Friday, November 21, 2008

Uncle!

Many months ago, I wrote about the da Vinci Robot Surgical System and expressed doubts about whether there was evidence to support the clinical efficacy of this equipment, as opposed to the marketing efficacy of the company selling it. Well, the time has come to graciously say, "Uncle!"

Without making any representations about the relative clinical value of this robotic system versus manual laparoscopic surgery, I am writing to let you know we have decided to buy one for our hospital. Why? Well, in simple terms, because virtually all the academic medical centers and many community hospitals in the Boston area have bought one. Patients who are otherwise loyal to our hospital and our doctors are transferring their surgical treatments to other places. Prospective residents who are trying to decide where to have their surgical training look upon our lack of the robot as a deficit in our education program. Prospective physician recruits feel likewise. And, these factors are now spreading beyond urology into the field of gynecological surgery. So as a matter of good business planning, concern for the quality of our training program, and to continue to attract and retain the best possible doctors, the decision was made for us.

So there you have it. It is an illustrative story of the health care system in which we operate.

25 comments:

you are young grasshopper, but you will learn said...

Paul,

I am interested in the decision making progress here as it is diametrically opposed to the budgeting criteria in the UK but then the Healthcare system is hugely different too.

If I understand you correctly it is a decision based on business rather than clinical grounds and in such light seems eminently reasonable.

My interest is in Clinical Leadership and I wonder where the interaction comes in your practice between clinical and leadership?

Anonymous said...

And this is why they say our health care costs go up, right? Do we get to know how much the robot costs?

Anonymous said...

Yet another sign of the need for greater governmental oversight of capital expenditures....since payers have no resolve to end the wasterful medical arms race....and providers are disadvantaged competitively if they don't pile on. Another example of reason 3 in the attached article by Uwe Reinhardt about why the US has such high medical spending:

http://economix.blogs.nytimes.com/2008/11/14/why-does-us-health-care-cost-so-much-part-i/

Matthew said...

My hospital bought one last year, and I had a chance to "play" on a demo model. It's extremely impressive to put your hands on and control. How your movements are so smoothly translated to the machines.

I've heard of some good outcomes, and Women friends have done the research and flock to certain Doctors who do the GYN surgeries with it. They say recovery time is far better.

I think our hospital's decision was a way to set us apart technology wise.

ChicagoKid said...

Paul,

As an institution that has multiple da Vinci's currently, I can honestly say that from a marketing standpoint, it does help draw residents, physicians, and a portion of patients.

Unfortunately, as you mentioned, there still isn't clear evidence that this is necessarily better for the patient in many surgery cases compared to laporoscopic. The case can be made for certain procedures that there is an actual benefit to the patient, but many cases have no proven benefit either. Also, nearly all insurance companies and CMS has not reimbursed at a higher rate yet, even though the cost is significantly higher.

This is definitely a prime example of a loss leader in technology, and what happens when the market only has one company that has a comparable competitive product. High investment costs, no proven additional benefit for patients, and no additional reimbursement for hospitals. Intuitive's stock certainly has risen significantly since their mass sales of da Vincis.

This may be medicine of the future, but I still question whether it's worth it yet in terms of added cost to the hospital with regards to purchase, supplies, OR time used, and ultimately, safety/recovery for the patient.

Good luck with da Vinci in your system! I'll hope that you provide updates with regards to its performance and usage, and your thoughts on it as you continue to use it.

Dan Kane said...

Like most medical decisions that include the public, it is one at this juncture based on sentiment and not scholarship. New = Better in every model in American health care.

As a imaging physicist with 20+ years in the field, this is no different than dozens of imaging devices in competitive use.

It is unfortunately an illustrative example of capital expenditures in health care.

Richard Neill said...

I trust this is also why you've invested so much capital in the primary care infrastructure that refers to and practices at your hospital?

Unlike robotic procedures, the evidence of health benefits of primary care are well documented, yet no one invests in it because it's not the popular (or, to be more specific, the renumerative) thing to do.

At least you're honest and transparent about the rationale, a move I deeply respect.

Paul Levy said...

Actually, we HAVE invested substantially in our primary care services, with very large subsidies each year to acocunt for the fact that insurance payments do not properly compensate this service.

Sean Roche said...

Monty Python had something to say about this.

Anonymous said...

I can only say sad, but true. Thanks for being upfront about it, unlike most CEO's. You should send this to the media - or to Obama. (:

nonlocal

Paul Levy said...

Media has picked it up:

http://www.boston.com/news/health/blog/2008/11/the_robot_is_co.html

... as have many other websites, notably one recommending the stock of this company: http://www.investorvillage.com/smbd.asp?mb=3128&mn=9624&pt=msg&mid=6160589

Some good discussion here, too:
http://www.prospect.org/csnc/blogs/ezraklein_archive?month=11&year=2008&base_name=surgery_robots

And here:
http://ourownsystem.com/2008/11/21/an-illustrative-example/

And here:
http://ergotism.org/2008/11/21/but-markets-fix-everything/

And here:
http://www.universalhub.com/node/21714

Anonymous said...

hey, several months ago you had a link to a friend's very cool photography site. mostly outdoorsy stuff- a whole section on patagonia. what is his name and how can i find him?

Paul Levy said...

Moe Witschard Photography
307 N Black Ave.
Bozeman, MT
406.570.3505
www.moephotography.com

Dr Grumble said...

