Assessment of Out-of-Pocket Costs for Robotic Cancer Surgery in US Adults

IMPORTANCE: Expensive technologies—including robotic surgery—experience rapid adoption without evidence of superior outcomes. Although previous studies have examined perioperative outcomes and costs, differences in out-of-pocket costs for patients undergoing robotic surgery are not well understood. OBJECTIVE: To assess out-of-pocket costs and total payments for 5 types of common oncologic procedures that can be performed using an open or robotic approach. DESIGN, SETTING, AND PARTICIPANTS: A retrospective, cross-sectional, propensity score–weighted analysis was performed using deidentified insurance claims for 1.9 million enrollees from the MarketScan database from January 1, 2012, to December 31, 2017. The final study sample comprised 15 893 US adults aged 18 to 64 years who were enrolled in an employer-sponsored health plan. Patients underwent either an open or robotic radical prostatectomy, hysterectomy, partial colectomy, radical nephrectomy, or partial nephrectomy for a solid-organ malignant neoplasm. Statistical analysis was performed from December 18, 2018, to June 5, 2019. EXPOSURES: Type of surgical procedure—robotic vs open. MAIN OUTCOMES AND MEASURES: The primary outcome of interest was out-of-pocket costs associated with robotic and open surgery. The secondary outcome of interest was associated total payments. RESULTS: Among 15 893 patients (11 102 men; mean [SD] age, 55.4 [6.6] years), 8260 underwent robotic and 7633 underwent open procedures; patients undergoing robotic hysterectomy were older than those undergoing open hysterectomy (mean [SD] age, 55.7 [6.7] vs 54.6 [7.2] years), and patients undergoing open radical nephrectomy had more comorbidities than those undergoing robotic radical nephrectomy (≥2 comorbidities, 658 of 861 [76.4%] vs 244 of 347 [70.3%]). After adjustment for baseline characteristics, the robotic approach was associated with lower out-of-pocket costs for all procedures: –$137.75 (95% CI, −$240.24 to −$38.63) for radical prostatectomy (P = .006); −$640.63 (95% CI, −$933.62 to −$368.79) for hysterectomy (P < .001); –$1140.54 (95% CI, −$1397.79 to −$896.54) for partial colectomy (P < .001); –$728.32 (95% CI, −$1126.90 to −$366.08) for radical nephrectomy (P < .001); and –$302.74 (95% CI, −$523.14 to −$97.10) for partial nephrectomy (P = .003). The robotic approach was similarly associated with lower adjusted total payments: –$3872.62 (95% CI, −$5385.49 to −$2399.04) for radical prostatectomy (P < .001); –$29 640.69 (95% CI, −$36 243.82 to −$23 465.94) for hysterectomy (P < .001); –$38 151.74 (95% CI, −$46 386.16 to −$30 346.22) for partial colectomy; (P < .001); –$33 394.15 (95% CI, −$42 603.03 to −$24 955.20) for radical nephrectomy (P < .001); and –$9162.52 (95% CI, −$12 728.33 to −$5781.99) for partial nephrectomy (P < .001). CONCLUSIONS AND RELEVANCE: This study found significant variation in perioperative costs according to surgical technique for both patients (out-of-pocket costs) and payers (total payments); the robotic approach was associated with lower out-of-pocket costs for all studied oncologic procedures.