Health and Medical News and Resources

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

Robotic Surgery Roundup: Take Me Out To The Ballgame and much more

rc_robotics_130614.412

 

From the 18 July 2013 article at HealthNewsReview Blog

Robotic surgery systems are spreading so quickly across the US and across the globe that trying to keep up with the news could become a fulltime beat.  Here are just a few nuggets in an attempt to catch up on things you may have missed.

The Reading (PA) Eagle reports, “Fans test surgical robot at baseball game.” Excerpts:

“Fans at FirstEnergy Stadium got the chance to try Reading Hospital’s da Vinci surgical robot before the Fightin Phils game Thursday night. … The hospital has three da Vinci robots, which are used for minimally invasive surgeries, including heart, thoracic, bariatric, urologic, gynecologic, cancer and other procedures.”

We’d seen robotic surgery promotions in shopping malls before, but the ballpark setting was a new one to us.  Maybe Reading readers should also read or watch stories like the next three we profile.

“The use of intensity-modulated radiotherapy (IMRT) and robotic prostatectomy to treat prostate cancer patients at low risk of dying from the disease increased from 32 percent in 2004 to 44 percent in 2009, researchers found in reviewing Medicare patient data. …

“The implementation of these technologies occurred in populations at a time when there was an increase in awareness that some prostate cancers might not warrant treatment,” said study co-author Dr. Brent Hollenbeck, an associate professor of urology and director of the Herbert H. and Grace A. Dow Division of Health Services Research at the University of Michigan….

What’s more, new technologies like IMRT, robotic prostatectomy and proton beam therapy have not been shown to be any more effective in treating prostate cancer or avoiding side effects than established procedures like traditional external beam radiation treatment (EBRT) and open radical prostatectomy. …

Aggressive direct-to-consumer marketing and incentives associated with fee-for-service payment may promote the use of these advanced treatment technologies,” the study authors wrote.”

“The story of the robot is really the story of American medicine: expensive technology, poor evaluation, and little communication with patients about the research and the data about robotic surgery.”

Visit NBCNews.com for breaking newsworld news, and news about the economy

And now a brief glimpse of some recent journal articles:

“Overall, robotic thyroid surgery is unlikely to show improved outcomes with typical metrics. It is unlikely to be cost-effective because it involves more equipment and, even in the best of hands, more operating room time. Length of stay is unlikely to be effected because most thyroid surgery patients are in the hospital for less than 24 hours. Robotic thyroid surgery is not minimally invasive; therefore, is there really any expectation of a decreased level of pain during the postoperative period? The implementation of the routine use of robotic technology will depend ultimately on what it means for the patient—the real stakeholder. Comparative efficacy studies have partially addressed the end points of robotic thyroid surgery by focusing only on the risk of complication or oncologic value when compared with conventional or endoscopic surgery, but what about other patient-centered end points? Are the patients happy and satisfied, and are they more satisfied than someone who underwent conventional thyroid surgery? At the end of the day, it will come down to how a third-party payer or health care provider system weighs patient-centered outcomes and whether such surgery would be covered and provided, or whether it would be considered purely cosmetic in nature.

In summation, once you strip away all the blinking blue and green lights, the hundreds of moving parts, and the beeps and occasional error messages, robotic thyroid surgery can be just as elegant, effective, and safe as conventional surgery. It can be efficient. However, to get to this point, the surgeon needs to be committed to this type of surgery and not merely regard it as a hobby or a sideline. It needs to be the focus of a truly dedicated thyroid surgeon who has excellent outcomes with both the standard and robotic approach. Emil Theodor Kocher was not the first surgeon to win the Nobel Prize for nothing. After a century of experience, the new high-profile version of his thyroidectomy may be good, but it is not better than the tried and true.”

“Given the high costs and small scientific evidence, the introduction of robotic surgery has been irresponsibly quick.- Better scientific research of robotic surgery is needed before this technology can be broadly applied in clinical practice.”

“Surgeons must try to avoid marketing operations behind some of the indications of companies producing robotic instrumentation. Otherwise, the first robotic surgery centers will be seen as “a real taste of Hollywood.” …

Robotic surgical procedures’ economic aspect should be analyzed and we have to reconsider whether our countries (Poland, the Czech Republic, Slovakia) are at such an economic level that they are able to compete with more economically developed countries such as Germany. I believe that they are not [1]. Certainly, only a few robotic surgical centers need to be built in each of our countries. They should carry out scientific research, should be supported by other than state funds, and should cooperate with each other so that the whole system does not become just “a taste of Hollywood” for a particular surgeon or center.”

In summary, when thinking about robotic surgery, you could sing “Take Me Out To The BallGame,” but remember the closing lyrics:

“Let me root, root, root for the home team,
If they don’t win it’s a shame.
For it’s one, two, three strikes, you’re out,
At the old ball game.”

