The challenge of new technology - as in the example of robot-assisted surgery - is that costly innovations often become the standard of care before there’s sufficient evidence to tell whether they add real value that justifies their expense.
It’s well known that new medical technology drives up costs, but how it does that is often more complex than appears on the surface. While the financial benefits of a technology to physicians and hospitals may accelerate its spread, some innovations become widely accepted because physicians and patients are convinced that they provide superior healthcare benefits.
A paper by Gabriel Barbash and Sherry Glied in The New England Journal of Medicine offers a good case in point: robotic surgery. Robotic surgery systems, which cost between $1 million and $2.5 million each, have spread across the U.S. and Europe in the past four years. Between 2007 and 2009, the number of da Vinci systems (the leading robotic surgery product) installed in U.S. hospitals jumped 75 percent to about 1,400, and the number purchased in other countries doubled to 400. Since 2007, the number of robot-assisted procedures has soared from 80,000 to 205,000 per year.
Before robots came along, manually performed laparoscopic procedures had already reduced hospital lengths of stay and recovery times for a number of common procedures. Robot-assisted procedures do the same, and they have also been substituted for some open procedures that previously had no minimally invasive alternative. There is no solid evidence that robot-assisted surgery produces outcomes superior to those of conventional procedures. Yet the use of robots adds about 6 percent to the cost of procedures, and twice that when one includes the cost of paying off the equipment.
One might think that robot-assisted surgery would pay for itself by reducing length of stay. But, as was the case with the earlier laparoscopic procedures, robotic surgery is associated with an increase in volume. Despite a decrease in the underlying incidence of prostate cancer, for example, there was a 60 percent rise in the number of hospital discharges for radical prostatectomy between 2005 and 2008. That just happens to be the period when robotic surgery for that condition was becoming widespread. Patients who received a diagnosis of prostate cancer were 14 percent more likely to have the procedure in 2007 than three years earlier.
Surgeons who do robot-assisted surgery undoubtedly believe it’s better than manual surgery; and after spending hundreds of hours learning the technique, they’re likely to tell patients who may need a procedure that they’re going to be safer, have less side effects, and recover more quickly if they have robot-assisted surgery. Meanwhile, hospitals are engaged in a medical arms race: If they see their competitors acquiring robotic surgery systems, they may feel compelled to do the same. So, in a short period of time, despite the lack of rigorous evidence that it leads to better patient outcomes, robot-assisted surgery has become the standard of care for some procedures.
Biomedical innovations have accounted for much of the gains in life expectancy over the past half century, notes Victor Fuchs, a Stanford University economist, in another recent NEJM article. But because new technology is a major driver of health cost growth, he says, we should require the advocates of new technologies to prove their value. To pass the test, he says, these innovations must be shown to significantly increase the quality of care (in terms of longer life or greater quality of life), and their cost must be reasonable in relation to the increase in quality.
Of course, both tests are somewhat subjective: For example, longer life might mean only a few extra months for someone with terminal cancer. That might be valuable to a particular patient; but if the treatment substantially decreased his or her quality of life, would it still be worthwhile? And how much is the patient with an average income willing or able to pay for it?
The argument is complicated, of course, by the fact that the patient might have good insurance. But as costs continue to skyrocket, we as a society also have to consider what the new technology is costing the patient’s employer. If that company reduces wages or benefits or doesn’t hire new employees because of the cost of healthcare, where do we draw the ethical line?
The challenge of new technology - as in the example of robot-assisted surgery - is that costly innovations often become the standard of care before there’s sufficient evidence to tell whether they add real value that justifies their expense. The comparative effectiveness research that the government is planning to conduct should help reduce uncertainties about value; but unfortunately, most of those studies will probably be done after it’s too late to act on the information.