered and revisited frequently to attain sustainable organizational models that ensure appropriate use of robotic technology.

Medical care is provided to improve the health and well-being of patients; however, it is also a business with finite resources. The financial burden of medical advances must be considered when evaluating new technologies since initial costs may ultimately decrease over time. Additionally, revenue considerations must be considered when analyzing expenses as newer models of accountable care organizations can quickly convert revenue centers into cost centers. Reimbursements from Medicare and Medicaid can be low. Thus, the additional expenses associated with robotic instrumentation must fit within bundled reimbursement schedules, which may lead to negative per procedure margins unless bare bones systems are used. Due to low operating margins in the hospitals in the United States, significant revenue enhancements must be present for robotic systems to be viable economically.

Robotic Surgery and Its History

Robotic surgery has a long history, beginning with the introduction of the “Puma 200” in 1985 for stereotactic brain surgery. Subsequent developments included the “PROBOT,” “ROBODOC,” “AESOP,” and “ZEUS” systems, culminating in the da Vinci Surgical System in 2000. The da Vinci Surgical System was approved by the U.S. Food and Drug Administration (FDA) in 2001 and is now used for various specialties such as head and neck, colorectal, general surgery, gynecology, cardiac and thoracic surgery, and urology. The latest version of this system is composed of four elements: a surgeon console with master controls that transmit hand movements to four robotic arms on a patient-side cart, a three-dimensional (3D) high-definition (HD) vision system with HD 3D endoscope, image processing equipment, and 7 degrees of motion surgical instruments. ¹

Robotic Surgery Benefits

Robotic system is a minimally invasive surgery (MIS) technology that has been increasingly adopted by surgeons across multiple specialties since its introduction in 1997. ² Advantages of robotic surgery compared to laparoscopic techniques include improved ergonomics, tremor filtering, 3D visualization, higher magnification of the surgical field, and more intuitive instrument handling. Despite its increasing popularity in recent years, its use continues to be slower due to high cost and other factors such as low interest from surgeons and organizational models of hospitals that are not able to afford wider development of new technologies.

For urologic surgeries, robotic surgery was associated with shorter lengths of stay but higher costs compared to open procedures. The decreased length of stay (LOS) after robotic urologic procedures supports the potential benefit of the robotic approach; however, other potential benefits such as decreased risk of small bowel obstruction and improved cosmesis may be necessary to offset the higher costs associated with robot-assisted technology in pediatric patients. For general surgery procedures, there was no difference in postoperative LOS, but robotic surgery was associated with significantly higher costs compared to laparoscopic procedures. Potential reasons for the higher costs include increased labor costs for additional ancillary staff, longer operating room time, consumption of single-use instruments, and the increased costs associated with a learning curve for robotic surgery by both the surgeon and ancillary staff. ³

To improve the robotic system in a surgical department, it is necessary to consider various categories such as availability or robotic system, ideal setting area, need for a team, broad application in general surgery fields, and motivation on robotic use. Additionally, departmental and institutional economical effort must be considered. Robotic technology has the potential to provide equal or better patient outcomes than less-costly alternatives, and should be considered when seeking fiscal responsibility and transparency in health care. While laparoscopy is currently the preferred method for many procedures, robotics may offer improved results in certain cases such as those involving the head and neck region or more complex surgeries. However, it is important to develop a structured organizational model to ensure that robotic approaches are used appropriately and that their benefits are realized. ²

Costs

Robotic surgery has been found to be cost-effective in some cases, but not in others due to its high cost of acquisition and maintenance. Boia and David ⁴ examined the financial aspects of running a pediatric surgery–dedicated robotic program in a former communist country and found that the initial investment for equipment and training of personnel was significantly high but was partially alleviated by donation with both charity and scientific medical research purposes. The cost per case was found to be in a deficit even without maintenance costs, mainly due to low reimbursement rate per case.