How long have these things been around? This link dates back to 2002. Have there been no proper trials in that time?

There's no denying the marketing powers of such a tool. The National Health Service surgeon in the above link has been compared with James Bond and has now been ennobled and made a member of the British government.

If that's anything to go by purchasing one of these toys in a system like yours makes sense. Why don't we evaluate expensive tools for healthcare in the same way that the FDA and other regulatory agencies evaluate drugs?

Dr Grumble said...

If there are other British readers who wondered what your uncle has to do with this here is a link that explains it.

Paul Levy said...

Thanks for translating, Dr. Grumble. After all, as Shaw noted, we are "Two peoples separated by a common language."

Anonymous said...

My hospital learned that owning this piece of technology is used by US News and World Report to rank hospitals in Gynecology, and then purchased one.
I find it marginally beneficial. The instrument is less important than how it is used. When young tennis players complained about their racquets, Mr. Bolleteri, of the Tennis Academy, used to beat them using a broom stick instead of a racquet, to make the same point.

Domenico Savatta, M.D. said...

Paul,
Welcome to the world of robotic surgery.

I'd like for you to have a yearly summary about your feelings on the subject, with input from your surgical leaders in minimally invasive surgery.

Since we discussed this last, I am performing 99% of my urologic cancer surgery robotically.

Difficult surgeries like testicular cancer, bladder cancer, and kidney cancer (including dificult partial nephrectomies) are done robotically now.

I think your opinion on this wil change and I predict you will have a 2nd robot in 2 years.

Best of luck in these difficult financial times.

Dr Savatta

Fibro Witch said...

So as I understand it, the surgeon is in another room, looking not at the patient, but at a computer screen. Who is with the patient? A nurse, an anesthesiologist? Can the robot see the entire patient? If my eyelids flutter or I start to convlus, does the doctor leave the screen, scrub up and then go to my side?

Can I opt out of using a robot and have a person take care of me?

The Medical Quack said...

Well right now with the financials of many hospitals too, there could be some very good "fire" sales on robotic equipment available.

I have been doing a series over at the Medical Quack that began in August with posts every so often on what's happening and with closures, and some even fairly new facilities, such as the Century City Hospital on the outskirts of Beverly Hills that ran out of money and could not get any financing or buyers having to close, there could be some opportunities there for robotic surgery units for another facility to benefit on the purchase.

Century City Hospital was only re-opened for a couple years and had everything state of the art, and was even used for movies and paid for that privilege as well, i.e. the Bucket List, and still could not make it. They had hospital patient suites too, so again I mention this to show what could be up for buyers in a "fire sale" type of scenario.

Just updated the Desperate Hospital series today and here's a link and it has related reading back to prior posts. Not really a bright spot to promote, but perhaps some savings versus purchasing new equipment could be helpful today where every area of any budget is scrutinized and yet still provide the best health care and surgery facilities all the way around.

http://ducknetweb.blogspot.com/2008/11/desperate-hospitals-updated-november-21.html

Anonymous said...

I am a Professor and Head of Urology at a University and tertiary center in Canada. The Robot has proven a delemma for me. Its cost is prohibitive in the Canadian system yet personal donors have given money to hospitals elsewhere in Canada to acquire one or two. We have difficulty in explaining the lack of robots to prospective residents yet it is very unlikely that our trainees will ever utilize a robot following completion of their training as only Hospitals with endowments will be able to fund these. This means the Academic centers will have them yet the community and smaller regional hospitals will not. Our current residents fear that the presence of a robot will affect their open surgical training.
I have decided not to acquire a robot. The pressures are for education not clinical care. There is a lot of bad surgery still being done on a robot as surger is cognitive as well as technical. The benefit of robotic surgery is very limited when compared to a well trained surgeon. It is of acdemic and marketing interest only.

Joe S said...

A quick note about costs for the person who asked.

Robot = $1,650,000
Maintenance (annually)= $150,000
Supplies per case = $2250

I work for a hospital system that is considering purchasing one or two of these robots and I struggle with this purchase for a couple of reasons. First, from an administrative standpoint, the clinical benefit (slim to none in most cases) does not seem worth the cost. In a system with limited resources, a tool benefiting 50 to 100 patients a year at this cost seems crazy. If market forces are removed and this decision is looked at from the perspective of what would benefit patients, how many hospitals would buy this robot? One per large city? Second, in the most global view, is this type of expense that we as health care consumers want to support?

virerus said...

Paul - I have a question and generally I agree with you on the high cost of the system. But in the defense of the robot - I assume like any hospital you guys generate most of the revenue from surgeries. So why not invest in where you make money? Plus in my opinion, also considering you pay a good surgeon 500K+ salary - why such an equipment purchase you consider expensive? isn't everything high cost in this business? anyway, just my opinion.

Please update us how "the robot" has been working for you so far? Do you do any return on investment calculations? Can you please update?

Anonymous said...

Paul, now that you've had the machine for a few months, what can you say about its impact on all the 'buy' issues you cited? is it costing more, is it attracting patients and residents?

Thanks,

Kymus Ginwala said...

Dear Paul:
Why is it not possible in the case of such large expenditures that the health system (reimbursement) or tax system (depreciation), not encourage the joint ownership of such facilities which would also provide training as well as an IT system to collect and disseminate the data?