Just six weeks ago, Rob Lucy had his cancerous prostate gland removed by a surgeon-controlled robot at Vancouver General Hospital. It cost him nothing.
If his operation had been booked for the new year, however, Mr. Lucy would have had to shell out more than $2,800 from his own pocket for exactly the same procedure.
Private funding for the advanced surgical robot at VGH has run out, and the province’s public health care plan has refused to cover the costs of keeping it going, despite claims by patients and surgeons that robotic surgery provides clear measurable benefits. At least in the short term.
So, starting Jan. 3, the hospital is imposing a series of rare, hefty user fees, ranging from $2,100 to $3,500, for procedures that are reimbursed by medicare, but only if performed in traditional open surgery.
Such patient fees, believed to be a first in Canada for robotic surgery, highlight one of the fundamental challenges faced by publicly funded health care in the age of modern, technology-driven medicine.
How much benefit should a new but costly procedure provide to patients before it is paid for out of the public purse?
That is the question, agrees veteran surgeon Larry Goldenberg, who has been performing robotic prostatectomies at VGH for the past three years.
“What is the threshold? This is not a home run, but it’s a base hit. Should the government pay for base hits, or only home runs? Somebody has to make that call.”
So far, no randomized clinical trials have been conducted to determine whether long-term outcomes are improved by robotic surgery. Anecdotal evidence suggests they are not, and the government has said no to funding them.
“Why should the taxpayer pay a whole bunch more money for someone to have a more expensive procedure, when we really don’t know that it is a significant net benefit?” asked Health Minister Colin Hansen.
He added that traditional prostatectomies continue to be provided to patients at no cost.
However, patients are not charged for robotic prostate gland removals at London Health Sciences centre in Ontario, the first hospital in Canada to use the technique. They are funded from the hospital’s global budget, although costs restrict the number to fewer than 100 a year.
Advantages of less-invasive robotic surgery include earlier discharges from hospital, faster recovery rates, and less loss of blood during the operation, said Joseph Chin, chair of surgery oncology at the University of Western Ontario.
“However, the advantages are not as much as a lot of Americans claim,” Dr. Chin said, referring to the preponderance of surgical robots in for-profit hospitals in the United States.
“We would like to expand our program, but we want to do more research, too.”
At Vancouver General, Dr. Goldenberg, 57, says he loves robot surgery.
“You have a degree of accuracy that is unmatched. I have colleagues who don’t think there are any advantages to robots whatsoever. But there are also an awful lot of surgeons who have converted to robotics, and they have not gone back to open surgery.”
Still, Dr. Goldenberg said his own rough research does not yet show a long-term benefit to patients.
“There are upfront advantages, yes. Yet, when I compared my first 175 robotics with my last 175 open surgery patients, the continence rates for both were the same.”
He likened the quandary patients face over whether to pay several thousand dollars for robotic surgery on the chance that it will result in a better outcome to buying a lottery ticket. “I tell patients that you can’t win the lottery if you don’t buy a ticket,” Dr. Goldenberg said,
Vancouver Coastal Health spokesman Gavin Wilson said the new patient charges cover only half the cost of robotic surgeries. The rest will be covered by the health authority.
“The jury is still out as to whether it’s better, but we wanted to continue to offer this new technology as part of our research mandate.”
Mr. Lucy, meanwhile, is grateful to have received his robotic prostatectomy at no cost. But he said he would not hesitate “for a moment” if asked to pay.
His recovery time has been quicker, and he has suffered less “than an awful lot of guys I talk to” who had open surgery, Mr. Lucy said.
“Knowing what I know now, would I find the money and pay? Absolutely.”