Patient Out of Pocket Costs for Robotic Cancer Surgery vs Traditional Open Cancer Surgery
John Lenihan Jr., MD
Robotic surgery has been criticized from the very start as being “too expensive.” Most of this criticism was based on early studies that compared the direct peri-operative costs of robotic surgery to open and laparoscopic surgeries. The robotic procedures took longer and the instruments and operational costs were more.1-2 These studies, however, were flawed in many ways: 1. They were based on large Insurance Payor Inpatient Databases, 2. They were typically done during the early learning curves of the surgeons and the teams, and 3. They didn’t look at indirect costs of the procedures (medications, complications, length of stay, etc.). A new study just published in JAMA-SURGERY took a different approach to the cost of robotic surgery and looked at the “out of pocket” costs for patients undergoing robotic oncology surgeries compared to patients undergoing the same procedures in an open fashion.3 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2758740.
This paper out of Harvard Medical School in Boston, Massachusetts, looked at 1.9 million insurance claims over five years from a de-identified insurance registry to identify what the “out of pocket” payments were for patients age 18-64 years old with an employer based insurance plan who underwent five of the most common robotic assisted vs. open cancer operations: hysterectomy, radical prostatectomy, partial colectomy, radical nephrectomy and partial nephrectomy. To make a long story short, they found that in all cases, the out of pocket costs for the patient were lower with robotic surgery vs. open surgery. The out of pocket costs varied by plans but ranged from $137.50 less for radical prostatectomy up to $1140 less for partial colectomy. Interestingly, total insurance payments to the hospitals were also less for all robotic procedures. The authors attributed this in part to decreased length of stay for all robotic procedures as well as a trend to decreased complications for most robotic procedures. They also noted differences in lower costs from centers that did high volume procedures.
These results are interesting indeed and support trends that most of us in robotic surgery have observed over time but should be interpreted with some caution due to the scope of the analysis.4-5 This data looked at both inpatient and outpatient costs (unlike most other studies). There were differences affecting costs that could not have been factored for including patient selection, resident training, and the ability of not for profit (tax exempt) hospitals pushing robotic surgery to use “debt” related to lower robotic surgery payments, compared to open procedures, to subsidize their operational growth. Limitations of this type of database driven analysis also include the inability of the database to account for race/ethnicity, stage of cancer, prior surgeries/treatments, or BMI: all factors that could influence the decision to attempt a robotic procedure vs. an open procedure.
In summary, this paper even with its limitations does support the growing body of evidence that robotic assisted surgery, in the right hands, can improve clinical outcomes in many cases and can also lower direct patient out of pocket costs. Despite the nay-sayers who still want to take a wait and see approach to robotic surgery, the market is moving. Training robotic surgeons and teams to be able to achieve the best outcomes has always made clinical sense, but now is starting to make more and more financial sense as well.
Jeong IG, Khandwala YS, Kim JH, et al. Association of robotic-assisted vs. laparoscopic radical nephrectomy with perioperative outcomes and health care costs, 2003 to 2015. JAMA. 2017; 318(16): 1561-1568. doi:1001/jama.2017.14586
Wright JD, Burke WM, et al. Comparative Effectiveness of Robotic vs. Laparoscopic Hysterectomy for Endometrial Cancer. J Clin Oncol. 2012 Mar 10;30(8):783-791. doi:10.1200/JCO.2011.36.7508
Nabi J, Friedlander D, Chen Xi. Assessment of Out-of-Pocket Costs for Robotic Cancer Surgery in US Adults. JamaSurgery/open. Jan 15, 2020. JAMA Netw Open. 2020;3(1):e1919185. doi:10.1001/jamanetworkopen.2019.19185
Epstein AJ, Groeneveld PW, Harhay MO, Yang F, Polsky D. Impact of minimally invasive surgery on medical spending and employee absenteeism. JAMA Surg. 2013;148(7):641-647. doi:1001/jamasurg.2013.131
Aggarwal A, Lewis D, Mason M, Purushotham A, Sullivan R, van der Meulen J. Effect of patient choice and hospital competition on service configuration and technology adoption within cancer surgery: a national, population-based study. Lancet Oncol. 2017;18(11):1445-1453. doi:1016/S1470-2045(17)30572-7