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.