Monday, November 19, 2012

Million-Dollar Surgical Robots: Worth the Cost?


The other day, a friend of mine had emergency surgery for a strangulated hernia.  While I have not pressed him for details (he’s still recovering), it’s possible that the surgeons used robotic surgery aids during the operation.  Believe it or not, there are ethical questions one can ask about such devices, and because they involve highly engineered robotic systems, I think it’s appropriate to discuss the question of whether these gizmos are worth the money they cost in a blog about engineering ethics.

Before we go any farther, I should make clear that we are not talking about replacing surgeons with robots.  (The surgeons wouldn’t stand for it, for one thing.)  A live human surgeon is always in control.  In the case of robotic laparoscopic surgery, for example, three small incisions are made to allow the insertion of a camera and operating tools.  The surgeon sits at a control console a few feet away from the patient, watches the camera field of view on a display console, and manipulates the tools remotely.  Obviously, such surgery requires special training, but many surgeons say they can do a better job with robotic aids once they have mastered the techniques involved.  An endoscopic camera can give a better view than you could get by standing above the patient and looking through an old-fashioned open-wound type of incision, which is much larger than the laparoscopic type used in most robotic operations.  It’s also easier to do finely-calibrated motions with the robotic instruments, because one’s hand motions get scaled down to allow better control of the tools.  A new million-dollar robotic surgery system recently described in the New York Times reduces the number of laparoscopic incisions from three to one.  Patients undergoing operations with this kind of robot for gallbladder removal (the only type for which this particular unit is approved by the U. S. Food and Drug Administration, or FDA) can go home with only one small incision, which can be near the navel and practically invisible.

It appears that most surgeons are generally in favor of robotic surgery—what about the patients?  Other things being equal, fewer, smaller incisions would be better.  But what about the cost?  Here is where things get complicated.

According to the Times article, one use of the million-dollar robot can add up to $60,000 to a surgical bill, depending on what auxiliary equipment a hospital already has.  Under the present fee-for-service model, if insurance companies approve, the patient can have the surgery and may not even notice the extra charge on the bill.  But if people had to pay directly out of pocket for their operations, I wonder how many folks would shell out an extra $60,000 to wind up with only one abdominal scar instead of three?  Maybe a few bathing-suit supermodels could justify the expense, but what about the rest of us?

This is a hypothetical question, because not many people pay for operations out of pocket.  Very poor people have Medicaid in many cases and most employed people (not all) have health insurance.  In the U. S., we are looking at a large change in how medical care is funded, with the gradual rollout of what even the President himself now terms Obamacare.  Without going into details, the net effect of this law will be to require more people to have health insurance and to extend governmental control of the system with regard to what interventions will and will not be paid for.  It is far from clear that Obamacare will have the net effect of making robotic surgery more accessible.

Expensive robotic surgery systems are just one specific example of a trend that has been going on for decades:  the soaring sophistication and cost of modern medical care.  Perhaps because U. S. health care is more free-market-oriented than in many other countries, this trend has been more noticeable here than elsewhere.  Although one might expect the U. S. to be more friendly to costly healthcare innovations than nationalized-medicine countries such as Canada, it turns out that the firm making the million-dollar robot is based in Toronto.  One reason for that may be that the FDA runs one of the more restrictive regulatory operations compared to many other countries.  It is very difficult, expensive, and risky to get drugs or other medical interventions approved in this country.  A good bit of the million-dollar price tag for the robot machinery goes to pay off expenses for getting the thing approved.  No one wants to go back to the bad old days when any quack could set up shop as a doctor and inflict wanton harm upon uninformed patients, but there is a lot of evidence that the FDA has gone too far in the other direction of making it too hard to get innovative medical advances approved.

From an engineering point of view, robotic surgery seems to be a basically beneficent kind of technology.  If it leads to fewer complications, faster surgery, and more rapid recovery, it might even be shown to pay for itself compared to the old-fashioned open-wound method, simply on the basis of efficiency.  Unfortunately, the medical profession is still learning how to measure its own performance in quantitative ways, and so it is hard even to obtain reliable data on such cost-saving possibilities.  This is where industrial engineers can help, but only if the medical community asks for assistance.

Industrial engineers are the efficiency experts of engineering.  They look at any process and find ways to measure how resources are used, what the goals are, and how the process can be made more efficient.  Up to now, applying industrial engineering principles to medicine has been somewhat of a novelty.  But if we as a nation are serious about doing something with regard to the rising costs of health care, I see a great future role for industrial engineering in the evaluation and comparison of medical procedures.  The tricky part will be to apply these techniques intelligently, and not in a one-size-fits-all way that will simply centralize control in Washington without making anything better.

My best wishes to my friend for his rapid recovery, and for the betterment of the nation’s health care system in general.  I for one hope robots will be a part of it.

Sources:  The New York Times article “When Robotic Surgery Leaves Just a Scratch” appeared in the online edition on Nov. 17, 2012 at http://www.nytimes.com/2012/11/18/business/single-incision-surgery-via-new-robotic-systems.html. 

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