In a landscape of value-based purchasing, do navigation and robotics pose economically-sound options?
Eeric Truumees, MD, CEO of Seton Brain & Spine Institute in Austin, Texas, presented on the economic aspect of navigation and robotic spine surgery at the North American Spine Society annual meeting in Chicago.
Dr. Truumees also serves as director of spinal trauma at University Medical Center Brackenridge and as director of spine research at Seton Spine and Scoliosis Center, Seton Medical Center Austin, both in Austin, Texas.
"Ultimately, I think I'm going to argue that there really can't be any blanket statement made, yes or no, as to these systems today," said Dr. Truumees. Each center should analyze its own circumstance, discussing with surgeons and service line managers, to decide if investing in navigation or robotics technologies makes sense for them.
"Both navigation and robotics systems have the potential to improve care quality," said Dr. Truumees. "They certainly have short-term costs, but the question is how are those costs going to be absorbed over the longer term?"
The United States' current trajectory for costs is unsustainable, but experts disagree on how to shift this trajectory.
From ad lib spending to draconian rationing, a variety of options exist for potential changes in healthcare spending. "The reality is, the current system uses some of all of this today," said Dr. Truumees.
The harsh truth of rationing
"What does rationing mean for us?" asked Dr. Truumees. "This is a fairly rational, but to U.S. audiences, harsh way of looking at healthcare." Before committing to new technology, organizations may want to consider the impact of a technology on the quality-adjusted life years offered to patients. This system involves analyzing the costs of technology compared to the extended life provided by the technology and the quality of life gained.
"It is actually very hard to show significant improvements in quality-adjusted life years through technical changes in the surgery alone," explained Dr. Truumees.
Although navigation and robotics may demonstrate decreases in complication rates, it's still challenging to prove improvements in quality adjusted life years based on technical changes in surgery. Therefore, the rationing system doesn't lend well to proving cost effectiveness of navigation and robotics.
Cost containment and bundled models
Cost containment is another option, involving the limit of healthcare expenditures to a capped sum for a certain time period. "The emphasis here is on financial control," said Dr. Truumees. "And the impact it can have on that care is highly variable."
Cost containment strategy is trending toward value-based purchasing. Value-based purchasing involves the willingness to pay more if receiving more.
"There's also a hundred different ways you can measure the relative cost effectiveness or value of something," said Dr. Truumees. "…Knowing how you're asking the question and from what perspective becomes a critical issue."
The federal government and payers don't support the term 'cost effectiveness,' as it sounds similar to rationing. So, the government and payers try to shift the risk back to providers and physicians, whether through ACOs or bundled care.
The future of these alternative payment models is already here with 20 percent of the cases using the alternative models. By the end of 2018, 50 percent of cases will be bundled.
"We're inexorably on a road from a fee-for-service model to a fee-for-value model," said Dr. Truumees.
As of now, bundling or episodic payment are the most common models for elective spine care. The episodic payment system involves coordinated care, where stakeholders and physicians become more actively involved in the care process from start to finish. The system is designed for providers to offer high quality care at low costs. Unfortunately, with the impending total joint bundle, this ideal bundle doesn't exist.
"In some hospitals in the U.S., their decision to use these [robotic] systems comes more from the hospital side than the physician side, because they're interested in advertising these systems," explained Dr. Truumees. "If you have a closed bundle that's mandatory, and these systems come out the hospital's bottom line, their desire to buy one of these systems for you might be less."
The lack of risk stratification in the CMS bundle poses another complication. That is, the system isn't designed for a physician to only use robotics or navigation for some higher-risk cases and expect better reimbursements.
Measuring cost-effectiveness
Little data exists about the economics of navigation and even less exists about the economics of robotics.
"Ultimately, it's a complicated measurement scheme," said Dr. Truumees of using data to assess the economics of navigation and robotics. "…Most of the studies out there today are positive."
Many studies support the theory that navigation reduces the number of revision surgeries. If that's the case, then lawsuits, iatrogenic neurologic insults and infections may theoretically also decrease.
However, healthcare providers may want to consider the associated costs before jumping in head first. Robotics and navigation costs include capital expenses, yearly maintenance and software updates, per case disposables and tech time. It's also important to predict whether the technology will decrease or increase OR time, with a time dependent activity-based costing.
"We have to understand what these costs are going to have in terms of impact on the sustainability of our practice and the future healthcare delivery system," said Dr. Truumees.
Adopt or forget?
Dr. Truumees suggests providers know their market and determine which service lines lend well to navigation and robotics. Also, know the patient group who will receive treatment with this new technology. Providers may want to consider their outcomes to determine whether this technology would offer significant improvements.
The technology will only be beneficial if physicians actually use it, so consider if the physicians and nurses welcome the idea of navigation or robotics. Further, systems not yet available may better suit an organization's needs, so waiting may be the best option at present.
And then it comes down to costs: acquisition, maintenance, alternative options and reoperation costs should all be evaluated.
"I think for most of us, this is a very intriguing area, but probably more of a wait-and-see proposition," concludes Dr. Truumees. "…The real take home message is, before you start making decisions on how you change your care, know where you are today and know what your patients really need."