For a robotic program to be financially sustainable, it must perform at least 120 procedures per year; however, pediatric hospitals have difficulty achieving this number due to a lack of trained surgeons or proven advantages over laparoscopy. It has been estimated that 100 surgeries are needed to obtain consistent results with robotic surgery in pediatric urology cases, with 1 surgery per week necessary to maintain surgical skills; however, few surgeons have surpassed 20 surgeries within a given time frame, which makes it difficult for them to become accredited according to standards set by organizations such as Society of Gastrointestinal and Endoscopic Surgeons and Minimally Invasive Robotic Association (SAGES-MIRA) Robotic Surgery Consensus Group or Society of Urologic Robotic Surgery. ⁵

Simulation is a crucial tool for the development of robotic skills, but few programs exist currently due solely or mainly to economic factors related with acquisition and maintenance costs associated with robotics technology. Therefore, it may be more realistic that pediatric hospitals become part of multispecialty adult robotic programs rather than having exclusive pediatric programs so they can share costs and maximize the use of the robot console. ⁵

Previous studies have also found that robotic-assisted surgery (RAS) has similar outcomes to laparoscopic and open surgery, but at a higher cost not only due to direct costs associated with the device itself but also due to increased operative time resulting in an opportunity cost from alternative uses for it as well as decreased resident participation when compared against laparoscopy procedures. When assessing the value for implementing robotics into general surgery residency programs, all effects must be taken into account including decreased resident participation, graduation without experience with RAS, and hospital costs similar between procedures despite increased operative time associated with RAS cases, among other factors. ⁶

While there is evidence certain types of surgeries benefit from the utilization of robots, there are many economic factors that must be accounted for before their implementation including: investment costs, maintenance fees, and other financial factors. If these technologies are not supported by additional funding sources such as donations or insurance policies, it may severely hinder the conditions under which they are accessible. It is important for health care providers to be cognizant of these fiscal limitations to robotic care, and balance state of the art care with financial sustainability.

Robotics in Thoracic Surgery

Robotic-assisted thoracic surgery (RATS) is a safe and feasible approach to lobectomy with comparable oncologic outcomes to video-assisted thoracoscopic surgery (VATS) and thoracotomy. Studies ^{7 8} have shown that RATS has shorter postoperative stays, lower mortality, and fewer blood transfusion than VATS or thoracotomy. Additionally, high-volume robot programs have been associated with decreased hospital stay duration and improved outcomes. Although there is conflicting evidence regarding the cost-effectiveness of robotic surgery compared to other approaches, several studies have found that it is cheaper than open surgery while still providing excellent results with minimal morbidity and pain. ⁸ Furthermore, a study by Abbas et al ⁹ showed that robotic thoracic surgery had the highest net margin compared to other services in an academic institution setting. Therefore, experienced thoracoscopic surgeons should initiate a robotic program early on in order to transition from thoracoscopic lobectomy safely for patients without compromising cost-effectiveness while integrating residents into robotic cases as the robotic volume in thoracic surgery continues to increase.

Robotics in Abdominal Surgery

Robotic surgery has become increasingly popular for abdominal surgery in recent years due to its potential for improved outcomes and decreased costs. ^{10 11 12} However, studies have shown that the additional costs associated with robotic instrumentation may not be offset by reduced complications or shorter hospital stays. ^{13 14 15 16} Additionally, the cost of robotic instruments must be taken into consideration when evaluating its use in clinical practice as they can only be used 10 times before they must be discarded. ¹³ Furthermore, administrative cost and reimbursement data for a subset of patients who received robotic gastric bypass surgery between 2012 and 2015 demonstrated that this surgery generated positive revenues in the Swiss health care system; however, with changes to the reimbursement for bariatric procedures in 2015, an average loss of CHF 2,060 was observed. ¹⁷ To address this situation, measures such as reducing surgical costs by avoiding routine cholecystectomy and carefully selecting low-risk patients have been considered, and a differentiated reimbursement scheme that reflects the incremental cost of unevenly distributed cases for high technologies has been proposed as a variable tool to support the introduction of innovation. Finally, it is important to create a workgroup involving hospital administration, surgeons, circulating nurses, sterilization department personnel scrub technician, and supply chain management with the goal of standardizing equipment/tools in pursuit of cost-to-benefit ratio improvement.

