Robotic Devices in ASCs

In this episode of the Advancing Surgical Care Podcast, ASCA Chief Executive Officer Bill Prentice interviews Andrea Lessner, senior director of perioperative services at USPI’s OASIS Hospital in Phoenix, Arizona. The two briefly discuss quality data and patient safety related to the use of robotic-assisted surgeries, then take a deeper dive into the business of robotic surgery in the ASC setting. Methods of evaluating robotic equipment, educating and training surgical teams and introducing and ramping up a robotics program in an ASC are addressed. The conversation takes place following Lessner’s presentation at the ASCA 2022 Conference & Expo in Dallas, Texas.

Transcript

Narrator:   0:06
Welcome to the Advancing Surgical Care Podcast brought to you by ASCA, the Ambulatory Surgery Center Association. ASCA represents the interests of outpatient surgery centers of every specialty and provides advocacy and resources to assist them in delivering safe, high-quality, cost-effective patient care. As with all of ASCA’s communications, please check to make sure you are listening to or viewing our most up-to-date podcasts and announcements.

Bill Prentice:   0:37
Hello, and welcome to the Advancing Surgical Care Podcast brought to you by the Ambulatory Surgery Center Association, or ASCA. My name is Bill Prentice, I’m ASCA’s CEO and the host of this episode. We’re recording today at the ASCA conference and expo in Dallas, Texas. My guest today is Andrea Lessner, the senior director of perioperative services at United Surgical Partners International’s OASIS Hospital in Phoenix, Arizona. Andrea has focused her perioperative career in orthopedic and neurosurgery and the use of robotic technology. In addition to her hands-on clinical experience, Andrea has also acted as the perioperative clinical supply manager for an Arizona-based hospital system, where she led the hospital’s evaluations of surgical implants and capital technologies. I asked Andrea to join me on the podcast to discuss the presentation that she gave at our conference earlier today on the acquisition and implementation of robotics in outpatient surgery at the ASCA conference and expo in Dallas, Texas. I found it incredibly insightful and informative, and I think our listeners will as well. Andrea, welcome to the podcast.

Andrea Lessner:   1:39
Thank you so much. The pleasure is all mine to be here.

Bill Prentice:   1:42
Andrea, on several prior ASC podcasts, we’ve touched upon the use of robotics in outpatient surgery, but we’ve never really gone deep on either the patient experience or the financial considerations for investing in robotic technology. But when I saw your presentation on robotics in ASCs, I was very eager to have you on the podcast to help answer some of these questions for our listeners. In a few minutes we can get into some of the business and financial considerations, but I’d like to start by talking about the patient experience with robotics. So, my first question is what does the data tell us about the safety and quality associated with robotic-assisted surgeries? And how are patients reacting to the use of this new technology?

Andrea Lessner:   2:22
There’s great data about patient satisfaction and their willingness to seek out robotic procedures. I will say that more time and more data is needed to really look at properly designed studies to show statistical significance, and the benchmark for that would be implant survivorship and reduced rates of revisions. We are actually participating on providing some of that data—we’ve provided retrospective data back to 2018, prior to a robotics implementation, and now we’re continuing to provide that data to an analytics platform with robotics. And so, we’re trying to be part of the data that we need to really have those properly designed studies.

Bill Prentice:   3:14
That’s great, and it’s going to be so important to obviously build the case for the value of robotics and how it fits into an ASC’s operations. And as we all know, ambulatory surgery centers are already very capital intensive as businesses. And I’m sure many ASC administrators are wondering how they add the entirely new expense of robotics to their operations without adversely impacting their operating margins. Can you tell us about how your experience has been and how an investment in robotics can return a profit for an ASC?

Andrea Lessner:   3:45
Most importantly, you have to have a surgeon champion. And if you’re really going to get it off the ground, you have to have a facility champion. You have to build the infrastructure for the program and get them comfortable enough, and then you can add robotics. And we did that—we did manual total knees and hips for about a year and then we added robotics. And over two years, we increased our volume by 500 percent.

Bill Prentice:   4:11
Wow, that’s very impressive, but I see what you’re saying there is you really have to have a surgeon champion who’s willing to really explain and justify the value of robotics for the other members of the ASC. That’s great. Listen, before we continue, I’m going to ask that we take a short pause to hear a quick word from our podcast sponsor. We’ll be right back.

Narrator:   4:32
This episode of the Advancing Surgical Care Podcast is being brought to you by National Medical Billing Services, an ASCA affiliate and leading ASC revenue cycle company that helps ASCs properly capture their revenue and maximize their cash flow in a highly compliant fashion. To learn more about National Medical Billing Services’ wide range of revenue cycle services and analytics, visit nationalascbilling.com.

Bill Prentice:   5:03
In your presentation, Andrea, you provide a review of several different manufacturers and several different robotic technologies. Now, I’m not looking for either a brand endorsement or a critical evaluation of any particular product. But I do think our listeners would benefit from your perspective on how to evaluate the different robotic technologies and products that are out there.

Andrea Lessner:   5:25
What administrators have to do is see if other surgeons will use the same platform and if they can convert them from a competitive platform. I used to do this thing where I’d set up a sawbones lab in the next operating room after their last case of the day, and I’d have the rep in there, the sawbones, the team, and I’d be like, “come on, come do a sawbones training with us,” and I’d just usher them into that room. And then they would do the sawbones training. And then if I needed to have them go do a cadaver lab with the vendor to become certified, that’s how I built the engagement to get the critical conversions so that the robotic platform wasn’t just for one surgeon.

