from Becker’s ASC – December 18, 2019
by Angie Stewart
ASCs considering introducing robotics should seriously examine whether it’s worth the major investment, according to Lumere Chief Medical Officer John Cherf, MD.
Dr. Cherf and Lumere Category Adviser Simon Kerr shared their thoughts on robotics with Becker’s ASC Review.
Note: Responses were lightly edited for style and length.
Question: What should surgery centers be cautious about when selecting new robotics technology?
Dr. John Cherf: ASCs will inherit some of the capital investment concerns that have plagued hospitals for years as more traditional inpatient cases transition to the outpatient space. Many new technologies are capital-intense and can have a significant adverse impact on financial performance. Robotic surgery is a good example. The current literature does not identify improved clinical results for many robotic procedures, particularly in orthopedics. This will impact the value proposition of robotic surgery, especially given the reduced payment to ASCs relative to hospital outpatient and inpatient payments. I don’t expect to see a lot of robots in ASCs, given the current market dynamics.
ASCs are ideal for high-volume, low-acuity cases. ASCs need to remain focused on [those] cases. It may be attractive to expand the scope of procedures performed at ASCs; however, a disciplined approach to adopting new technologies and additional types of cases will be important to retain the competitive advantage. Without this strategy, ASCs risk becoming similar to hospitals, when most patients and physicians prefer the ASC environment over a hospital.
Simon Kerr: The first question that needs to be asked by ASC leadership is, “Will robotic technology increase the value of care we provide our patients?” These systems require tremendous upfront capital investment along with recurring service contracts and additional disposables in every case. Another important factor to consider is the lack of long-term data supporting improved clinical outcomes for joint replacement and spine procedures compared to traditional surgery. Therefore, ASCs must consider if they will see enough increased volume to justify the investment when each case will cost more, and reimbursement is generally the same for robotic and traditional surgery.
Q: What are some traps to avoid?
JC: Sound financial planning will be important before deploying robots in the ASC space. Significantly lower payment to ASCs relative to hospital outpatient and inpatient [payments] will make it difficult to justify the current capital expense for robots, especially given the additional incremental costs and lack of improved clinical outcomes. Given this, ASCs should cautiously consider whether acquiring the latest robotic technology is the best strategy.
SK: Due to the lack of significant clinical evidence, vendors are marketing robotic technology on the promise of increased volume and surgeon satisfaction. Vendors have even offered additional resources (for additional fees) to assist healthcare facilities in developing sophisticated patient-centric marketing campaigns. This is added to the high six- or low seven-figure capital cost and ongoing service contracts. When the economics of performing procedures with robotics in ASCs is already questionable, these incremental costs quickly add up.
Q: What’s one myth about robotics technology that needs to be debunked once and for all?
JC: The biggest myth is that there is an abundance of clinical evidence to justify the expense and payback of the investment. There is not. The one theoretical advantage of providing robotic surgery is increased market share; however, if these cases are not profitable for the facility, then this “advantage” must be questioned.
SK: The advantage of robotic technology that has been demonstrated in the literature is extremely accurate placement of implants compared to manual surgery, whether you’re talking about femoral and tibial components in knee replacement or pedicle screw placement in the spine. However, there are more cost-effective ways of achieving accurate implant placement, such as patient-specific guides or existing computer-assisted navigation. Regardless of the technology used to achieve incremental improvement in implant placement accuracy, there is an ongoing debate whether it will translate to better long-term outcomes for patients.
Q: Are certain robotic devices better suited for ASCs than others?
JC: Most of the large orthopedic vendors are now offering robots. We should expect to see more innovation with these products that may enhance their value proposition. It is important for ASCs to monitor this market with a focus on clinical performance, operational performance and financial performance of robotic technologies.
SK: If an ASC is going to invest in robotic technology, there are several key elements to consider. Cost is certainly one of them, and depending on the system chosen, there is a wide range of upfront and recurring costs. Due to lower reimbursement in ASCs for surgical procedures relative to hospitals, the cost of disposables required in each case must be considered. Another important element is the footprint of the robotic system in the operating room; these systems range from quite large (e.g., TSolution One, MAKO) to very small (OMNIBot). Whether the robotic system requires preoperative imaging may be an important consideration, depending on payer coverage and patient preferences. DePuy Synthes’ robotic technology, expected to come to market in 2020 or early 2021 for knee surgery, reportedly has an extremely small footprint and does not require disposable instruments or preoperative imaging.
Read the full Q&A here.