If we went back in time and walked into a hospital in the mid-1800s, we would likely be shocked. Hospitals weren’t places of healing… hospitals were facilities where the poor would hopelessly visit as a last resort, often ending with their death. Fast forward to a little over 150 years later, and we see hospitals saturated with the latest and most expensive technology the world has to offer. Hospitals have the capability to take you from near death and restore you to nearly full life. Even the most complex surgeries are now being done with robots, utilized for their high dexterity and precision. The increasing prevalence of robotics in surgery has raised questions about the role that technology has played in rising healthcare costs. Several studies have shown that technological advancements, in fact, are the primary drivers of higher healthcare costs in America. I had the privilege of speaking with Dr. Manu Sancheti, director of robotic thoracic surgery at Emory, about the role of technology in rising healthcare costs. Dr. Sancheti practices thoracic surgery and teaches as an assistant professor of surgery at the Emory University School of Medicine.
The da Vinci is one of the most popular robotic surgical systems, with the robot having been used for over 6 million surgeries worldwide since its manufacturer Intuitive Surgical received FDA clearance for the machine in 2000. The robot itself costs $2 million with around $180,000 in maintenance fees each year, and these high costs raise questions about whether the da Vinci’s increased prevalence is worth it. This is particularly important to look into because using the da Vinci generally does not produce better outcomes compared to when surgeons utilize a laparoscopic or thoracoscopic technique, in which narrow tubes are inserted through small incisions to perform a surgery in the abdominal or thoracic cavity, respectively.
I started our conversation about robotics by asking Dr. Sancheti about the concept of “Supply Sensitive Care,” which states that the use of health services depends upon the availability or supply of that service. For example, evidence shows that if a hospital has an MRI scanner available to them in their facility, they are more likely to use it more frequently than necessary. The same is true for hospitals with lots of beds: the more beds a hospital has, the more likely a patient will be recommended to stay overnight for “monitoring.” When I asked Dr. Sancheti if he believed that the availability of the da Vinci in a hospital led to the robot being used more often than necessary, he said that “The difficulty lies in terms of how you get to the point where you are comfortable using the technology for its main advantages. I do a surgery to recreate the esophagus after removing it because of esophageal cancer, and it’s much easier for me to do the surgery with the robot compared to using thoracoscopic instruments. However, yes, the robot initially may need to be used in some ways that are not cost-effective in order to build up to the repetition level necessary to achieve cost-efficiency. There’s no question that robotic technology is more expensive than laparoscopic instruments, so we have to be smart about our utilization of the robots. However, those of us who do a lot of robotic thoracic surgeries feel that the da Vinci provides an advantage in complex cases, and we want to provide that advantage to the patient if we can.”
A key factor protecting robots from being potentially overused for financial gain is the fact that Medicare, the government insurance plan for Americans over 65, does not reimburse doctors or hospitals more when they use robots over a laparoscopic technique. When I asked Dr. Sancheti if he believed reimbursement rates should be greater for robotic-assisted surgeries, he said, “The robot is just an instrument used to assist in a minimally invasive operation, so I don’t think reimbursement rates should be different when using a robot vs. a laparoscopic technique.”
Our conversation then moved to what some call a “Medical Arms Race,” in which competition among hospitals leads to overconsumption of medical technology because after one hospital adopts a new, exciting piece of technology, other hospitals in the area follow suit in order to stay competitive. When I asked Dr. Sancheti if he has observed this phenomenon, he said, “Yes. Our health system is very business oriented, especially in a big city like Atlanta where there are hospitals everywhere. Patients are intelligent consumers, so they are going to go wherever they can get the best medical care for their situation. So to stay market competitive, the adoption of a new piece of technology at one hospital often leads to other hospitals getting it as well.”
Georgia is one of 35 states with a “Certificate of Need” program, which requires healthcare facilities to receive state approval before obtaining any piece of technology costing over $1 million. The National Conference of State Legislatures states that “the basic assumption underlying Certificate of Need regulation is that excess health care facility capacity results in health care price inflation.” Essentially, these programs are in place to theoretically stifle unnecessary care and higher prices by only allowing hospitals to purchase technologies that are needed to serve the community and not anything extra. When I asked Dr. Sancheti what he thought about Certificate of Need programs, which are highly debated in state legislatures, he said that “the concept sounds good.” However, it doesn’t work as well as it sounds. As Dr. Sancheti says, “You can imagine the bureaucracy that can be involved. Even when you genuinely need a new piece of technology, it’s hard to get it because of all the bureaucratic layers you have to go through ”
When I probed him further about the dynamic between hospital administrators, who are often businessmen, and physicians, he said, “All doctors have to deal with their hospitals’ administrators in different ways, and what we need as clinicians is for business leaders to bring their business acumen to the table, but listen to our clinical needs. I fortunately work in an environment where administrators and doctors work together really well.”
To close, I asked Dr. Sancheti about the future of robotics in medicine, and he said, “I think that all surgeries, at some point, will have some kind of computer assistance. Having some kind of guidance from a computer is just vital.” Dr. Sancheti discussed how “augmented visualization technology is being developed where tissue, such as blood vessels, can be seen on a screen while you’re doing a surgery even though you’re not actually able to see the vessels…almost like virtual reality. There is also research on marking tumors with fluorescent chemicals, then using fluorescence detectors on the surgical tools’ cameras to identify the location of cancer cells.” In all, Dr. Sancheti made clear that robotics had a valued and justifiable place in surgery, despite the additional expense to hospitals.
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