costs approximately €6420 per case. This amount does not include the additional training costs.
Naturally, those costs heavily depend on the yearly throughput, in the case of a high-volume service (300 cases per year), the global costs would amount to an additional
€4070.
Currently, the endoscopic lump sum charged is €510 to the national health insurance and €170 to the patient. If the patient is charged an additional €1200 as done by some hospitals, around €1880 of the robot-assisted radical prostatectomy cost can be considered as covered from the hospital perspective.
5.6 BUDGET IMPACT FOR ROBOT-ASSISTED RADICAL PROSTATECTOMY
In the recent national agreement between doctors and mutualities, the technical council for implants (TRI/CTI) was asked to present a reimbursement proposal for the materials needed for robot-assisted radical prostatectomy by the end of March 2009.192 Radical prostatectomy indeed represents the bulk of procedures currently performed with robot-assistance. In this section we evaluate the budget impact if a partial reimbursement of supplies would be considered for this intervention.
5.6.1 Current number of procedures
Belgian reimbursement data available at the time of analysis were until the end of 2007.
In the previous period from 2002 to 2006, an average of 15.3% of the radical prostatectomies performed each year was only billed the year after. Therefore, and based on the available number of procedures performed and billed in 2007, the number of prostatectomies performed in 2007 but billed in 2008 was estimated at 494 procedures, which meant that 3226 procedures could be evaluated for 2007, or 3250 to round the figure at the nearest fifty. Figure 5 shows the evolution of the number of radical prostatectomies in Belgium since 1995. From these data it appears that the number of radical prostatectomies is relatively stable in recent years, although there is an obvious risk that this number could increase due to supply induced demand caused by the widespread availability of robot-assisted surgery in this country. It is too early to observe this in currently available data.
Figure 5 : Number of radical prostatectomies in Belgium per year
0 500 1000 1500 2000 2500 3000 3500 4000
Year
Number of procedures
Year+1 367 378 419 532 623 613 489 557 552 540 477 461 494
Year 1429 1609 1867 1902 2552 2614 2811 2663 2826 2945 2929 2959 2732 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 20.4%
19.0%
18.3%
21.9%
19.6% 19.0% 14.8%
17.3%
16.3%
15.5%
14.0% 13.5%
15.3%
Source: INAMI/RIZIV doc. N – 2008-06-30. Numbers for radical prostatectomies performed in 2007 and billed in 2008 are preliminary and incomplete.
Based on the answers of our survey (see 5.2.2) mainly related to the first semester of 2008, we estimated that about 1200 robot-assisted radical prostatectomies would be performed in the year 2008, which represents more than a third of all the radical prostatectomies performed in Belgium.
Created in 2005, the lump sum for endoscopic material in case of radical prostatectomy (code 694610 – 694621) was billed in 26.5% of the cases performed in 2005, in 39% in 2006 and in 49.2% in 2007 (=1344/2732). This percentage, which includes laparoscopy but also robot-assisted surgery, could still increase in the future. In the United States, 70% of the radical prostatectomies are performed with the assistance of a da Vinci robot.193
5.6.2 Potential scenarios for reimbursement
In the current situation, the patient is often additionally charged twice for robot-assisted surgery; once for endoscopy and again for the usage of robot disposables, but at the same time using the robot still leads to a net loss from the hospital perspective.
In case it is found socially or morally unacceptable to ask the patient for such a large supplement, some alternative scenarios might be made to cover part or all of this extra cost to the patient. A reimbursement under art. 35, §3, category 5, would potentially have the advantage of a clear registration of the robot-assisted radical prostatectomies in Belgium, separately from the pure laparoscopic approach.
Table 3 gives budget estimations needed under different assumptions, from 50% to 100% of the current €1200, and for several assumptions about the proportion of radical prostatectomies performed with robot-assistance.
Table 3 : Simulation of budget impact of reimbursement of da Vinci radial prostatectomy under article 35, §3,category 5
N=3250
It is important to note that our estimations rely on a 100% appropriateness assumption for every procedure. Moreover, we assumed that there will be no indication shift towards radical prostatectomy because of the availability of robot-assisted surgery and a supply induced increase in the demand.
In Table 3 we assumed the current level of radical prostatectomies to remain stable in the future but also to be slightly more prudent if we assumed a number of radical prostatectomies somewhat higher, for example 3500 procedures per year, given, for example, the aging of the population or possible indication shifts.
Key points
• Some foreign countries reviewed have a specific financing: in England, through the hospital HRG financing system, in some parts of Sweden via a DRG-based system and in the Netherlands where a hospital may negotiate a tariff for robot-assisted prostatectomy with health insurers.
• The main cost-drivers of the robot-assistance in surgery are the capital acquisition and maintenance, followed by the high costs of limited re-usable surgical instruments.
• Considering a $1.7 million capital investment, a 10% maintenance, robot instruments and disposables, one robot-assisted radical prostatectomy would additionally cost from €4070 to €6420 per patient, depending on the hospital volume (300 to 100 cases per year). The da Vinci ‘reposables’ alone would amount to approximately €1900.
• Training costs are not included in this estimate but should also be taken into account.
• Surgeon’s learning curve and staff experience represent a key factor influencing operating costs.
• Supplementary patient charges vary from one hospital to another from €0 to €1200.
• In case it is found socially unacceptable to ask the patient for such a
supplement and assuming every procedure is performed appropriately, a full reimbursement of the current supplement of €1200 would require a yearly budget of around €2 million assuming that half of the radical
prostatectomies would be carried out with robot-assistance.
• Reimbursement would allow quantifying robot-assisted interventions.
• Policy makers should remain vigilant to avoid potential supply induced demand that could lead to an increased number of radical prostatectomies (or other interventions) in the near future due to the availability of robot-assisted technology or to the reimbursement criteria.