ADDENDUM ON JULY 19:  See our next-day post, “FDA warns robotic surgery maker, which complains of ‘negative press’ ”

July 22, 2013 Posted by | health care, Uncategorized | , | Leave a comment

Skeptical Scalpel: Robots attack America, but Canada not so much

A laparoscopic robotic surgery machine. Patien...

A laparoscopic robotic surgery machine. Patient-side cart of the da Vinci surgical system. Into the sealed Computer God Robot Operating Cabinet, as a Frankenstein slave, at night. Da Vinci Surgical System. (Photo credit: Wikipedia)

Robotic surgery has its place. However, robotic surgery is not superior to traditional surgery in every case or for every surgery candidate.  It is best to discuss the pros and cons (and alternatives)  of any surgical procedure with trusted health care professionals.
Discussion starters below under Related Resources.

Why I am posting this? Partly because a recent article in my local newspaper read more like an advertisement for robotic surgery than an unbiased news item.  It seemed to have been written the surgeon interviewed (or at least had only one source of information — the surgeon who touted robotic devices). Am seriously considering a letter to the editor gently inquiring about their journalistic standards. I know they have a skeletal staff of reporters, and no longer have a staff librarian to do research. Still.

Skeptical Scalpel: Robots attack America, but Canada not so much

As of December 2011, 1548 surgical robots have been sold and installed in the United States as opposed to 16 in Canada.

The estimated population of the U.S is 313,388,000 and for Canada, 34,764, 600.

Canada has a population that is 11.1% of the U.S. population but Canada has only about 1% as many robots. Or put another way, Canada has 1 surgical robot for every 97 robots in the U.S….

..

The estimated population of the U.S is 313,388,000 and for Canada, 34,764, 600.

Canada has a population that is 11.1% of the U.S. population but Canada has only about 1% as many robots. Or put another way, Canada has 1 surgical robot for every 97 robots in the U.S.

California’s population is 37,691,912, which is about 3 million more than the population of Canada, but California, with 114 robots, has seven times as many robots as Canada..

Related Resources (will be adding resources included unbiased items about robotic surgery by the end of the week)

April 17, 2012 Posted by | Consumer Health | , , , | Leave a comment

Some questionable medical marketing practices via HealthNewsReview.org

A laparoscopic robotic surgery machine. Patien...

A laparoscopic robotic surgery machine. Patient-side cart of the da Vinci surgical system. Into the sealed Computer God Robot Operating Cabinet, as a Frankenstein slave, at night. Da Vinci Surgical System. (Photo credit: Wikipedia)

One pitch states “This is a good time to have it done so you can recover while spending a couple of days on the couch watching hoops with your wife’s approval.”

The editor soberly concludes that “more players in the health care field have learned that lesson and are acting on it all the time – “with appropriate marketing” you can make almost anything a trend.  Full body CT scans…prostate cancer screenings in mobile vans….Botox parties…

The article outlines how robotic surgery is touted as a great way to quickly recover from surgery so one can resume daily graveside visits to a recently lost spouse.

  • Plastic surgeon with nose for news has PR, YouTube video, and now – ethics investigation

    Some journalists recently received this news release: Miami Plastic surgeon –“Dr. Schnoz” offering a nose job, trip to Miami to the winner of a video contest March 8, 2012 – Dr. Michael Salzhauer, leading Miami Plastic Surgeon at Bal Harbour PlasticSurgery Associates, announced today “A Nose Job Love Song Giveaway.” Dr. Salzhauer’s contest involves creating [...]

     

March 21, 2012 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

Hospitals Misleading Patients About Benefits Of Robotic Surgery

From the 18 May Medical News Today article

An estimated four in 10 hospital websites in the United States publicize the use of robotic surgery, with the lion’s share touting its clinical superiority despite a lack of scientific evidence that robotic surgery is any better than conventional operations, a new Johns Hopkins study finds.

The promotional materials, researchers report online in the Journal for Healthcare Quality, overestimate the benefits of surgical robots, largely ignore the risks and are strongly influenced by the product’s manufacturer.

[An abstract of the article may be found here.
Click here for suggestions on how to get this article for free or at low cost]

“The public regards a hospital’s official website as an authoritative source of medical information in the voice of a physician,” says Marty Makary, M.D., M.P.H., an associate professor of surgery at the Johns Hopkins University School of Medicine and the study’s leader. “But in this case, hospitals have outsourced patient education content to the device manufacturer, allowing industry to make claims that are unsubstantiated by the literature. It’s dishonest and it’s misleading.”

Click here to read the rest of the Medical News Today article

May 19, 2011 Posted by | Medical and Health Research News | , | Leave a comment

   

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