While robotic surgery in abdominal surgery has potential benefits such as improved operative field visualization and increased degrees of freedom of surgical instruments, which could lead to improved outcomes at comparable or lower costs, there are significant financial considerations that must be considered when evaluating its use in clinical practice due to potentially increased costs associated with using a robot compared to laparoscopic approaches. Therefore, it is important that hospitals consider all aspects when deciding whether or not to invest in robotics technology including patient safety outcomes versus financial implications before making any decisions about implementing new technologies into their practices. ^{12 16 17 18}

Robotics in Spinal Surgery

Robotic-assisted spinal surgery can lead to improved accuracy placement, decreased radiation exposures for the patient and operative team, fewer postoperative complications, and cost savings over time. ¹⁹ However, Passias et al ²⁰ found that patients treated with robot-assisted fusion experienced higher rates of complications and decreased cost-effectiveness compared to patients treated with open and MIS lumbar fusion. This decrease in cost-effectiveness may be due to a learning curve associated with implementing new technology in clinical practice as well as the costs of initial purchase and logistical difficulties associated with operating the equipment. Additionally, long-term projections for cost-effectiveness were found to be below established thresholds by life expectancy. Despite this evidence, a systematic literature review ²¹ identified 25 studies that evaluated the role of robots in spinal surgery, which showed a highly accurate instrumentation placement with a significantly lower rate of accuracy between robotic placement and free hand placement but no proximal facet disruption using the robot. It is clear that while there are some drawbacks associated with robotic technology (such as increased costs and a learning curve for surgeons when first implementing it into their practice), overall, its use has been shown to provide numerous benefits, including improved accuracy of screw placement, decreased radiation exposure for both patient and operative team members, fewer postoperative complications, and potential long-term cost savings when compared to traditional methods used in lumbar fusion surgeries.

Robotics in Colorectal Surgery

Traditional laparoscopy achieves similar clinical outcomes for segmental colon resection at a significantly decreased cost to the hospital compared to robotic-assisted procedures. Additionally, studies have found that robotic rectal resection (RRR) has a lower conversion rate than laparoscopic rectal resection (LRR), but higher economic costs due to initial purchase cost of the robotic system. ^{22 23} Finally, population-based studies ²⁴ have shown that minimally invasive laparoscopic or robotic operations incur lower payments than open procedures and selection bias may be less confounding when comparing laparoscopic to robotic approaches. Therefore, it is clear that traditional laparoscopy is a more cost-effective option for segmental colon resections and other MIS procedures.

Robotics in OB-GYN Surgery

Robotic surgery in OB-GYN is not yet recognized as a separate procedure requiring increased reimbursement. Outcomes for robotically assisted hysterectomy for benign gynecologic diseases have been found to be comparable to laparoscopy while costing $2,189 more per case. ²⁵ This could potentially add another $418 million in annual costs to the health system. However, studies have shown that robotic surgery may be advantageous in cases involving high body mass patients or when a surgeon is not proficient or no longer able to perform procedures using traditional laparoscopy, or when replacing certain costly laparotomy procedures if traditional laparoscopy is not an option. Additionally, robotic-assisted and laparoscopic transperitoneal para-aortic lymphadenectomy (TIPAL) provide similar perioperative outcomes with no advantages of one approach over the other; however, overall cost was higher for robotics than laparoscopy due to higher surgical costs compensated by higher hospitalization costs in the laparoscopic group. ²⁶ A cost-minimization analysis comparing robotic sacrocolpopexy with laparoscopic and abdominal sacrocolpopexy showed that robotic-assisted sacrocolpopexy (RASC) was more costly than either of these approaches with an incremental cost of $1,155 over the laparoscopic approach and $2,716 over the abdominal approach. ²⁷ Furthermore, a population-based analysis ²⁸ examining factors associated with prolonged LOS after hysterectomy for benign conditions found intraoperative factors such as operative time were most important predictors of prolonged LOS for both abdominal and minimally invasive hysterectomy, while nonmodifiable demographic factors such as age, race, and year of surgery contributed most to prolonged LOS for vaginal hysterectomy. Taken together, these findings suggest that although there are potential benefits associated with using robot technology such as enhanced visualization and increased stabilization of instruments compared to traditional minimally invasive techniques, it may not always be economically feasible due to its high initial expenditure on equipment along with ongoing maintenance costs, which can lead to significant costs being added onto health care systems without any evidence-based benefit being seen from its use compared to other surgical methods available today.

