TAMING THE HEALTH COST BEAST: Breakthroughs helpful, but at high price

Ron Solberg's physician's assistant just wanted to make sure. His prostate test results were normal during his yearly checkup but jumped to a degree that flagged a follow-up.

So the 54-year-old Fargo man, fit and feeling just fine, went to see a urologist, who found a small lump. The biopsy's finding: prostate cancer.

That meant surgery to remove his prostate gland. The operation once required an incision 6 to 8 inches long. But advances in techniques and technology gave Solberg options.

He could have conventional, "open" surgery, with a long incision.

Or he could have what's called minimally invasive surgery, performed by a robot controlled by his surgeon.

Several small cuts, instead of one bigger cut, were made with robotic precision, a refinement of earlier laparoscopic methods. That translates into less pain, less scarring and faster recovery.

After getting a second opinion from a cancer specialist, Solberg opted for robotic surgery. His surgeon would have four hands.

In a matter of weeks, Solberg found himself lying on a gurney in the operating room. His anesthesiologist said he was giving him something to relax. As Solberg looked up, staring with eyes fast falling asleep, he was struck by one last, flickering impression.

"It looked," he recalled later, "like a big spider to me."

Technological marvels

Modern medicine is full of technological marvels: Miracle drugs. Exotic devices. Diagnostic machines that peer deep inside the body, eliminating the need for much exploratory surgery.

Medical technology saves countless lives, improves quality of life for countless others, and marches forward with dizzying speed.

It also costs a lot of money - sometimes staggering sums. Technology, in fact, accounts for roughly half of the rising health care costs that have piled up in recent decades, according to a study by the Congressional Budget Office.

Take, for example, the automatic implanted cardiac defibrillator, a device similar to a pacemaker that's inserted into a patient's chest. It detects irregular heart rhythms and delivers a jolt of electricity to restore normal heartbeat.

Studies show the life-saving devices work better than drugs for treating irregular heartbeats and also are used to help congestive heart failure patients.

But the price tag is steep: about $41,000 to $48,000, depending on whether it's implanted in a clinic or hospital - more than double the average $20,000 cost a decade ago, according to figures from Blue Cross Blue Shield of North Dakota.

Stem-cell treatments, which use new cells to repair damaged cells, are used to treat some patients with leukemia and lymphoma. But the cost is considerable: about $190,000.

"We're certainly getting value from the technology," said Dr. David Hanekom, chief medical officer for Blue Cross Blue Shield of North Dakota. "The issue is the cost of the technology."

To approve a new treatment method, Blue Cross Blue Shield and other insurers evaluate the technology or method to determine whether it is effective enough to warrant payment.

"We're not in the business of denying technology," Hanekom said. "If something's effective today, it's in everybody's best interest to do it today."

He added that innovation is vital to health care and insurers try not to stifle the creativity that can produce new and better treatments.

Still, the history of innovation in medicine is full of examples of unexpected applications for a new technology. A classic example is the MRI, or magnetic resonance imaging scan, which initially was used to examine internal organs and other soft tissues.

Soon, however, orthopedic surgeons began using the technology as a diagnostic tool for joint problems, just one illustration of how new uses evolve.

New vaccines that prevent illness are a clear example of new technologies that deliver cost savings. But overall, new treatments that produce clear long-term cost savings are rare, the Congressional Budget Office study concluded.

Coronary angiography, which allows doctors to observe blood flow and gain access to blockages, greatly enhanced the diagnosis of heart disease, for instance. But it also increased the average cost of treatment, and the number of angiographies rose dramatically over time.

"It's really one big circle," Hanekom said. "We live in a country of innovators."

Robotic surgery

The surgical robot that Ron Solberg's surgeon used to remove his cancerous prostate comes with a price tag of $1.5 million to $2 million.

A predecessor robot first came to the Sanford Medical Center in Fargo about five years ago. Surgeons have used the machines for cardiac, orthopedic, urological and gynecological surgical procedures.

Dr. Thomas Noah, the urologist who operated on Solberg, was specially trained and certified to use the robot, but he also operates conventionally. He says both conventional and robotic methods have their pluses.

Not all patients are suitable for the small incisions, including those with advanced cancers or very enlarged prostates.

But for those like Solberg who are eligible, the robotic method offers clear advantages, Noah said.

"The whole idea is they typically have much less pain and quicker recovery," he said.

Most patients who have robotic, minimally invasive surgery spend one night in the hospital, compared to three nights for conventional surgery.

Also, patients who had robotic surgery resume normal activity within three weeks, "with no real restrictions," compared to as many as six weeks for conventional surgery, Noah said.

Sanford's average cost for robotic prostate removal surgery is $5,300, compared to $3,500 for conventional surgery. Still, the shorter hospital stays save money, and a faster return to work or productive activity also have a financial benefit that is hard to calculate.

Providers must weigh those decisions when deciding to invest in a costly new technology.

"There's no question that technology enables us to learn more about a patient more quickly, more safely," said Dr. Bruce Pitts, president of Sanford Clinic in Fargo. "People expect that and deserve that and it's expensive."

Because technology costs are so varied - including everything from drugs to electronic medical records - tallying the total a system like Sanford Health spends on new technology is difficult.

"It's in the tens of millions of dollars," Pitts said. "It's huge."

Many costs are ongoing, involving upgrades. Sanford recently spent $300,000 for new CT/PET scanning equipment and is budgeting $4 million to replace its linear accelerator, used in radiation treatments for cancer patients.

In some cases, technology automates routine tasks once performed by people, freeing time for health professionals to spend with patients. Nurses, for example, no longer handle medication refills.

"These are highly trained nurses whose time can be much better spent with patients," Pitts said.

In other cases, such as robotic surgery, technology allows health professionals to do what they did before with greater precision and ease.

"Suddenly a two-armed surgeon gets four arms," Pitts said. "It's kind of amazing what they can do now."

In either example, automated medication refills or robotic surgery, machines are freeing trained professionals to focus more on the areas where their expertise really matters.

"You're using their brains," Pitts said. "You really want to free people up to use their education. This is really using human beings for the skills, the talent and the education they have."

Back to work

Three weeks after his Jan. 5 surgery, Ron Solberg was back at work, starting with half days. "I still have some soreness," he said, five weeks after surgery. "I'm not back in the gym yet."

But his prognosis is good, with no signs the cancer has spread. As of now, he isn't scheduled for radiation or chemotherapy. He goes back to Noah for a follow-up exam and another test in three months.

"I'm thinking in my mind," he said, "everything is real good."

Readers can reach Forum reporter Patrick Springer at (701) 241-5522