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General interest items edited by Janice Flahiff

[Reblog from KevinMD.com] Insurers should stop paying for robotic hysterectomies

Those of you who follow me know I do not usually post items on specific procedures.
However, I frequently repost items which point out contributions to rising health care costs.
Thus this entry.

From the 21 October 2013 post by Jennifer Gunter MD at KevinMD.com

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.

 

Excerpts

“The study, published in the Journal for Healthcare Quality earlier this year, focused on incidents involving Intuitive Surgical’s da Vinci Robotic Surgical System over nearly 12 years, scrubbing through several data bases to find troubled outcomes. Researchers found 245 incidents reported to the FDA, including 71 deaths and 174 nonfatal injuries. But they also found eight cases in which reporting fell short, including five cases in which no FDA report was filed at all.”

“James F. Blumstein, director of the Vanderbilt Health Policy Center and Professor of Constitutional Law and Health Law & Policy, said with robotic surgery, for patients it’s not necessarily about knowing which procedure would be best but being fully informed of their options. He said that if there are known injuries and routine problems, health care providers need to disclose that information to patients.

“If you as a patient are going to a doctor, and they’re using a robot, it’s a question of who’s in charge,” Blumstein said. “If it’s a mechanical malfunction, would the professional standard of care apply to a robot?”

If problems occur during robotic surgery and subsequent litigation, a question might arise about whether the doctor, the hospital or the manufacturer was responsible, introducing the potential issue of product liability. But there may be protection for doctors performing robotic surgery in disclosing the risks, Blumstein said.

“If a doctor discloses to a patient there’s a comparative risk (between regular surgery and robotic surgery) and that disclosed risk materializes, I would have a hard time thinking the doctor would be considered negligent,” he said.”

November 7, 2013 Posted by | health care | , , , , , , | Leave a comment

[Reblog] How hospitals recoup the cost of buying robotic surgery systems (& questions to ask surgeon before consenting to robotic surgery)

A laparoscopic robotic surgery machine. Patien...

Image via Wikipedia

The blogger known only as the Skeptical Scalpel (self-described as a surgeon for 40 years and a surgical department chairman and residency program director for over 23 of those years) continueshis thread of posts raising questions about the proliferation of robotic surgery.

The latest is entitled “Study: Robotic surgery financials explained.” It’s his take on a paper presented at the annual meeting of the American Association of Gynecologic Laparoscopists.  Excerpts:

The headline, “Robotic Hysterectomy Cuts Blood Loss in Obese,” is certainly catchy. Let’s look deeper. 

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.

I congratulate the authors for their candor [though no doubt inadvertent] in sharing the financial data and the reasons why robotic surgery is more costly. I am gobsmacked* at the differential in charges and reimbursement for the two types of hysterectomy and that the secret would be so openly shared.

I guess someone has to help the hospital “recoup the cost of the robot purchase.” But I wonder why third party payers are shelling out almost two-and-a half times more money for a procedure that has not been proven more effective than standard laparoscopic surgery?

And you wonder why health care costs are skyrocketing?

Comments

Walter Lipman posted on February 13, 2012 at 9:25 am

Using this “pay as you use” logic, I wouldn’t be the least bit surprised to see one set of charges for your bed being located in the hospital’s parking lot versus another and higher set of charges for your bed being located in a room inside the hospital.

Reply

Michelle Luthringshausen, MD posted on February 21, 2012 at 8:54 am

As a surgeon, I am fascinated by this shallow analysis of cost and complete disregard for what is best for the patient. An open hysterectomy has a complication rate of 11%, highest in obese patients. A robotic hysterectomy done by an experienced surgeon in an obese patient has a complication rate of 3%. Complications are expensive for hospitals, health systems and especially patients. According to the American College of Surgeons NSQIP data, one complication’s DIRECT costs are around $12,000.
My second comment is that “charges” are only relevant in the uninsured patient, which will rarely be recouped anyway. The “cost” is what the insurance company and patients actually pay or reimburse, which is a contracted price based on the procedure done, NOT the way it was done, in an insured patient. In most cases, the hospital and surgeon get paid the same fee whether the robot was used or not…..

Related article

A 27 February 2012 article at HealthNewsReview.org summarizes a recent Chicago Tribune article on the evidence (sorely lacking) that robotic surgery allows for quicker healing and less pain.

Excerpts

Despite a flood of scientific papers associated with the da Vinci, there is a dearth of randomized, controlled studies showing patients do best if procedures are performed with the da Vinci. Federal oversight of medical devices such as the da Vinci is light. There have been voluntary recalls — more than a dozen since 2005 — involving problems with software and surgical instruments. Lawsuits have helped raise concerns that some surgeons are using the devices before the doctors are adequately trained.

Here are some questions patients should ask their surgeon when considering a robot-assisted procedure:

•When did you do your first robot-assisted procedure? How were you trained? How many robot-assisted cases have you done? How often do you do them? How many robot-assisted cases have you done of my procedure?

•Are you more comfortable doing this type of procedure laparoscopically, robot-assisted or the traditional open approach? What are the pros and cons of each?

•What happens if the robot malfunctions during surgery or you have to convert to open surgery? How many open cases of my procedure have you performed? How often do you do them?

•What kind of training on the da Vinci do the nurses and other surgeons in the operating room get? How experienced are they? How experienced are they in converting to an open procedure mid-surgery?

•Will you be mentoring another surgeon during my procedure? Will he or she be doing any of it? If so, how many cases has he or she performed?

 

Related articles

“When hospitals buy robots they also use them as a marketing tool in direct-to-consumer marketing. That startedwith the drug companies and it worked well. It’s very effective,” said Dr. Hugh Lavery, a urologist at Mount Sinai Medical Center in New York who authored the study.”

February 14, 2012 Posted by | health care | , , , , , | Leave a comment

   

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