>>Catherine Mohr: I'm going to be talking to you today about surgical robots, but to
give a little bit of context for this, I would like to first step back and look a little
bit at the intersection or the communication between surgery robotics and technology and
society.
Technology has the option -- the possibility of helping us solve many of the big problems
that face us today from water to energy.
And big technologies which require an upfront investment, like desalinization or wind energy,
have the potential to really help us break the back of some of these problems that face
us.
But one of the questions when we're investing in these types of technologies is: Are they
going to play out and give us the benefits that we think they're going to have in the
future?
Or are we going to be left with a legion of unintended consequences because while we are
in the midst of these technological transformations, it is often rather difficult to figure out
where it is all going to end up.
When we're also looking at technology, we need to understand that incremental changes
in technologies are often going to incrementally move us towards a solution but more radical
changes in a technology give us the chance to perhaps leap frog a little bit further.
I've had the opportunity to be involved in really trying to upset some of the conventions
when we're trying to solve some of these problems.
This is the Helios, high altitude aircraft, that I had the opportunity to be a member
of the design team for in an earlier chapter of my life.
And it shares very little from a design point of view with the aircraft that it shares airspace
with or the satellites that it was intended to replace and, yet, it can fly to the edge
of the atmosphere.
When we're looking at technology, we also need to understand that it can take 20 years
for these technologies to come into common use in our society and we're going to feel
the effects of this over decades, not days.
And so when we see these changes and we're in the midst of these technological transformations
we often really can't see where it's going to end up.
But I do believe in health care, just like in energy and in water and in computers.
We had the opportunity to really change and reframe the problems using these kinds of
technologies.
And wouldn't we all rather be in a world that's innovating its way out of scarcity rather
than surviving by rationing old technologies.
And so with that, I'm going to move to robots now.
This is the Da Vinci surgical robot.
What it does is it allows motions of the surgeon to be shrunk down to very small instruments
that can be placed in the body through very small incisions.
Every motion, every nuance of what the surgeon is doing, is translated into these instruments
that are inside.
You can even repair the heart from the inside of the heart without cracking the sternum.
You just place the instruments in between the ribs.
But like some of those other technologies that I was talking about, it requires a fairly
large up-front investment in a big surgical robot.
And so when we are -- there are quite widespread use of these robots right now.
They're in hospitals all over the world.
But it still really is in the very early stages of how we are seeing this technology will
transform surgery.
Granted, it doesn't touch every aspect of the healthcare system, but it really does
have a fairly large effect on how we do surgery.
So we have to ask the fundamental question, if we're trying to figure out where is this
going to go: How on earth can a million-dollar robot bring more value to the healthcare system
than it's bringing in cost?
And we really want to think about that from the point of view of all the different constituencies
in the healthcare system, whether these are patients, the payers who are paying for the
surgery of those patients, the providers who are performing the surgeries, and then eventually
society as a whole.
And so to understand this, we can first look at the payers -- or the patients, rather,
and for them, it's relatively more straightforward.
If you take large incisions and get rid of them and, instead, give someone a smaller
incision, they will have less pain and they will be able to get back to work sooner.
Now, this only will help them in the long run if, in the end, you've given them a better
surgery or at least an equivalent surgery.
Now, in the early days of an adoption of a technology, you really can't tell what those
long-term effects are going to be, and so early on we saw a lot of small studies that
were looking at robotic surgery and the effects, but there were no -- we simply didn't have
enough data out there to do these large population-based studies, so they were largely absent from
the literature.
We're now at the stage where those studies can and have been done -- and the geeks in
the audience will be really happy, I'm going to get to the data -- so this is a study that
was done by a group at Harvard looking at a 100% sample of the Medicare database over
a five-year period, and they looked at 78,000 surgeries, prostatectomies, some done robotically
and some done open.
And when they compared the two cohorts, they found that people were going home, on average,
a little over two days earlier with robotics, fewer complications, fewer transfusions, and
many fewer deaths.
That same group went and looked at the healthcare cost and utilization project database, which
includes many younger patients that are privately insured in addition to the Medicare sample,
and in the last quarter of 2008 they looked at a broad swath of different kinds of surgeries
that were being done and came to the conclusion in all of the ones that they looked at there
were demonstrable improvements in every area of surgery.
And in the 21,000 patient subset for prostatectomy, they again found that they were going home
earlier, fewer complications, fewer transfusions, and fewer deaths.
In Europe, when you look at this sort of data, there's a very different kind of postoperative
course, and so patients tend to go home six days earlier in the European data that we've
seen.
In Canada and also in Ireland, a little closer to home here, there was a meta-analysis done
of the 95 studies chosen out of over 2,000 peer-reviewed journal articles looking at
the outcomes in a wide variety of surgeries where robotic surgeries were being done, and
they found that across the board, again, there were improvements with robotics.
Particularly notable in hysterectomy, where, again, they were going home quite a bit earlier
and much better outcomes.
