Robotic surgery is attractive to patients and surgeons alike. These procedures can result in quicker postoperative discharge and lower levels of postsurgical pain. Performing them in the ASC setting has the added benefit of lowering costs for payers.
At Becker's ASC 26th Annual Meeting: The Business and Operations of ASCs in Chicago in October, Intuitive sponsored a workshop to explore the role of robotic surgery in the ASC. Jeremy Parcells, MD, a general and bariatric surgeon with Surgical Associates of Mansfield (Texas), outlined how his organization incorporated robotics into its operations.
Why surgeons like robotics in the OR
Surgeons like robotic surgical systems for various reasons. The wristed instruments make procedures more facile, the 3D pictures offer better visibility, and the higher resolution leads to a cleaner dissection. Robotics result in more efficient and less painful operations for hernias, cholecystectomies and more.
Some robots also include features designed to improve patient safety. Da Vinci Xi robots, for example, have technology that shows any anatomical structure containing ICG, a compound molecule given to many patients prior to surgery.
According to Dr. Parcells, "ICG lets us operate more safely. The ability to see the cystic ducts feeding into the common bile duct is essential. Common bile duct injuries are catastrophic, leading to a statistically significant decrease in life expectancy. It takes a morbid operation to fix them and they are one of the most litigated complications."
Payers are pushing for robotics in ASCs
ASCs and hospital outpatient departments tend to see the same types of cases. Reimbursement is the single biggest difference between ASCs and HOPDs. HOPDs are paid under the Outpatient Prospective Payment System. This is the same payment mechanism used for outpatient cases handled in the main hospital OR.
In contrast, ASCs are paid under a completely different fee schedule which represents a significant discount to payers. CMS, for example, wants to see procedures done in a minimally invasive setting in an ASC setting and in 2018 started reimbursing for certain ASC-based surgeries.
Success = The right surgeons doing the right cases with the right technology
When it comes to robotics and the ASC, patient selection is a key success factor. In general surgery, the three major candidates include ventral hernias, inguinal hernias and cholecystectomies. Other promising opportunities include benign gynecology cases, urologic cases and sleeve gastrectomies.
Dr. Parcells believes that the da Vinci X is the best robot for an ASC. He noted, "The cost savings between a da Vinci X and Xi can mean the difference between a program that's barely breaking even and one that's financially viable."
Experienced surgeons are also essential. ASC procedures must be done efficiently and cost-effectively. Dr. Parcells commented, "Surgeons dabbling on the Da Vinci Surgical System shouldn't be doing cases in the ASC. The learning curve should be undertaken in a setting that's more forgiving, like the main hospital OR."
5 best practices for integrating robotics into the ASC
For ASCs interested in offering robotic surgeries to patients, Dr. Parcells recommended five best practices:
- Think about the capital outlay. In addition to the Da Vinci Surgical System, another capital outlay is a sterilizer for the robotic instruments.
- Consider whether you can do 23-hour observation. This can expand the types of robotic procedures that an ASC can handle.
- Evaluate whether the ORs are big enough for robotic surgery. In most cases, they are. Dr. Parcells noted that having a robot in an OR doesn't preclude non-robotic procedures from being performed in that room.
- Remember that staff doesn't need prior robotics experience. Other than the surgeons, none of the staff at Surgical Associates of Mansfield had robotics experience. Dr. Parcells said, "Give me someone with a good attitude and half a brain. In one to two months, I'll give you a viable member of the robotics team; in five to six months, I could give you a superstar."
- Have a realistic expectation about volume and reimbursements. Making robotics work in the ASC will depend on the payer mix in your area, as well as how reimbursements vary by region and case setting.