The Economics of Robot-assisted Spine Surgery

Isador Lieberman, MD, MBA, FRCSC, was involved in the development of the original Mazor robot, and has been one of the pioneers and champions of robotic spine surgeries ever since. After a half-decade of trial and error in the product's development, he began using a robot for live surgeries in 2007.

"The first year I had 10 surgeries," he says. "The next year, I did probably 30 surgeries. And then every year after that it's been between 150 and 200 surgeries using robotics." He estimates 10% to 15% of spine surgeons currently use robots.

Dr. Lieberman has gained ample experience in the real-world economics of spinal robotics. Here's how he crunches the numbers on purchasing a $1 million robot: Let's say the average spine surgeon does 300 spinal procedures a year, and that 1 in 10 patients runs into an issue because of misplaced screws. The cost of a complication with spine surgery is about $35,000. So at 10%, you've got 30 cases with complications — which amounts to $1,050,000.

Viewing it through that prism, you've paid off a $1 million robot in one year. He estimates that a spinal robot's cost-per-case, including the amortization of the capital amount as well as disposable instrumentation, is about $2,000.

"The risk rate with the robot is less than 1%," says Dr. Lieberman, director of the scoliosis spine tumor program at Texas Health Plano and president of the Texas Back Institute, also in Plano.

Robots for spine can be "cost-effective" and result in decreasing revision surgery and infection rates, reducing length of stay, protecting patients and staff from excessive radiation exposure, and shortening operative time, according to a September 2018 Neurospine paper, "A Cost-Effectiveness Analysis of the Integration of Robotic Spine Technology in Spine Surgery" (osmag.net/Zf9PcB). The authors created a live model at Louisiana State University Health Sciences Center in Shreveport in which robotic-assisted spine surgery on 557 cases led to a savings of $608,546 in 1 year.

Co-author and neurosurgeon Richard Menger, MD, MPA, an assistant attending and spine fellow at Columbia University Medical Center in New York City, says your center can lower your purchase price of a robot through savvy negotiation and by leveraging increased competition in the robotics market. Today there are 3 robots available for spine: Mazor Robotics's Renaissance, Zimmer Biomet's ROSA and Globus Medical's ExcelsiusGPS.

Let's examine the cost-benefit arguments for a robot purchase.

1. More accurate surgeries, leading to fewer revisions and complications. Spinal procedures, as Dr. Lieberman points out, aren't foolproof. While surgeons have been largely excellent in placing screws and cutting bone with their own hands over the decades, the specificity and precision necessary to ensure exact placement requires tremendous skill and a flawless performance. Misplaced screws can cause complications and result in return visits for revision procedures, both of which can negatively impact your bottom line.

Dr. Lieberman says accurate, image-guided screw placement is currently the core function of a spinal robot. And that's powered by accompanying pre-planning software that not only enables precise screw placement using the robot, but also provides the adjunct benefit of getting him and his team prepared and on the same page before they begin the operation. "All the implants are prepared," he says. "The sizes of the screws are all ready to go, the rods are all ready to go. Everybody knows what we're going to do and everybody knows each step of the operation." That results in increased cost savings due to decreased revisions and complications, while also decreasing time in the OR for each case, he says.

Essentially, the robot streamlines his process, and makes it more efficient, he says — a goal to which many surgery centers aspire. "The robot helps facilitate the surgery," he says. "It makes me as a surgeon more precise and more efficient. It's guidance, it's navigation, it's pre-operative planning, it's execution and workflow in the operating room." Those increased efficiencies can deliver across-the-board impact, and have the potential to positively transform a center's operations.

2. Quicker surgeries can lead to increased patient volume. If used properly, a robot can bring more patients, and potentially more profit, to your spine service. Because surgeries are performed more quickly, you can accommodate more patients on a given day. "An operation that used to take me 6 to 8 hours is now only taking me 3 to 4 hours," says Dr. Lieberman. "Now I can do 2 of those operations a day instead of 1. I'm doubling the number of patients I can take care of."

"An operation that used to take me 6 to 8 hours is now only taking me 3 to 4 hours. Now I can do 2 of those operations a day instead of 1. I'm doubling the number of patients I can take care of."
— Isador Lieberman, MD, MBA, FRCSC

3. You can boost your regional profile and attract more patients. Robots are sexy and intriguing to many consumers, which is important in a highly competitive healthcare marketplace. Surgery patients are becoming much more attuned to hunting and researching for value, quality and innovation in their healthcare choices. A surgical robot can entice patients who are looking for the latest and greatest surgical approaches and medical care into your building. It can help spread awareness of your center through word of mouth, as well as become a prominent component of your marketing strategies.

"You need to ask, what kind of surgery center do we want to be?" says Dr. Menger. "Do we want to be a cutting-edge surgery center that's pushing the field, an early adopter of technology? Or do we want to watch other people do this while we do something that's been done in the past?" He adds that having a robot can impact your payer mix: "Are we seeing X percentage of Medicare patients, and now we're going to be able to see more, because patients are drawn to the robot?"

4. Less exposure to radiation. Dr. Lieberman says his robot has enabled a sharp reduction in the amount of X-rays needed to perform his surgeries. His robot's pre-planning software incorporates a pre-op scan of the patient that lets him map a game plan of exactly what his team needs to do. Once in the OR, one more scan is taken to ensure the pre-op and perioperative scans line up. And that's it.

"We extrapolate physiologically the risks of radiation to the patient and to the operating room personnel every time you take an X-ray in the operating room," he says. "By only taking 2 X-rays, it's going to be less risk than taking the 10, 12, 15 that we used to for each screw we put in."

5. Associated costs. Don't focus solely on the capital expense when assessing potential costs of a robot, says Dr. Menger. You must also account for the expenses that come with operating and maintaining the robot, which can vary across the available brands. For example, certain robots need other adjunct technologies, like an interoperative CT scan, as well as one-time-use instruments.

There's also a startup cost of sorts associated with purchasing a robot: training, education, and learning how to properly and efficiently handle the machine. Dr. Lieberman estimates an experienced surgeon will need 5 to 10 cases to be comfortable using a robot in the OR, and up to 30 cases to get comfortable with the planning method and executing that plan. The OR team will need a day in the lab to figure out the equipment. The scrub tech will need 10 cases to figure out the workflow, how to set up the table and how to help the surgeon be very efficient with the surgery, he says.

Economically, will a spine robot work for your facility? Talk to vendors and colleagues, evaluate all the factors, crunch the numbers, and come up with a decision that's right for you. OSM