And then they also duplicated some of the prostatectomy work and that agreed with some
of the larger studies.
But while these studies were unanimous in their praise of the technology for the patient,
they all had very strong criticisms about the cost of the technology.
When you're doing a surgery with this robot, you've bought your robot and you're having
to amortize that over every surgery that you're doing.
You're buying instruments.
You have to maintain it.
There's all sorts of costs associated with it.
And the question is: Are we going to bankrupt our healthcare system by getting these kinds
of high-tech systems in to be able to do surgery?
And so let's ask what the payers think of all of this, because they are the ones that
are footing the bill for this.
But it turns out in most of the markets, most of the countries where robots are being used
currently, the payers pay no more money for a robotic surgery than they do for an open
surgery or a laparoscopic surgery.
And this is because they simply pay for the surgery and it's up to the hospital how they're
going to do it.
There are a few exceptions to this, and they're mainly in healthcare systems where they've
decided they want to pay more for the robotic surgery because they want to increase the
incentives, because they see the downstream benefits of fewer complications and the patients
going home sooner.
But if we want to understand what is going on, why are the providers, then, perhaps footing
the bill when the payers aren't paying extra for this, we want to look closely at a few
different kinds of case studies, trying to understand what's going on here.
Looking at a for-profit hospital in the United States in a competitive market, a hospital
is marketing itself to patients that have insurance.
They want to get them to their hospital.
So if they invest in a high-tech toy, they can market themselves as being much more technologically
advanced than that other hospital down the road, and all of the patients will start to
come over to their hospital.
So this is a very short-lived advantage because the other hospital is quickly going to retaliate,
it's going to get its own robot, and the medical arms race is on.
Pretty much all the hospitals start buying robots and the advantage to different hospitals
goes away.
And so critics would say that this competitive behavior, in the long run, is really just
driving up costs.
Everybody feels that they need a robot to compete and so they've all got one but they
don't really need them.
And if this was the only model that we were seeing, we would wonder whether there was
-- if there was something else going on, but what we notice is that more than a quarter
of the hospitals out there that have robots have more than one.
In fact -- and there are several hospitals out there that have only one that are contemplating
getting more.
Cleveland Clinic and Mayo Clinic, respectively, have five and seven robots in their main hospitals
and several more in their satellite facilities, and you've got to wonder what's driving this
kind of behavior.
And it turns out when you've made your big up-front investment and you're now using it
to its fullest capacity, it's not costing you any more to have robot surgery.
Your -- the incremental costs are considerably lower.
And it still may be not enough to drive purchasing five robots.
So then we have to look at what's going on.
Why would they be getting quite so many.
And it turns out if you look at -- talk to the CFOs who are most heavily invested in
robots, what they see this doing is preventing them from having to build any more hospital
beds.
If you are doing surgery and the patient is going home in half the time, you can do twice
as many surgeries to pass them through your hospital without having to build any more
hospital.
And this is what a lot of these that are heavily invested in robots are doing.
And as all of our societies have aging populations, we're either going to have to figure out how
to more efficiently use our hospitals or we're going to have to be building more of them.
So the Kaiser model is an interesting one also, where they take care of the patients,
they insure them, they do primary care, they own their own hospitals, and then they care
for the patients after surgery.
And what we see with them is they're heavily invested in robots and they are using them
to their fullest extent.
And this is an interesting phenomenon, that the more economic interest you have in the
long-term health of the patient, the more the robot economics make sense to you.
This is one of the reasons why we see that this is not just a competitive U.S. market
phenomenon.
The same group in Canada that was looking at the outcomes data in Canada looked at whether
robots made a good investment for them and they found if they used their robots for between
3 and 500 cases per robot per year, they not only broke even, they started to make more
money.
We also see this in healthcare systems in Europe.
Over in Sweden, where they not only take care of the population cradle to grave, but also
pay for all of the healthcare surrounding, you know, when they're off work after surgery,
they did a study where they wanted to see how long people took before they went home
after surgery.
And with open surgery, people generally went home after 49 days -- 7 weeks -- and with
robotic, they were going back to work after 11 days.
Now, they still groused about the up-front cost of this technology, but they recognized
that that investment was good in terms of the overall healthcare system.
So we've seen that there are benefits for the patients, the payers, the providers, and
society, but these are really predicated on it actually being better but also on having
to use that technology.
It's not every single -- every single procedure is an incremental cost.
You're paying up front.
And what we see in a lot of these big technological investments is that when you have made your
big up-front investment and you have yet to see all the benefits downstream, you are wondering
whether this was the right thing to do.
I mean, it's really -- it's not -- the economics aren't looking terribly good yet.
But like the big investments that we do in water and in energy, I believe that even though
we don't yet know how all this is going to play out, when we look back at this time of
this technologically driven innovation and changes that are going on in medicine, we
will see that they did bring a lot of value to our overall systems, and I think we should
be bold about continuing to innovate and try to bring new technologies in to solve some
of our most pressing problems.
So thank you.