Pictured: da Vinci system in an operating room. | Photo courtesy of Intuitive/press resourcesMore and more, surgical robotics are being discussed as having potential to bring savings and new surgical cases to ambulatory surgery centers (ASCs).
Yet implementing robotics systems often comes with financial and operational challenges.
Ambulatory Surgery Center News spoke with Deb Yoder, vice president of facility development at Compass Surgical Partners, to discuss the growing adoption of surgical robots in specialties like orthopedics, urology and gynecology, as well as the complexities of reimbursement and financing.
Highlights of that conversation can be found below, edited for length and clarity.
ASC News: In which surgical specialties and procedures are robots being used in the ASC setting, and what are the reimbursement challenges or considerations when implementing robotic surgery there?
Yoder: So in ortho, you see robots for total joints. You also are seeing, in the ASC, the larger ones that have a big volume of general surgery, gynecology and urology. You’re seeing Da Vincis being used. They’ve been used in the hospital setting in many services for years, but we’re seeing it move into that environment.
The hard part of using a Da Vinci on belly cases in the ASC market is that we get reimbursed the same for that procedure, whether a robot’s used or it’s done laparoscopically, and so it’s hard to manage costs when you’re using the robot. You have to have good insurance contracts, because nobody pays you. Typically, they won’t pay you extra to use the robot.
What are the potential benefits of robotic surgery for traditionally inpatient procedures, and how might payer policies impact the shift of these procedures to outpatient settings?
The advantage is, cases that used to have to do with an open belly, especially in urology, work now can be done with four or five poke holes on an outpatient basis.
It’ll be interesting to see where Medicare goes with that and the payable codes that they use, because it could mean that cases that were always inpatient-only could move into that ASC arena. We just don’t know. And we know some of the private payers already are doing that, but we’re seeing more lap-assisted cases in the ASC market, done with the Da Vinci or just done laparoscopically. You have to be really good at your analytics, though, to make it work, and you have to have, typically, a really solid hospital partner that is willing to place one of their extra older robots at the ASC or help you with it, because most ASCs don’t have the cash financial position to just buy one outright.
How do operators typically finance this technology?
It varies from center to center. It varies on the case volume, how many different providers there are, how many different kinds of joint vendors you have. Some management companies or hospital systems will tell all of their providers, “You can only use the XYZ system for your knees, and you can only use this one for your hips.” So then it’s easier. But when you have docs, it comes down to your philosophy. Are we going to mandate that the physicians all use the same implant? Conceptually, they all kind of do the same thing, but they’re different. You know, it’s like a Ford and a Chevy: I can get in and drive both of them, but they might have some differences.
Even the ortho robots are very expensive. You’re looking at $600,000 to $1 million. Now, the ortho companies will do placement programs based on the number of joints you use. There are also lease options. So when you’re doing the analytics for it, you have to understand the cost difference – purchase versus rent, lease, or placement. Really understand physician volumes, which vendor they want to use, because you can’t afford to have two or three different robots in a surgery center unless it’s a really big center with lots of volume. Because then you’d have two machines sitting there at, you know, $800,000 or $1 million dollars, and if you don’t do enough joint procedures – if you don’t buy enough implants and components to keep it there at the discount – then it doesn’t make sense either.
And you also have to be really savvy about what they’re charging for those implants, because some will upcharge on the consumable implant side to place this. So you have to know: Is it better for us to go get an equipment loan at 4% interest versus committing to buying all of these joints when we’re not sure on the volume, or doing a lease? And most of the vendors do a lease at whatever the national rate is, which is high right now.. But again, you have to have good financial analysis to understand that and really help these physicians understand the options. I think that’s where our role is in the ASC world and as management companies. To provide those analytics and let them see side-by-side comparisons, so as owners, not just hospital partners, management companies, but physicians, all can see the different options and decide as a leadership board which direction makes the most sense.
A lot of times, physicians are kept out of some of those decisions, or at least all those analytics, in the hospital world. They don’t see it. They’re not owners. The hospital CEOs and finance teams, you know, our directors, just make decisions.
How do you go about training staff on shifting to more robotic systems?
Most of the clinic nursing staff, they learn it. Physicians do extra training; they’ll go to the company vendor and have to start looking at it. And even before we use it, we want to see that they have demonstrated competency. They may have to work, like any new procedure, with a mentor or some sort of preceptor for so many cases before they would do it on their own. And they get privileged to do those procedures with a robot or without, and that all comes down to credentialing.
But the newer fellows in ortho, the total joint fellows, the majority of them all rely on some sort of integration. The older physicians learned without it. I mean, we see it even with integration in spine and ENT. The old ENT docs doing sinus surgery never used integration, and the new ones have come out and said, “Yeah, for revisions or when you’re working on the frontal, it’s now best practice.” So it’s changed the landscape of how we do things and what staff have to know. We have smaller incisions for everything compared to in the late 80s when I started in the OR. In our operating rooms, we have more equipment in them because of all of this, and more things that the nursing staff have to learn how to manage and fix and troubleshoot, hook up.
Most physicians are – they may be trained on multiple kinds, but they get used to a comfort level for one or may determine there are advances in one vendor over another based on the clinical presentation of the patient. “I need an LRG knee, and that’s only made by this company. I need a really high-acuity knee because I have a 50-year-old professional skier. I need a different kind of makeup for this knee versus what I might put on an 80-year-old grandma who isn’t going to be skiing moguls and skiing five days a week.”
What role do you think emerging technologies will play in health care and surgical settings beyond the traditional use of surgical robots?
I think we’ll see more and more – maybe not actual robots doing things, but we will see more artificial intelligence. We already are seeing that in the GI space with interpretation of colonoscopies. You see robots or machines in pharmacy packaging and doing things, even in dictation and interpretation. And, you know, the talk-to-text is a simple concept, but as physicians dictate and look at images, they still have to do that. But there are also now systems that look at it too to help them. Our simple EKG machines know enough that they print out what the rhythm is. It doesn’t mean that we still don’t need a cardiologist, because machines can make mistakes just like humans can. But I think we all are tasked with living and learning in a world where it’s changing really fast, and how do we use those tools for the best of our patients?