Bill Prentice:   6:06
Right, because you need volume in order to make it work and so you need to basically get, if not all of the surgeons, at least a healthy number of them willing to adopt the technology in order for it to be a success.

Andrea Lessner:   6:20
Correct. Now, I do have one robotic platform with one very high-volume surgeon and nobody else uses it, but the volume justifies a one-user robotic system.

Bill Prentice:   6:32
But that’s the exception. That’s hard to make that work in most markets.

Andrea Lessner:   6:36
Yes. Otherwise, it’s conversions. I was successful at actually converting eight surgeons to a competitive robotic platform.

Bill Prentice:   6:43
Interesting. Well, I want to keep talking about the return on investment question that we’ve kind of been talking around. I took note of the recommendation in your presentation that ASCs should explore partnerships when considering an investment in robotics technology, including partnering with local hospitals. And that certainly could be one way to reduce the expense, but not without raising lots of other questions, I’m sure. Have you seen many of these partnerships occurring in the marketplace? And if so, what can you tell us about them?

Andrea Lessner:   7:12
The two most common arrangements I see is a rental agreement and then asset transfers.

Bill Prentice:   7:18
Alright, well, let’s start there. Explain both of those if you wouldn’t mind.

Andrea Lessner:   7:22
So, a rental agreement—the hospital joint venture partner may have already purchased the robot or may be willing to purchase another one, and they’ll let you use it for a rental fee. So, unless there is a fee or no fee, that may be a good way to get into robotics because there’s low risk and you just pay for the case per cost to see if you can sustain the volume.

Bill Prentice:   7:46
Alright, let’s talk about the other.

Andrea Lessner:   7:48
Asset transfers. So, many of the hospitals are willing to do an asset transfer when they upgrade their robotic systems. I see this mostly with Xi and Si da Vinci systems. Xi is the new one the hospital upgrades, and then they are willing to do an asset transfer of the Si to the ASC.

Bill Prentice:   8:09
So, it’s still obviously really excellent technology, still really works well, but you’re getting it at a discount because the hospitals bought the newer, brighter, shinier version.

Andrea Lessner:   8:19
Exactly. And then usually they’ll move it over onto your asset list, and its depreciation is already factored into it, as well. But there is one kind of pitfall to that.

Bill Prentice:   8:30
Alright, let’s hear that.

Andrea Lessner:   8:31
Your vendor: How long are they going to support the older technology? So, it may get you into robotics, but then if they stop manufacturing the instrument or the disposable or the implant, they will get you in a situation where you’ve started to build your robotics program and then all of a sudden, they don’t want to support that version. But the silver lining of that is at least you built your infrastructure for your robotic program, and by now you can probably support it with volume.

Bill Prentice:   9:00
Right. Because you’ve also in that time period gotten enough of your surgeons to adopt the technology, be familiar with it, that you know that you could support a program even if you have to buy a new robot.

Andrea Lessner:   9:12
Yes, and your team too.

Bill Prentice:   9:13
Right. Great last point there because before we run out of time, I want to talk about education and training. Understanding that the requirements are likely to vary from one product to the next, can you tell us generally how much education and training are required to qualify a surgeon and the surgical team to use robotic equipment?

Andrea Lessner:   9:32
It’s directly proportional to engagement. How interested is the surgeon? How interested is your facility champion and the staff? So, if you have a highly integrated team that is all rah-rah robotics, your training is going to have a quicker plateau because they’re all interested in it, and they’re taking ownership of it, and they’re treating that robot like it’s theirs. It’s not the rep’s robot anymore, it’s ours, we bought it. And they’re calibrating it and registering it themselves. But if your team really isn’t engaged and you don’t have that strong surgeon champion and facility champion, it’s going to be a much longer curve to get there and you’re going to have to keep doing retraining. Now, for surgeons, it’s a credentialing thing. They have to have certain lab time, cadaver time, to be able to be credentialed to do robotics. So, that’s one thing that they have to commit to as well.

Bill Prentice:   10:27
Very interesting. So, it really, I guess you’ve got to either generate or find that enthusiasm for adopting robotics, both at the surgeon level and then the surgical team level, if you really want a robotics program to work in a surgery center.

Andrea Lessner:   10:42
Yes. One other interesting study, it was called Online Crowdsourcing of Public Perception of Robotic-Assisted Surgery, and in all the respondents, 69 percent said that they would prefer to have robotic surgery because they thought that it offered better outcomes, fewer complications and less pain. And 49 percent of those respondents said that they’d go see a surgeon using robotics who had lower volume than a surgeon who had higher volume using manual techniques.

Bill Prentice:   11:18
Fascinating. That’s really interesting. Well, listen, Andrea, I don’t want to take more of your time. I very much appreciate you being on the ASC podcast. I’ve learned a lot, I’m sure our listeners will as well. So, thank you again for speaking at ASCA 2022 and for being on this podcast.

Andrea Lessner:   11:36
Thank you so much.

Bill Prentice:   11:37
So before concluding, I’d like to once again thank our podcast sponsor, National Medical, an ASCA affiliate and leading ASC revenue cycle company. To learn more, visit nationalascbilling.com.