Financial impact of adapting robotics to a thoracic practice in an academic institution

In the current healthcare environment there is increasing pressure to deliver high quality care to more people at less cost. Robotic assisted thoracic surgical procedures (RATS) have been shown by some to be more expensive than conventional endoscopic or open surgery. We initiated this study to assess the financial impact of RATS compared to robotic non-thoracic surgery in an academic institution.

A retrospective study was performed for all patients who underwent any robotically assisted surgical procedure at Temple University Hospital (TUH) in fiscal year 2015. Surgical volume, operative time, length of stay (LOS), case mix index (CMI), direct and indirect costs, hospital charges, surgical charges, contribution margin (CM) and net margin (NM) were collected for the thoracic surgery service in addition to other services which performed more than 20 robotic cases a year. We analyzed the data according to the following strategy: (I) financial performance for both inpatient and outpatient robotic procedures for the entire hospital; (II) compared financial data for robotic and non-robotic surgeries in the thoracic surgery division; (III) compared thoracic surgery data with the STS database for the same time period in order to calculate any potential cost saving (PCS).

In FY15, a total of 696 robotic procedures were performed by the various services at TUH with a mean of 58 cases each month. Although CM was highest for cardiovascular surgery, the highest NM was by thoracic surgery. Despite having the highest volume and a positive CM, the mostly outpatient urology service showed a negative NM in FY15. A CMI-adjusted comparison on 208 of the 589 robotic procedures where there was a comparable group of inpatients who had open procedures, the mean direct cost for non-robotic procedures was $6,239, 9% less than for robotic procedures. The mean total cost for non-robotic procedures was only 3.64% ($435) less than that for robotic procedures ($11,502 vs. $11,937). When compared with the UHC expected LOS, the robotic group had a lower LOS while the non-robotic group had a higher LOS. The mean total direct costs were $3,510 less for the robotic procedures ($16,502 vs. $20,012). When compared to similar cases reported to the STS in FY 2015, the length of stay, conversion rate, transfusion rate, post-operative complications and OR time compared favorably. Using calculations based on published data, the potential cost savings are in the 1 to 2 million dollar range compared to traditional endoscopic or open procedures reported to the STS.

High acuity services such as Thoracic Surgery drive higher CM per case as long as variable costs especially LOS are kept low. Procedures with lower CMI may not provide a high enough CM to offset the fixed and variable costs. Robotic surgical cases performed in the outpatient setting may incur significant losses as the reimbursement does not cover the direct costs. Hospitals should preferentially allocate robotic resources to inpatient procedures with higher CMI and work to decrease overall LOS.