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Ethics, health insurance, hysterectomy

Insurance companies should stop paying for robotic hysterectomies

A new study confirms what previous studies tell us. That a robotic hysterectomy is not a safer or a more efficient way to remove a uterus for non-cancerous (benign) surgery than a traditional laparoscopic approach. This study (Rosero et al, Obstet Gynecol 2013) indicates that there is little difference between the two types of surgery with one glaring exception, a robotic hysterectomy was $2,489 more expensive than a laparoscopic hysterectomy.

Several months ago the American Congress of Obstetricians and Gynecologists (ACOG) issued these statements:

Robotic surgery is not the only or the best minimally invasive approach for hysterectomy. Nor is it the most cost-efficient. It is important to separate the marketing hype from the reality when considering the best surgical approach for hysterectomies

And

there is no good data proving that robotic hysterectomy is even as good as—let alone better—than existing, and far less costly, minimally invasive alternatives.

Robotic hysterectomies for benign disease provide nothing additional from a medical perspective although they are a welcome marketing ploy for doctors and hospitals (Hey, we have a robot! Come see us! That’s so cool!). Some hospitals and GYN practices have literally built their marketing around the robot. And obviously the more robotic hysterectomies performed the greater the profits for the makers of the da Vinci robot.

There is enough data for insurance companies to say, “We won’t pay the price difference.” If insurance companies capped hysterectomy fees at the cost of a laparoscopic procedure then if hospitals and doctors wanted to eat the price difference or pass that price difference along to their patients, so be it.

Wasting money on a procedure that offers nothing over a less expensive alternative is an outrage. As an aside, this is the biggest issue I have with Obamacare. We should all be insured, but doctors, hospitals, and medical device companies should not be allowed to take advantage of that. The need to curtail egregious expenses is urgent. A robotic hysterectomy does offer advantageous for cancer surgery, so I’m all over that, but isn’t it better to channel the money to where it can actually improve outcomes?

And so my plea is to insurance companies. Whether procedures and drugs are covered or not depends in a large part on the body of medical literature and recommendations by professional organizations (like ACOG). There is not one study that shows the benefit of robotic hysterectomy over a traditional laparoscopic approach. Since the doctors and hospitals that push robotic hysterectomies don’t have the ethics to police themselves, insurance companies must step in and stop the madness. Insurance companies can either flat-out deny robotic hysterectomies or simply cap what they will pay at the cost of a traditional laparoscopic procedure. If there were a $2,489 co-payment for a robotic hysterectomy versus a $200 co-payment for a laparoscopic hysterectomy, given they have similar outcomes, which do you think would be more popular?

It is wrong to pass the additional cost of a more expensive and non medically advantageous procedure along to other purchasers of the same insurance. I don’t want my premiums to go for medically unindicated expenses and I certainly don’t want my premiums paying for corporate perks at Intuitive Surgical (makers of the da Vinci, and who are, by the way, laughing all the way to the bank).

Given that we are all curators of the health care system it is unethical to recommend robotic hysterectomies for benign disease. If doctors and hospitals refuse to read the literature (never mind reducing the waste in the system) then they should not be surprised at all when a third party steps in to do it for them.

Someone has to help stop the madness.

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Discussion

7 thoughts on “Insurance companies should stop paying for robotic hysterectomies

  1. I agree, and have written about it, too. Even published a piece in our local paper when our hospital bought, and touted, Da Vinci. On the other hand, since “effectiveness research” is a part of “Obamacare,” aimed at exactly this sort of thing, I have a hard time seeing why you say it’s the biggest issue you have with it Obamacare.

    Posted by Sid Schwab | October 12, 2013, 1:17 pm
  2. I disagree with notion on reimbursement for the hospitals.
    The study you are citing mentions that in general robotic cases were taking care of pts with higher BMI and more comorbidities, and (what is most important) were taking a share of abdominal hysterectomy “route”
    I think you could interpret this study that robot allows physicians to convert a more invasive route into the less invasive which a) decreases the cost, b) decreases the morbidity. I would read that as a beneficial finding.

    Posted by Dmitry Fridman | October 13, 2013, 9:06 am
  3. I had a robotic hysterectomy three years ago. A laparoscopic procedure was not presented as an option to me at the time. How different are the two procedures?

    Posted by Mary H. | October 14, 2013, 3:46 pm
    • The Da Vinci reps always say robots are better because of the articulating graspers, scissors, cautery, etc. That is the standard line. “Having the ability to use your wrists inside the abdomen allows for better tissue manipulation.” As an RN working on MANY robotic cases, I remain unconvinced about their arguments.

      The primary difference lies within the abdomen. Robotic arms have “wrists” that allow realistic movement inside the cavity, allowing tissue to be manipulated more precisely. Traditional laparoscopic instruments have no “wrists” thus cannot be manipulated to the same degree. Does this really make any significant difference? We’ve done many years of laparoscopic surgery and outcomes have been excellent. Enter the robot, and enter extreme expense. Just draping the arms on the robot costs a lot of money, and each instrument costs $8,000. Many surgeons will routinely BREAK multiple instruments during a case because they are so aggressive.

      Costs are out of control because limited resources aren’t properly allocated by administrators who spend ZERO time in surgery and know NOTHING about what REALLY goes on in the O.R.

      The two procedures are not vastly different in terms of mechanics, They are similar. The big difference comes in tissue handling abilities. If you have cancer, then yes, robot is better. Otherwise, it’s marketing hype and hospital and surgeons who are drinking the coolaid.

      Posted by Tom Glander | October 24, 2013, 7:15 am
  4. One thing I’ve noticed being an design engineer. My latest is why does the dentist charge $125 for dental x-rays, or the thyroid doc charge $900 to look at your thyroid with an ultra-sound machine. When I run the numbers, it isn’t the cost of the machine, or the time. It’s insurance has a billing code for it. (What is the time amortized cost of a dental x-ray machine, or a ultrasound machine, $5 per patient visit maybe. (Ever notice you can rent a car for $40/day)

    Seriously, the stuff I’m using is similar in a lot of ways in cost and training, but we’d never charge the customer a ‘spectrum analyzer fee’. We don’t because in our industry machines pull their weight by saving the customer money, not as an excuse to jack more money of them.

    Posted by Gibbon1 | October 15, 2013, 2:45 am

Trackbacks/Pingbacks

  1. Pingback: [Reblog from KevinMD.com] Insurers should stop paying for robotic hysterectomies « Health and Medical News and Resources - November 7, 2013

  2. Pingback: Robotic surgery problem that will keep Human Doctor & Surgeon on payroll. | Doctor & Surgeon - December 21, 2013

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