The evidence presented in studies by Flack et al, ²⁹ Baker, ³⁰ and Haraki et al ³¹ suggests that RASC is more costly than non-RASC vaginal suspension procedures. Private insurance was associated with increased reimbursement for RASC; however, regardless of primary payer, RASC was consistently more costly by up to $5,500 compared to non-RASC procedures. Enhanced Recovery After Surgery (ERAS) implementation led to a decrease in mean LOS from 2.9 to 1.8 days for open sacrocolpopexy patients; however, ERAS did not reduce the cost difference between the robotic and open approaches. Minimally invasive sacrocolpopexy was approximately $4,200 more costly than native tissue repair (NTR). Therefore, it can be concluded that RASC is significantly more expensive than other pelvic floor repair surgery options and may not be a cost-effective alternative for hospitals or patients seeking treatment for pelvic floor disorders.

Robotics in Urologic Surgery

Robotic-assisted radical prostatectomy (RARP) is becoming increasingly accepted and implemented in the health care settings, with improved clinical outcomes, minimal perioperative morbidity, higher rates of negative resection margins, and reduced intra- and postoperative complications when compared to open surgery. ³² Furthermore, studies have shown that RARP may be associated with lower all-cause costs per patient than open surgery due to fewer postoperative complications and shorter hospital stays. Additionally, patient-specific variables such as comorbidities can influence the cost of RARP procedures. The diffusion of robotic technology across the United States from 2005 to 2009 was likely propelled by competition among hospitals as well as patient and hospital factors such as private insurance coverage, surgical specialists, and larger hospitals with the market power to maintain sufficiently high revenue. ³³ These findings suggest that RARP is a cost-effective alternative to traditional open surgery for many patients due to its improved clinical outcomes and lower overall costs.

Establishing a Successful Robotic Surgery Program

The successful implementation of a robotic program in a hospital requires an initial design and implementation phase, followed by maintenance and growth to maximize the benefits of the program. This process involves purchasing technology, developing and implementing intense training, marketing, and dedication from surgical team members. The success of such a program is dependent on the hospital's ability to provide equipment and personnel as well as economic factors to each region. ³⁴

Program Design

A business development plan for the implementation of a robotic program should include an evaluation of direct and indirect costs, such as the cost of the robot, associated materials, training of staff, operating room (OR) modifications, and recruitment or training of a lead surgeon. Additionally, a market analysis should evaluate health competition and patient population. To ensure success, it is recommended a robotics committee composed of hospital individuals from different lines of work be created. Furthermore, it is necessary to estimate the patient population in order to determine if there is any interest in robotic surgery. The number of cases necessary for sustainability has been calculated by successful programs at the beginning: three to five cases per week are needed. The purchase cost for a da Vinci robotic system ranges from US$0.5 to 2.5 million with additional variable costs associated with execution and maintenance contracts; other associated costs include marketing programs, patient education, and OR employee training. Financing sources may include state/federal programs, foundation grants, or donations from employees/doctors, among others. ³⁴

