In this post, we provide a reimbursement policy update for robotic-assisted surgery in three key geographies: France, Germany, and the UK. In all three, there is a considerable appetite for adopting robotic techniques by clinicians, hospitals, and health systems. However, the architecture of the respective reimbursement systems makes it difficult to accommodate the additional cost of robotic technologies without payers making an explicit decision to cover the additional cost. This usually requires strong evidence that clinical outcomes are better and is further supported when there is additional evidence of efficiencies such as:
• Reduced postoperative morbidity associated with less (or minimally) invasive techniques
• Fewer complications
• Fewer returns to the operating theatre
Despite these structural headwinds, several companies are currently innovating and offering highly differentiated robotic surgery systems, following the remarkable successes of Intuitive Surgical. Customers are being activated by presenting a business case that articulates broader value to the facility along with evolving financing options.
UK
In the UK, there are examples where a robotic surgical technique attracts a higher tariff compared with alternative techniques to perform the procedure. For example, robotic prostatectomy maps to an HRG (a UK DRG) specific to robotic urological surgery. This has a higher payment (or reimbursement) than the comparable open procedure.
This does not uniformly apply to many other procedures. The challenge is not the need to create new procedure codes but to justify an adequate reimbursement level assigned to the relevant coding combination through either the creation of a new HRG which is then priced, or by repricing an existing HRG. Until this is routine, National Health Service (NHS) hospitals, which work under a quasi-DRG system, will continue to struggle to invest in the technology if it adds to cost. Private hospitals with access to investment funding and a need to offer up-to-date technology may be able to adopt robotics more quickly than hospitals in the NHS.
The National Institute for Health and Care Excellence (NICE) reviews all ‘new’ interventions to establish that there is sufficient evidence of safety and effectiveness to support them as a treatment option outside a research setting. In many cases, NICE has decided that a review is not required because the robotic approach is a minor variant of an established procedure. In other cases, it has considered the robotic approach to be different enough to treat it as a ‘new’ intervention requiring a review in its Interventional Procedures Programme.
The NHS is being encouraged to adopt new technology where it has been shown to be cost-effective, but adoption of robotic procedures by the NHS is inconsistent, depending on local rather than national decision-makers. In the latest published statistics (for 2022-23), the robotic approach code was used in association with almost 48,000 procedures.
As always, it is important to be able to demonstrate improved outcomes when seeking support for the creation of a new HRG, which is an opaque process. Demonstrating value for money (cost savings or cost-effectiveness) is key to persuade a hospital and or commissioner to adopt a new procedure.
France
Use of robotics varies widely by region in France. Private hospitals perform robotic prostatectomy, bariatric surgery, and posterior hysteropexy more commonly than public hospitals. Robotic pulmonary lobectomy, hysterectomy, and non-bariatric digestive surgery are performed more commonly in public hospitals.
In 2023, the French government launched the France 2030 incentive plan for the development of medical robotics, backed by targeted funding. The aim is to support the development of projects from seed to market. Innovations are being encouraged through specific schemes such as the innovation package, which calls for projects backed by funding and fast-track routes to market. These include:
• Micro-robotics
• Flexible and biomimetic robotics
• Augmented reality
• Advanced navigation systems
• AI-assisted robotic surgery
For medical device companies, taking advantage of France’s incentives and reimbursement structures can be a crucial strategy for accelerating the adoption of their technologies in this market.
Germany
Robotic surgery is rapidly gaining ground in Germany and for many procedures is seen as the standard of care. Despite a difficult reimbursement environment, Germany features a more positive investment environment than in England or France. The costs of robotic equipment should be covered by the German federal states, but hospitals do not routinely receive the level of investment required. Federal financing programmes, such as the Hospital Future Fund (KHZF) play an important role.
The costs of using robotic surgery, including maintenance of the equipment, are funded through DRG tariffs. Although there are specific codes for robotic surgery, these are used to monitor the number of robotic procedures performed and do not result in any additional tariff compared to the equivalent non-robotic procedure. The tariff paid, which is based on actual historical costs, will be a combination of the robotic and non-robotic procedure costs.
Reducing length of stay is usually a winner in a DRG-based system with a fixed tariff for a procedure, but this is not always true in Germany because a minimum length of stay is necessary to trigger the full tariff payment for some DRGs.
Successfully approaching and succeeding in each these markets requires innovators of robotic surgical technologies to develop country-specific strategies that addresses these unique dynamics. BeaconOneTM actively monitors changes to global robotic surgery reimbursement and market access initiatives.
Contact us to make sure you are fully aware of the evolving reimbursement policy environment and so that you can take advantage of these initiatives as you prepare your business case and strategy.