Summary
Robotic-assisted thoracoscopic surgery (RTS) is safe and effective, but is associated with high capital and operating costs that are not reimbursed by the Canadian government. Currently, patients have access to RTS only when it is supported by research or philanthropic funds. In a recent study, we assessed the extent of patient-reported satisfaction with RTS, whether patients would have been willing to pay out of pocket for it, and what factors were associated with patients’ willingness to pay. Many patients (290 of 411 [70.56%]) stated that they would have paid the additional $2000 to supplement the government health care coverage to have access to RTS. Factors found to be significantly associated with participants’ willingness to pay were an annual income of $60 000 or more (p = 0.034), private insurance coverage (p = 0.007), overall experience with RTS rated as 8 or higher out of 10 (p < 0.001), and overall postoperative postdischarge experience rated as satisfying or very satisfying (p = 0.004).
Robotic-assisted thoracoscopic surgery (RTS) is a minimally invasive platform for lung cancer surgery that has been demonstrated to be safer, more effective, and associated with more favourable patient outcomes than thoracotomy.1 However, RTS is associated with a high capital cost of purchase ($2 million to $4 million), and additional ongoing operating costs ($2.9 million/7 yr).2 To date, there are 30 surgical robots operating in 14 Canadian cities, performing about 6000 operations annually.3 Currently, RTS is not funded by the Canadian public health care system, and its existence depends solely on philanthropic and research funds, limiting patient access to this technology.
In a recent study, we hypothesized that Canadian patients who have undergone RTS at a centre where the procedure costs were covered by research or philanthropic funding would have been willing to contribute a $2000 supplemental payment (incremental cost per case for RTS) out of pocket to gain access to this technology.
Survey
All patients who underwent RTS for early-stage lung cancer at our tertiary care centre from January 2014 to July 2020 were invited to participate in a short telephone survey between August 2020 and February 2021. Patients were asked about their demographic characteristics, experience with RTS, and willingness to contribute to the cost of RTS (Appendix 1, available at www.canjsurg.ca/lookup/doi/10.1503/cjs.021721/tab-related-content).
Of the 459 eligible patients who were contacted, 411 (89.54%) participated in the survey (Figure 1). The mean age of patients at surgery was 65.44 ± 10.27 years, and 241 (58.64%) participants were female (Table 1).
Response rate flow diagram. RTS = robotic-assisted thoracoscopic surgery.
Respondent demographics and socioeconomic status (n = 411)
On a scale of 1 (poor) to 10 (excellent), 353 (85.89%) of the respondents rated their overall experience with RTS as 8 or higher. On a 5-point Likert scale ranging from “too short” to “too long,” 223 (54.26%) rated the wait time for RTS as “adequate.” With regards to overall postoperative experience, 365 (88.81%) were either satisfied or very satisfied with their hospital admission, and 354 (86.13%) were either satisfied or very satisfied with their recovery postdischarge (Table 2).
Thoracic surgical patients’ experience with robotic-assisted thoracoscopic surgery (n = 411)
Most respondents (333 [81.02%]) expressed a willingness to pay out of pocket for RTS. A somewhat smaller majority (290 [70.56%]) stated that, in the absence of research and philanthropic funds, they would have paid the additional $2000 to supplement the government health care coverage in order to have access to RTS, while the remainder of those who expressed a willingness to pay out of pocket (43 [10.46%]) stated that they would have contributed between $1 and $1499 (Figure 2). However, 78 (18.98%) participants stated that they would not have been willing to contribute toward the cost of their RTS, and this includes patients who had a negative surgical and/or posoperative experience, low annual income levels, and/or lack of private insurance coverage (Table 3). The majority of participants (341 [82.97%]) stated that they would not have paid to shorten their wait time for RTS. This suggests that although most patients believe it is justifiable to pay to access nonfunded technology, most of them still believe in the equal accessibility of the Canadian health care system.
Breakdown of willingness to pay, willingness to contribute, and contribution amount.
Characteristics of patients willing to pay $1–$2000 for robotic-assisted thoracoscopic surgery compared with patients unwilling to contribute
Discussion
Factors we found to be significantly associated with participants’ willingness to pay a fee for RTS were an annual income of $60 000 or more at the time of surgery (p = 0.034), private insurance coverage at the time of surgery (p = 0.007), an overall experience with RTS rated as 8 or higher out of 10 (p < 0.001), and an overall postoperative experience postdischarge from the hospital rated as satisfying or very satisfying (p = 0.004) (Table 4). The socioeconomic association suggests that patients with higher income levels are more willing to pay. This could be related to an improved awareness of health care innovations or a better ability to afford health care costs. Participants who had private insurance coverage at the time of surgery also seemed to be more willing to pay, likely because they are accustomed to receiving upgraded health care options in general. The associations with positive surgical and postdischarge experiences suggest that patients place value on their experience receiving treatment as well as on the outcomes of treatment. Age at surgery, gender, ethnicity, education level, wait times, and overall postoperative experience in hospital were not associated with patients’ willingness to pay.
Characteristics of patients willing to pay $2000 for robotic-assisted thoracoscopic surgery compared with those unwilling to pay
Although RTS is associated with significant capital and operating costs, which are borne by the host institution, several Canadian hospitals have chosen to invest in robotic surgery because it has been shown to be cost-effective at high-volume centres.4,5 In a review of Canadian prostatectomy data, Parackal and colleages found that the robotic platform is cost-effective with an incremental cost per quality-adjusted life years gained ratio of $25 704 and recommended its uptake in prostate cancer surgery.4 In a microcosting analysis of RTS resections for lung cancer, Kaur and colleagues found that RTS compares favourably to video-assisted thoracoscopy.5
Although many of the patients in our study would be willing to pay for access to RTS for lung cancer, we do not believe that patients in the Canadian health care system should be made to pay for cancer surgery. In contrast, we believe that the willingness to pay is a surrogate for the patients’ desire to have access to this technology. This study demonstrates that patient preferences and experiences are important factors that funders in the Canadian health care system should consider when making decisions about whether to fund new technology and treatment techniques.
Conclusion
Most Canadian patients who have experienced RTS at a high-volume centre would have been willing to pay a supplemental fee out of pocket in order to have access to RTS technology. At a time when patients are being recognized as important stakeholders in health care policy, our survey results provide important insights into the conversation about the role and funding of robotic surgery in the Canadian health care system.
Footnotes
Competing interests: W. Hanna reports a grant and stock or stock options from Intuitive Surgical, consulting fees from AstraZeneca, and honoraria from Minogue Medical. He also participates on the advisory board of Roche/Genentech. No other competing interests were declared.
Contributors: All authors contributed substantially to the conception, writing and revision of this article and approved the final version for publication.
- Accepted January 18, 2022.
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/
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