Implementation

The design of the OR must be modified to accommodate the necessary equipment such as the console, robot, anesthesia equipment, operating table, and instruments. A sufficient stock of surgical instruments is essential to avoid any instrument failure during a procedure. A dedicated robotic OR is recommended in order to avoid damages that may occur during transport and ensure an efficient and safe environment. Additionally, dedicated areas should be reserved for education purposes in order for anyone involved in the robotic program (trainees, fellows, or visitors) to observe both the performance of the team and details of the interventions. The success of a robotic program depends on having an experienced robotic team with a lead surgeon who has completed their learning curve and can collect permanent surgical data while training/coordinating other members in the OR. The team should also be trained by lab exercises on cadavers/porcine models as well as case observations and video-based learning proctors if possible. In addition, it is important that all members understand each step of surgery so that patient safety and efficiency are maximized with a devoted, well-trained and consistent team. ³⁴

Marketing

The increasing interest in robotic over open procedures is attributed to the cutting-edge technology, satisfactory results, and previous experience from patients and physician referral. To attract more patients to the institution, an appropriate promotion campaign should be implemented that highlights the benefits of this technology. Additionally, collaboration among surgical specialties on the marketing side is recommended to cover advertisement costs. Furthermore, hospital and surgeon websites should provide veracious information about robotic services with suitable links, while social networks such as Facebook, Twitter, and Instagram can be used as a powerful to keep surgeons connected to potential patients by conveying informative messages about health and prevention along with publications related to robotic surgery. ³⁴

Research and Outcome

Data collection is essential for quality control and diagnosing program deficiencies in robotic surgery programs. Clinical parameters such as surgical time, hospital stay, blood loss, postoperative pain, time to return to normal activity, continence, erectile dysfunction, and surgical margins in cancer surgery should be evaluated. Additionally, consumer satisfaction and economic costs should be assessed. An internal review should be conducted annually and the experience shared with colleagues during meetings and scientific events or reported as peer-reviewed articles. A complete collection of surgical videos is necessary for surgical audits or training of fellows and residents. ³⁴

Improving Efficiency and Outcome

There is an urgent need to increase efficiency in ORs in order to improve quality and success of patient care. This can be achieved by reducing case cancellations, starting on time, avoiding predication bias, having adequate room requirements and equipment/supplies, having a well-trained robotic team, and reducing turnover times. Strategies such as providing high-quality pre-op counseling, ensuring all paperwork is completed at least 4 to 6 weeks before the procedure, revision of all paperwork by qualified nurse/provider, and calling the patient 3 days before surgery have been implemented to reduce cancellation rates. Additionally, it is essential that medical records and clearances are ready on time for the procedure to start on time. To avoid prediction bias, it is important to consider anesthesia time and turnover when planning OR schedules. Room requirements should include enough space for the da Vinci Surgical System as well as other necessary equipment/supplies such as scope warmers, scope warmers, suction devices, irrigators, and chairs while personnel should overlap for critical roles such as surgeon, first assistant, etc. Finally, strategies based on reward have shown to be effective in reducing turnover times with less than 10% of prolonged turnovers lasting longer than 60 minutes in well-functioning ORs. ³⁴

Conclusion and Future Directions

Robotics has the potential to improve the field of plastic surgery, particularly in the realms of microsurgery and supermicrosurgery, minimally invasive flap harvest, transoral surgery, and nerve surgery. The general benefits of utilizing robots include tremor filtration, higher magnification of the surgical field, and access to narrow surgical corridors. These advantages, however, must be weighed against the main challenge of the high cost of using the robotic technology. Some strategies that could mitigate these costs and make it a more attractive option would be searching for vendors who would be willing to pay for partial costs of acquisition or maintenance, obtaining charity funding, or obtaining research funding. The field of plastic surgery has always remained on the forefront of technological and surgical innovation, and the promising applications of robotics in plastic surgery will need to be thoughtfully balanced along hospital finances and reimbursement.

Funding Statement

Funding None.