Earlier this month, well known surgeon Dr. Marty Makary wrote an opinion piece for the Wall Street Journal titled “A Minimally Invasive Approach to Health-Care Reform.” In the article, Dr. Makary touts the benefits of minimally invasive surgery as a cost-effective way of reducing health care costs in the United States. Complications following surgery cost roughly $25 billion annually, and Makary posits that minimally invasive surgery, with it’s lower overall complication rates, could save billions of dollars each year. He further notes that by avoiding larger incisions, patients spend less time in the hospital, have less pain, fewer infections, lower medication use during recovery, overall faster recovery, and lower risk of needing subsequent surgery.
However, Makary bemoans the fact that minimally invasive surgery is not the standard of care in hospitals across the United States. In fact, many patients are never even offered a minimally invasive approach. Furthermore, in a study conducted by Makary and colleagues at Johns Hopkins, they found little if any correlation between the use of minimally invasive procedures and the location, size or affiliation of a hospital. He correctly notes that the disparity likely comes from difference in culture between hospitals as well as the training of the surgeon, as some surgical training programs have heavier focuses on minimally invasive techniques. Makary continues to say that “standardizing minimally invasive and open technical training should be a priority for residency programs, rather than emphasizing on approach over the other.” He goes on to say that a hospital’s surgical outcomes should be transparent and available to prospective patients, and he even claims that a hospital’s rate of using minimally invasive surgery for specific operations should be considered a new quality measure. After all,
If there were a new medication that greatly reduced surgical infection rates, lowered pain medication use, and quickened recoveried, policy makers and health-care professionals nationwide would be asking one simple question: Why aren’t people getting it?
I agree with Dr Makary on many points in his article, but as he well knows, that question and the answers to it aren’t so simple. Dr Makary is correct with his contention that surgical training should be more standardized. Furthermore, publishing surgical outcomes and making those outcomes transparent to patients has been heavily argued for in the not so distant past – an idea that hospitals and physicians vehemently oppose and one that the Affordable Care Act is slowly trying to address through Medicare. And yes, minimally invasive techniques have an overall lower complication rate than open procedures, when performed by skilled surgeons.
But Dr Makary misses the mark on many levels, most importantly with regard to cost. First, minimally invasive techniques are more costly than open techniques; there is the added cost of specialized equipment, and in general, minimally invasive techniques take longer to perform, leading to higher operating room costs. Much of that added cost is recovered by the hospital with shorter lengths of stay and recovery times for patients undergoing minimally invasive techniques as compared to open procedures. But what Dr Makary fails to mention is that if we converted every open procedure currently being performed to a minimally invasive one (where feasible), we would certainly save money from less complications – but only if the number of procedures performed remained unchanged. Let me explain.
Minimally invasive techniques revolutionized medicine quite some time ago, with laparoscopic cholecystectomy (minimally invasive gallbladder surgery) being the best example. Prior to the introduction of laparoscopy, patients were forced to undergo painful open surgery which often necessitated hospitals days of 3-5 days or more, and the recovery time after leaving the hospitals was even longer. Open cholecystectomy was therefore reserved for patients with true emergencies; patients suffering from gallstones or biliary colic (occasional pain from the gallbladder) were told to change their dietary habits and take analgesics in order to avoid a painful operation and prolonged recovery period. Laparoscopic changed all of that by reducing risk, shortening hospitalizations, reducing pain, and decreasing recovery times. Proponents posited that despite the higher cost of performing laparoscopic cholecystectomy, the operation would greatly save money for hospitals and the health care system as patients no longer required hospitalization post procedure. They were right – but the number of gallbladder operations skyrocketed, as patients no longer wanted to deal with their gallstones and biliary colic. The result was that even though costs to hospitals decreased, overall health care costs increased due to the higher number of procedures performed. Minimally invasive approaches to nearly every other operation have likewise increased overall health care costs due to the higher number of procedures performed.
Finally, Dr Makary fails to mention that even though there may be a minimally invasive technique for a given procedure, not all operations are amenable to minimally invasive approaches. Partial colectomy (removal of a part of the colon) can be performed laparoscopically, but the minimally invasive technique is not always appropriate. And with regard to his prime example of appendectomy, the surgical literature still does not support that laparoscopic appendectomy is superior to the open technique.
There are many reasons to perform minimally invasive procedures, however, cost is not one of them. If Dr Makary’s intent is to improve the quality of care, then he’s right on the mark.