Milford Medical's Robot Highlights Business-Patient Care Balance

Photo/Courtesy Drs. Sanjay Kumar and Eddie Michli, urologists at Milford Regional Medical Center, with the hospital's newest investment, a da Vinci Surgical Robot.

Photo/Courtesy Ed Kelly, president of Milford Regional, said the “couple of million dollars” the hospital spent on a surgical robot has allowed doctors to perform less invasive surgeries.

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By Livia Gershon

From MetroWest495 Biz's latest print issue: How do hospitals weigh capital investments in new technology? Milford Regional Medical Center's new surgical robot offers a glimpse into the considerations of hospital executives and doctors.

What makes a new technology a good investment?

When Milford Regional Medical Center announced in February that it was introducing a da Vinci surgical robot, the first reaction from some local patients might have been relief. To get the increasingly popular robotic-assisted urologic or gynecological procedures done with the machine, it meant they would no longer have to travel to Worcester or Boston.

But this spring the U.S. Food and Drug Administration (FDA) launched an investigation into safety concerns around the robotic system, and a spate of media reports have questioned whether the da Vinci is any more effective than other types of surgery. Meanwhile, Milford Regional President Edward J. Kelly says the robot, which cost the hospital a "couple million" dollars, doesn't provide any direct financial benefit for each surgery performed compared with traditional surgery.

Still, Kelly said he's thoroughly convinced the da Vinci was a good purchase, both from a medical and a financial perspective. The reasons why demonstrate some of the complex factors involved whenever a hospital decides whether to invest in new technology.

When Milford Regional is deciding whether to buy a new piece of equipment, it reaches out to ECRI Institute in Pennsylvania, an organization Kelly describes is as the Consumer Reports of hospital procurement. Robert Maliff, director of applied solutions for ECRI, said that no matter what hospitals are considering buying, their first question is whether it improves patient care and is safe for both patients and staff.

"Obviously, if the answer is 'It works, it's clinically effective for our patients,' the next question may be, 'Well, do we have any money for it?'" Maliff said.

When it comes to the da Vinci, Kelly said it's easy to see the potential value. He did when he tried out the device three years ago at a demonstration hosted by the Massachusetts Medical Society. Using the robotic hands, he was able to pick up pennies and do little tricks, using the system's magnification capabilities and flexible arms.

"The things that you can do seem incredible," he said. "When it goes in, you're not limited by your hand motions ... You have much more hand motion flexibility and control."

Kelly said he's been impressed with the medical value of the device since the hospital introduced it. It's allowed for patients who would previously have required open surgery to have their operations done in a less invasive way, with just hole punctures.

But not everyone is convinced that robotic surgery represents an advance in patient treatment. The FDA investigation stems from hundreds of reports that surgeries done with the da Vinci resulted in injuries and even deaths.

Maliff said it's not an easy matter figuring out the medical benefits and hazards of a particular piece of equipment. Vendors selling the products "come armed often times with studies claiming the superiority of their device." Not surprisingly, he said, companies may cherry-pick the studies that are most favorable to their point of view. But even ECRI, whose mission involves going through all the available studies to determine the best equipment for hospitals to buy, can't always be sure whether a product is a good choice

"The gold standard is the double-blind randomized controlled study, but those are expensive," he said. "A lot of times they're not even done."

Kelly said the hospital's investigation into the da Vinci, done with ECRI's help, concluded that the crucial element to make robotic surgery effective was providing excellent training to surgeons who would be using it and making sure they would have enough patients coming through the process to keep their skills sharp. Kelly said the shift from laparoscopic surgery to robotic surgery is comparable to the learning curve for someone switching from a BlackBerry smartphone to an iPhone. At first, he said, "going over to the iPhone is neutral if not a step backwards," but "if you use it every day you get really good at it."

Alongside the questions of safety and effectiveness, hospitals must, of course, consider the financial return on investment for any technology they buy. In an era when hospitals advertise their new digital mammography systems on billboards, Maliff said it can be hard to resist competing with other providers' latest investments.

"We're relying on hospital leaders and clinicians to really say 'That's a nice element but it's not necessary for clinical care,'" he said.

Fortunately, he added, in recent years the industry has moved in the direction of consistent, transparent processes to determine whether to buy a new item.

At Marlborough Hospital, Interim President and CEO Candra Szymanski said the process for major additions like radiation therapy are made at a system level, with parent organization UMass Memorial Health Care considering the entire corporate budget, as well as local medical need and patient volume.

"If the need exists we move on to developing a business plan," which addresses a marketing plan, financial data and strategic compatibility, among other issues, Szymanski said via email.

"Smaller purchases are made on the local level and must be supported by our own capital budget," she added. "We follow the same process as above for larger purchases (3-D mammography, CT scanners, etc). Smaller purchases such as new beds, renovation projects, etc. do not require extensive planning."

Kelly said Milford Regional also has a formal process for considering all big purchases. But he said the da Vinci purchase was a bit unusual. Since insurance companies don't pay extra for robotic surgery compared with laparoscopic procedures, he said the system doesn't offer a great payback at first glance.

Instead, he said, the financial value for the hospital lies partly in its ability to attract and retain doctors. A turning point came, he said, when the hospital was seeking a new doctor in urology.

"I think the reality hit us that, if you're looking for a new doctor out of training, if you don't have a robot you're really less attractive," he said.

Between the fact that medical residents are commonly trained with the robotic systems, and the desire of some Milford doctors to perform robotic surgeries, Kelly said the hospital became convinced that using the system was becoming standard practice.

"If we didn't buy the robot, what would happen?" he said. "We'd probably get less business." n