Robotic Surgery and Insurance- A Viewpoint
Introduction
A few days ago, there was a group discussion on whether robotic surgeries should be covered in the traditional group insurance/ Mediclaim plans. There were mixed responses from the group, some saying we should cover and some showing apprehension about the same. A consensus was reached when the group decided to gather more information regarding the topic and then articulate suggestions on inclusion of Robotic surgeries into the insurance plan. This paper attempts to consolidate information on Robotic surgeries like indications, trainings, infrastructure, outcomes, cost implications, procedure coding systems, advantages, challenges and so on.
We shall also consider two studies on same topic with contradicting ideas. The objective is to weigh both sides of the coin and provide valuable suggestions to our clients.
A brief history
Puma 560, developed by Victor Scheinman at Unimation, was used to perform neurosurgical biopsies in 1985. This method improved surgical precision since it eliminated hand tremors of surgeons which could result in error during the placement of biopsy needle. The Puma 560 was used for the first time to perform transurethral resection of the prostrate subsequently in 1988.
The minimally invasive Da Vinci robotic surgical system was approved by the FDA in 2000. It is currently the only robotic surgical system used in the U.S.
The main technology used in robotic surgery is ‘Telepresence’. Telepresence surgery system (TeSS) permits the surgeon to operate on a patient across distances. This is achieved through real-time 3D video vision, stereo audio, and remote instrument control with haptic feedback.
Study 1- Robotic surgery is ready for prime time in India: For the motion
In this study, the authors Mahesh Desai, Jaspreet Chhabra and Arvind P. Ganpule have provided insights on the advantages of the use of Da Vinci system. They have quoted Sushrut as, ‘a surgeon, by his own experience and intelligence, may invent and add new instruments to facilitate the surgical procedures’. The earlier methods of open incision surgeries were considered gold standard in treatment of certain urological cases up until the advent of ‘laparascopy’. Laparoscopy marked the era of minimally invasive surgeries and soon became the norm and replaced open surgeries especially in urology. However, there are certain limitations of laparoscopic procedures. Some of them being:
- Limited degrees of freedom
- Two- dimensional system
- Transmission of physiological tremors
- The fulcrum effect
This study emphasizes that being a combination of computer technology with surgical handicrafts, robotic surgery is envisaged as a revolution.
Some of the advantages of robotic surgery system are:
- 10-15X magnified images
- Three-dimensional view
- Reduced chances of inadvertent tissue injury
- Better appreciation of anatomical structures
- Improved and increased freedom of movement
- Less exertion for the surgeon and surgical assistants as they do not need to stand at the operating table
- Motion scaling features dramatically reduces physiological tremors
The authors also mention advantages of robotic surgeries for the patients as:
- Minimally invasive
- Smaller incisions
- Improved cosmesis
- Less post-operative discomfort
- Less blood loss
- Early recovery and discharge
Study 2- Robotic surgery is ready for prime time in India: Against the motion
In this study, the author, T.E. Udwadia, argues that the robotic surgical system has only marginal improvement of outcomes, however, the cost of the same is very high. He emphasizes that there are numerous areas of ambiguity and controversy with relation to the advantages, disadvantages, results, complications, and outcome of robotic surgery. The stakeholders that actually benefit from robotic surgeries are:
- The surgeon as it improves comfort and reduces physical strain while providing excellent vision and manoeuvre
- The manufacturers of the robotic surgical system as the system costs a minimum of $two million
- Hospitals, as it is a growing business opportunity
Some of the disadvantages of the Robotic surgical system are:
- Larger operating room (OR) space
- Longer OR time
- Difficulty in changing operating table position after docking
- Conversion to laparoscopic or open surgery in case of difficulty is laborious and time consuming and could be life-threatening in a dire emergency
- Inadequate training opportunities for surgeons currently
- Chance for human error if the physician incorrectly programs the robot prior to surgery- the computer cannot change the course of the surgery as the surgeon himself could
- Potential cybersecurity risks such as hacking and malware
Comparison of the findings of both the studies
The significant argument in the above studies is that Robotic surgery is quite a recent invention and its full consequences are not yet recognized. Both the studies point out that the cost of the system is significantly high as compared to marginal improvements in the surgical outcomes. The common consensus is that the number of robotic surgical systems in India with a ginormous population is still very low. Since the cost of the system is high, the same is passed to the patients for whom it becomes very expensive.
