Radicals, Robots, and Reimbursement

Radicals, Robots, and Reimbursement

L. Michael Glode, MD, FACP, FASCO

Apr 18, 2014

So how did the robot take over? As I recall, it started with "hospital A" buying the fancy robot for their urologists to use, after said urologists insisted that this was the way of the future. The Intuitive Surgical Company did an outstanding job of selling the technology. I remember going to our parking lot, going into a fancy 18 wheeler, and playing with the robot, tying a few knots on a fake surgical template, and thinking "really cool." Of course any boy (and probably a lot of female surgeons as well) loves new toys. Why only this last Christmas, I bought myself and my adult children several of the very cool (and I still recommend them for your toy-loving children by the way...) RC indoor helicopters.

But back to "hospital A." The results of their investment of about $2M plus several hundred thousand in maintenance costs was that patients flocked to their urologists to get their prostates removed by the "new, improved... step-right-up-sir" technology. And, of course, our hope was that there would be improvements in cure rates, preservation of potency, and less incontinence since there was NO doubt that the surgeons could see their tissues better, control their shakiness, and relax at a console rather than accomplishing the acrobatic feats required for reaching way down behind the pubic bone to get at the evil prostate. And so . . . the urologists at "hospital B" started losing cases and lobbied their hospitals to take the plunge and also invest. In the end, robotic surgery replaced open prostatectomy in 85% of cases. But, in the three areas patients care about most—cure, potency, continence—there was no improvement. There were very small improvements in blood loss (which for most patients never requires transfusion anyway), time in hospital (reduced from something like 28 hours to 24 hours), and pain (which has always been very minimal anyway, usually handled easily by pain medication for two to three days). But Intuitive made out like a bandit. Their stock price soared from $12.75 on December 22, 2000, to $540 on April 3, 2014. I should have seen this coming!

And now comes this article in JCOComparative Effectiveness of Robot-Assisted and Open Radical Prostatectomy in the Postdissemination Era. The authors use the SEER database to evaluate open versus robotic radical prostatectomy (RP) in 5,915 patients who had their procedures done between 10/08 and 12/09. 42% of the patients had "old fashioned" open RP's (ORP) while 59% had robotic RP (RARP). As stated in their abstract, "Patients undergoing RARP had similar odds of overall complications, readmission, and additional cancer therapies compared with patients undergoing ORP. However, RARP was associated with a higher probability of experiencing 30- and 90-day genitourinary and miscellaneous medical complications (all P ≤ .02).”

Combined with numerous other articles showing no improvement in cure, potency, or incontinence, this paper adds to the rather sad tale of how sometimes our technology leads to higher costs with minimal if any benefit. You can read elsewhere on my prost8blog about similar findings with proton beam therapy. "Let the buyer beware" should become a more frequent paradigm for medical advances. Of course, if Medicare did this, we would hear the chorus chant the echo-chamber commentary on how "government is stopping us from getting the care we deserve." If you like this system, just continue to vote for no change in how we deploy our Medicare tax dollars.

This post originally was published on prost8blog and is reprinted with permission of Dr. Glodé.


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