The New Health Dialogue

As anyone with an interest in health economics knows, the supply and demand for medical services often function differently than normal consumer goods.  Until  the robots showed up.  

Gina Kolata’s recent piece in the New York Times highlights prostate cancer patients who want robotic surgery to cure their prostate cancer and will settle for nothing less. In the old days, patients would get diagnosed with a condition and weigh the treatment options relayed to them by their physician. Especially astute patients would get a second opinion. That’s where it ended. 

But now, patients are interviewing doctors to ensure they use the robot. And if they don’t, the patients walk.  (See this related post on why some hospitals have bought them when they didn't really plan on it.)

In one sense, the demand for robotic surgery is the contemporary example of consumer-directed health care.  Despite the plateau in enthusiasm for consumer-directed insurance products like health savings accounts, more and more patients are informing themselves about different options and picking their preferred method of treatment (whether or not they really understand all the implications of what they are picking). According to the NYT story, last year 73,000 of the 85,000 American men who had prostate cancer surgery opted for the robot (86 percent). In 2002, there were fewer than 5,000. What would be really interesting, though, is what demand for robotic surgery would look like if more men were accessing an HSA to pay for their care. Traditional PPO/HMO products that use reference pricing/tiering would accomplish this too. Call it double consumerism. Would men shell out the extra $1,500 to $2,000 of their own money to pay for robotic surgery costs?

As I wrote in the fall, the first large-scale study on robotic surgery revealed that it could result in higher rates of impotence and incontinence for men who receive the procedure for prostate surgery, when compared to traditional surgery. But with practice, surgeons could eliminate those risks and patients would reap the benefits, including reduced length of stay and fewer transfusions, respiratory complications, and surgical complications. In other words: the procedure will still cost more, but it will most likely be better.  (I want to be clear that in this post I'm talking specifically about prostate surgery; robots are being used for other procedures as well.)

Instead of trying to convince patients and physicians that “regular” prostate surgery is a better bet, policy enthusiasts should now concentrate on making robotic surgery better.  The article cites Dr. Ashutosh K. Tewari from Cornell as saying 200 to 300 robotic surgeries are necessary to become highly proficient.  My previous blog post cites another NYT story that claims the average surgeon performs 12 robotic surgeries a year. (Author’s note: 12 < 300). Volume precedent for quality does exist -- see here and here. And see the Leapfrog Group’s thoughts on volume here. 

Fortunately, such training already exists. Mimic Technologies in Seattle has a robotic surgery trainer that tests a surgeon’s ability to tie knots, cut patterns, and manipulate a peg board (see here and here). No, a surgeon isn’t asked to tie a knot during surgery, but if you ask skier Lindsey Vonn how much time she spends training on a bicycle, you might be surprised. I had the opportunity to view a patient simulator (medical, not surgical) at East Tennessee State University in 2004. It serves as a great learning experience for students, it can be used repeatedly, and it eliminates the need to “wait for a teaching moment.” 

Mimic’s training can allow surgeons to practice the number of times necessary to become highly proficient at robotic surgery. With one in six American men set to develop prostate cancer at some point in their lives, physicians must commit to become excellent at performing surgeries for serious but common ailments.  Physicians are largely self-regulating; therefore, the American Medical Association and the American College of Surgeons should begin to investigate volume requirements as conditions for peforming robotic surgery.