Improvements in robotic technology in the past decade have led to greater utilization in the field of medicine. Already, more than 3,000 surgeons are certified in one or more Mako application. I personally foresee buy-in to this technology to continue to increase significantly.

In addition, outpatient total joint surgery is expected to grow by 77% over the next 10 years.¹ From my point of view, the Mako System is a logical fit for an ASC setting. Presently, partial knee, total knee, and total hip procedures can be performed with the assistance of Mako, which has demonstrated increased accuracy of implant placement to the pre-operative plan. (This was demonstrated in a cadaveric study for Mako Total Knee.)^2-5 Additional benefits include the potential to increase patient satisfaction^6,7, and in my practice, I've seen lower case costs.

On the surface, the decision to invest in robotic technology at an ASC might seem as simple as computing the ROI and break-even case volumes, but there are several other factors I would propose you consider.

1. Is your ASC ready for robotic technology? At my practice, the integration of Mako Technology in our ASC's previously established, well-functioning outpatient TJA program, required little effort. My OR team became comfortable with Mako cases in a very short period of time. Similarly, it was demonstrated in a recent study that surgeons can expect to overcome the learning curve during the first 10-15 cases using robotic-arm assisted TKA, even with limited surgical experience.⁸ In my opinion, in order to realize increased productivity with Mako, an ASC must be organized to efficiently perform multiple joint cases. Processes like room turn-over, anesthesia, equipment sterilization, etc., must be optimized so that the rate-limiting step becomes the Mako procedure. For our center, this means utilizing two rooms, two anesthesiologists, and two OR nursing teams. We’ve witnessed that one surgeon performing ten Mako Partial Knee procedures in an eight-hour day is achievable, but requires coordination and an experienced staff.
2. Do you have the case volume to support a Mako program? Many variables come into play which affect the volume of cases performed at an ASC. I found that our patient selection criteria changed as our comfort level with the Mako Technology increased. We also believe that positive word of mouth around the Mako technology may have led to a steady increase in case volumes over time.
   
3. What is your average reimbursement for Mako cases? Your contracted rates for PKA, TKA, and THA, are critical in calculating the return on investment for Mako. If you’re considering Mako in an ASC setting, I suggest you take a close look at your payor mix, outcomes data and quality benchmarks. I’ve observed that payers in my market are becoming more receptive to the value in moving TJA from the hospital setting to the ASC. Consider making a realistic but conservative estimate of the number of cases required to break even on the investment.
   
4. Are you committed to educating your staff? I believe that increasing the efficiency of an ASC to handle high volume joint arthroplasty requires committed surgeons and a significant commitment to educating your staff, among other things. In my experience, the nursing staff plays one of the greatest roles in the success of the endeavor. Most nurses were trained that TJA patients should spend three days or more in a hospital and then several weeks in a rehab facility. Although setting the expectation for same-day joint surgery starts at the pre-op visit, getting your staff to embrace the change in expectations is critical to establishing a comfort level in your patients and their families for same-day discharge.
   

In summary, the Mako Technology is great but never forget it requires commitment to developing an efficient outpatient joint arthroplasty program.

We are certainly happy with our decision to bring Mako Technology to Greater Phoenix Orthopedics!

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