New questions about the $3B/year robotic surgery business

When Intuitive Surgical, manufacturer of the DaVinci robotic surgery system, last month reported that it had exceeded revenue and earnings expectations for the quarter, the company CEO said, “We’re neither satisfied nor comfortable.”

But, clearly, neither are some observers in medicine satisfied or comfortable about the technology’s explosive growth.  This is the final sentence of a research letter published in today’s Journal of the American Medical Association:

The continued use of the robotic platform in surgery requires demonstrating the superior clinical benefit of these devices while considering the full set of costs for these systems.

Dr. Christopher Childers, one of the authors, is a surgical resident at UCLA who is interested in health economics and cost issues – especially about the drivers of cost related to surgery.  He believes that “most clinicians and administrators don’t know the true costs” of robotic surgery. And he thinks that past cost estimates have been flawed. So he and co-author Melinda Maggard-Gibbons, MD, dug into the financial statements of Intuitive Surgical, Inc., and found the following.

Robotic system sales & usage

By the end of 2017, the company had shipped 5,770 robotic surgery systems.

65% of all global installations were in the United States.

The estimated yearly number of procedures skyrocketed from about 136,000 in 2008 to 877,000 in 2017.

General surgery uses (Childers believes these would be gallbladder, hernia repair, rectal surgery) are increasing the fastest, followed by gynecology and urology uses.

2017 revenue was $3.1 billion, with $2.3 billion of that coming from the U.S.

A noteworthy 52% of that revenue came from instruments and accessories – a point we’ll come back to shortly.

The estimated cost per procedure was $3,568.

If you don’t see journalists exploring these issues, it’s time for a different news source

We have written about issues surrounding robotic surgery systems dozens of times.

Sometimes it’s been about cost issues.  More often it’s been about questions about the evidence for the explosive growth.  Sometimes cost and evidence questions collide, as with the following example.

Dr. Childers says one of the cost drivers for robotic procedures is that Intuitive Surgical insists that hospitals “not use most instruments for more than 10 procedures.”  He writes, “To our knowledge, no clinical data support this limit.”  He told me that with laparoscopic surgery, by which surgeons insert a small camera and instruments into the body through small incisions, “the instruments can be used until they break – potentially for years on end.”  He says that some surgeons who use the robotic systems may not even be aware of the 10-use limit.  He thinks it’s just accepted as “This is the way it is.”  But to Childers, it seems like a big cost issue that may not be backed by evidence.

He also raises questions about why the general surgery uses (e.g., gallbladder, hernia repair) are increasing when there isn’t evidence that the robotic approach is any better than laparoscopic surgery for these uses.

Childers has a message for journalists:  “It is a disservice in the health care market we’re in to talk about quality care without discussing costs.  It shows a lack of connection with consumers or patients, who don’t see these costs, but who are inevitably affected by them.” (Note:  70% of the 2,500+ news stories we’ve reviewed in the past 12 years have been graded unsatisfactory on the question of whether they adequately addressed cost issues when reporting on treatments, tests, products and procedures.)

How and why does this matter to patients?

Childers says, “You can’t add $3 billion in costs to the health care market without somebody paying for it.  And at the end of the day it’s consumers who pay.” Even if it seems like Medicare or private insurers are shouldering much of this, either taxes or premiums will go up as a result, he says, and in either scenario, it comes back to bite the consumer.

“We need to demand of this company that they reduce the price or justify why it is so high,” says Childers.

All of these points are things you should think about when you read or hear the next glowing, gee-whiz story about robotic surgery.  And, if you need a visual reminder, watch the segment on robotic hysterectomy in “The Bleeding Edge” documentary on Netflix, which we wrote about last month. In it you’ll hear women who are clearly not “satisfied nor comfortable” with their outcomes.