Robotic surgery with its bundled advantages is still in its burgeoning phase, the best of which is yet to come. What we need today, is feasible equipment and maintenance cost thereby increasing the supply of robotic surgical systems in the hospitals leading to an affordability of procedures resulting in increased demand for these surgeries.
Coverage of Robotic surgeries in Health Insurance/Group Mediclaim policies
So, should we cover the new and expensive robotic surgery into insurance? Well, there is no black and white answer here. One would argue that just like day care surgeries came under the purview of insurance and replaced the traditional surgeries, robotic surgical systems should also be considered as better procedure and be covered under insurance. However, day care surgeries manifested significantly better outcomes in terms of length of stay, less post-surgical complications, improved quality of surgery, reduced time; all this without significantly increasing the costs.
Robotic surgeries may be covered under the following circumstances:
- It is an absolute indication- no other surgical module can provide the desired outcome
- The procedure is properly coded
- If covered under the treatment at reasonable cost clause
- If covered under the medical advancement clause
- If the client insists, and it does not have a significant premium loading due to poor experience and with cost control mechanisms like limitation in number of cases, sublimits or deductibles
- If the procedure is covered only in corporate buffer on HR approval after thorough due diligence of individual cases
Conclusion
Robotic surgery is essentially another way of doing laparoscopic surgery albeit with better technical inputs and technology. It may have equivalent or better results in some surgeries but for most of surgeries across various specialties, it offers no real patient benefits in terms of surgical outcomes. Like most of today’s world, healthcare industry is also driven by market forces. The market forces in the healthcare industry are private/corporate hospitals, pharmaceutical companies and instrument and equipment manufacturing companies. In a country like India, although about 26% of our population lies below poverty line, about 80% of healthcare services are provided by the private sector. This profit making private healthcare sector can afford high end technology but like any market driven force, it will try to force this new but at times unnecessary technology upon an uninformed patient. Robotic surgery will be pushed for most surgical cases as, if the doctors stick to the actual indications for the same, the hospitals may not be able to recover costs. This in turn will make medical treatment very expensive and drive up the premiums for health insurance, ergo, health insurance shall become unaffordable to a huge majority of our population!
Thus, we must have a cautious approach while recommending coverage for robotic surgical systems as time will only tell if these systems shall provide a much better outcome and shall eventually be affordable as evidence based medical procedure!
References
Desai M, Chabra J, Ganpule AP. Robotic surgery is ready for prime time in India: For the motion. Journal of Minimal Access Surgery. 2015;11(1):2-4. doi:10.4103/0972-9941.147649.
Udwadia TE. Robotic surgery is ready for prime time in India: Against the motion. Journal of Minimal Access Surgery. 2015;11(1):5-9. doi:10.4103/0972-9941.147655.
Cooper MA, Ibrahim A, Lyu H, Makary MA., “Underreporting of robotic surgery complications”. J Healthc Qual. 2015 Mar-Apr;37(2):133-8. doi: 10.1111/jhq.12036
Sahu D, Mathew MJ, Reddy PK. 3D Laparoscopy - Help or Hype; Initial Experience of A Tertiary Health Centre. Journal of Clinical and Diagnostic Research: JCDR. 2014;8(7):NC01-NC03. doi:10.7860/JCDR/2014/8234.4543.
Priya Shankar at University of Houston, Advances of Robotic Surgery: The da Vinci Surgical System, March 14, 2018