Improving Outcomes and Reducing Costs With Minimally Invasive Surgery

An interview with Deborah S Keller, MD, Department of Surgery,  Baylor University Medical Center

Can you discuss some of the proven clinical benefits of minimally invasive surgery?

The clinical benefits of minimally invasive surgery  are well proven, accepted, and numerous. These include less physiologic damage, less postoperative pain, lower rates of ileus, faster time to ambulation, return of bowel function, diet, and normal activities, shorter lengths of hospital stay, and lower complication rates. 

While there are positive benefits, this study does not focus on the clinical benefits of minimally invasive surgery. It focuses on the economics of the surgical process, demonstrating the overall value of minimally invasive surgery for the surgical episode of care. It also stresses the emerging paradigm of surgeons using minimally invasive surgery to reduce their own costs and overall health care consumption. 

Can you describe a scenario where treatment options include minimally invasive surgery, but instead typically favor another form of treatment?

There are few scenarios where minimally invasive surgery is not appropriate. Despite this, the overall utilization of minimally invasive surgery for colectomies is approximately two-thirds of appropriate cases, and patients’ access to minimally invasive surgery is largely random. Thus, methods to increase utilization are warranted.

From a payer’s perspective, is minimally invasive surgery cost-effective?

Yes. Compared with open surgery, both the costs associated with the procedure and hospital stay, and post-discharge period are significantly lower with minimally invasive surgery.  

Would minimally invasive surgery be an ideal option for bundled payment or accountable care sharing programs?

Because minimally invasive surgery provides better outcomes that reduce costs greater, minimally invasive surgery adoption in risk sharing payment models, such as bundled payment and shared savings, is an ideal option for all stakeholders.

Would acceptance and increased utilization of minimally invasive surgery require a shift in treatment and reimbursement trends? Or are payers and providers already showing evidence of shifting towards more minimally invasive surgeries?

There is a trend in increased utilization over time, but given the clinical benefits for the patient, and cost benefits to both the patient and payer the rate of transition to minimally invasive surgery seems exceedingly slow. There is still a significant percent of patients who could be offered minimally invasive surgery, but are not. We are hopeful that, as the benefits of minimally invasive surgery continued to be realized, more patients will receive minimally invasive procedures. New quality-based reimbursement models would do well to capitalize on the clinical and economic benefits of minimally invasive surgery.   

Can you breakdown how minimally invasive surgery reduces costs?

From this study’s data source—a commercial claims database—cost savings were demonstrated in a variety of ways. Cost savings came from: a reduction in hospital length of stay; a reduction in the total number of complications and colorectal-specific complications; a reduction in facility and professional fees; and a reduction in the use of postdischarge resources, such as skilled nursing facilities, pharmacies, emergency departments, and outpatient clinics.

Are there any downsides to minimally invasive surgery when compared to open surgery?

There is a learning curve to minimally invasive surgery. A time investment is needed, but the patient benefits and financial outcomes are worth surgeons working through the curve.

Your research focuses on minimally invasive colectomy; can your conclusions be broadly extrapolated to other forms of minimally invasive surgery? 

Colectomy is just one model, and an ideal pilot as the principles of enhanced recovery with minimally invasive surgery are well established. There is also a significant amount of published evidence of the benefits of minimally invasive surgery in other surgeries such as thoracic resections, hernia repair, and hysterectomy.

Is there anything else you would like to add?

This study builds on an already impressive medical literature demonstrating the clinical benefits of minimally invasive surgery. I am thrilled to have added to this literature by demonstrating some of the financial benefits of minimally invasive surgery as we move more and more into the era of value-based health care, which prizes clinical and cost efficiency.