Case Study: Surgical Robot Arms Race
By Jeff Wong, Bellevue College
In the greater Seattle-Tacoma area, an arms race continues between hospitals to gather the most modern technology available to use on their patients – currently this arms race’s primary device of choice – robotic surgical systems. Why robotic surgical systems? These systems in theory allow surgeons to be more precise in performing complex surgical procedures on patients. With greater precision comes a greater chance of successfully healing the patient as well as reducing the patient’s possibility for complications and recovery time. In addition to these benefits, hospitals through the use of superior technology can serve more patients and potentially reap greater benefits from insurance companies and patients for these advanced medical services.
The price of this superior care though comes at a cost to the patient (increased charges) as well as purchase costs to the hospital. One of the most popular robotic systems is called da Vinci and is manufactured and sold by Intuitive Surgical (http://www.intuitivesurgical.com/). The da Vinci was FDA approved in July 2000 and can currently perform urologic, gynecologic, colorectal, head and neck, cardiothoracic, and other general surgery procedures. As important as the device is the surgeon that is trained in the use of the system. The more repetitions on the robotic system, the more skillful the surgeon becomes.
Depending on the options that a hospital chooses to purchase, the cost of a da Vinci system can range between 1 million and 3 million dollars with the associated sales taxes. As with all surgical instruments, there are also disposable items needed during a surgery associated with equipment – specifically the da Vinci which must also be purchased. These items range from $1,000 to $3,000. Finally, as with many pieces of sophisticated electronic technology, it must be maintained. These maintenance costs can be upwards to $200,000 a year. In addition to these specific costs, hospitals must continue to maintain the surgical suites that this equipment occupies as well as utilize all other supplies that would be used in any surgical setting.
A local hospital in the Puget Sound area faced a dilemma in the medical arms race. Surrounding hospitals were purchasing and utilizing the da Vinci robot system. Management began to worry about the erosion of patients that would seek out this modern technology over more traditional surgical procedures. To this end, a strategic decision was made to acquire the da Vinci robotic surgical system. The following data was presented to an analyst in the Finance Department for review:
Quite often, analysts are provided leasing information by the leasing company. Hospitals may choose to purchase equipment outright or acquire equipment using a lease. Leases are generally considered operating or capital leases under current accounting rules. Hospitals may purchase equipment outright if they have sufficient capital money that can be used to purchase equipment of significant amount – usually greater than $5,000). Otherwise, they may decide that if the interest rate of payments being charged is lower than their internal cost of capital (debt financing, equity financing, etc.), they may utilize the lease directly from the equipment seller.
Given the information provided in Table 1:
1. What is the annual rate of interest being charged to the hospital? The total interest paid over the entire term of the lease?
2. Given this rate of interest, give some reasons on why or why not the hospital should accept this lease contract. Is this a good deal for the lessee?
3. Assume that the hospital has a current borrowing rate of 3.75% is this a capital lease or operating lease? Please explain each of the criteria and your conclusion based on ASC 840. Assume a 7 year life to the equipment, that there is no transfer of ownership to the lessee at the end of the lease term, and that there is no bargain purchase option.
4. Why would a hospital care whether it was a capital lease or an operating lease? When would one be an advantage over the other?
Upon Further Review:
After the initial review from the analysts, management entered into further discussions with the leasing organization. This equipment would be new to the hospital. In addition, to the training and recruitment of surgeons to use this equipment, the hospital would have to develop a suite that would function ergonomically and efficiently with the surgical robot. This would mean additional costs for the acquisition of the surgical robot. Despite the fact that it was important to bring in this piece of equipment to be competitive with other hospitals, management needed to perform its due diligence in order to be fiscally responsible. To this end, management negotiated and was presented the following key proposal items.
1st 11 Payments:
12th Payment On:
5. Given the new situation, how does that affect questions 1-4? Would your answers be different and why?
6. If the contract were signed, what would be the first journal entry entered by the hospital. What would be the final journal entry? Are they the same or are they different? Why? What underlying principal would explain why they would be the same…? What underlying principal would explain why they would be different?
After several years of utilizing the da Vinci robot, new technologies and new equipment have entered the market. The most recent monthly operating expenses for da Vinci were presented:
Salaries and Wages
Supply Expense – da Vinci
Supply Expense – Other
Allocated Hospital Expenses
The salaries and wages related to da Vinci surgeries are the support personnel which include RN’s, Medical Assistant’s, etc. during the procedure. Employee benefits are related to the support personnel of the da Vinci procedures. The supply expense – other relates to expenses associated with the surgical procedures done by the da Vinci but are not directly for the da Vinci equipment itself (sponges, linens, etc.). The lease expense in the monthly lease for the da Vinci. Maintenance expense is the support agreement to maintain the da Vinci.
Depreciation expenses are for other equipment located within the da Vinci surgery suite. Allocated Hospital Expenses are fixed overhead expenses that are incurred and would be absorbed by other departments if da Vinci surgeries did not occur. For the purposes of the analysis, management has determined the following:
Average Cases Per Month 10
Average Net Revenue per case $5,000.00
7. Calculate the contribution margin. Be sure to identify the variable versus the fixed expenses.
8. Based on the determination you made in the above question, discuss the break-even point in number of cases per month. What are the implications associated with this number?
As part of the overall discussion concerning the da Vinci surgical system, management is contemplating the new technological advances in the system as well as the fact that the existing lease is ending. Given the situation, management is evaluating the current number of procedures, an expansion of the robotic surgical system with addition of an additional surgeon, and the lease for a new system.
New Robot Cost
Cost of Financing
Lease Term (Years)
Average Cases Per Month
Average Net Revenue per case
9. Determine the monthly payment for the new lease for the da Vinci robot.
10. Assuming that other existing variable and fixed costs carryover for the next 4 years and that this is an operating lease, what is the net present value of the da Vinci robot assuming a 12% discount rate and the ability to sell the robot for $500,000 at the end of the lease?
11. What is the new break-even point?
12. Is this a profitable venture for the hospital? If profitable, is it profitable enough? Why or why not? If it is not profitable, should the da Vinci robot be discontinued? Why or why not?
Recently, there has been an inquiry into whether robotic surgical procedures provide any net benefits to patients based on the costs. The Seattle Times on July 7, 2012 originally published an article, “Use of surgical robots booming despite hefty cost,” http://seattletimes.com/html/localnews/2018631542_robot08m.html. Recently, CNBC posted a series dated from April 18, 2013, http://www.cnbc.com/id/100650872
The IMA Code of Ethics describes the ethical framework in which management accountants should operate. More often than not, decision makers ask management accounts to perform analysis based on certain facts and predictions. These analysis are turned in to potential models that are reviewed in order to make final decisions. In a hypothetical situation, you have performed all the analysis above and noted that the net present value of performing robotic surgical procedures exceed 15%. After reviewing your report, you become knowledgeable of information concerning a figure that was not part of the original calculations… Risk management has determined that the cost of lawsuits due to complications and potential loss of life associated with robotic procedures will reduce profitability by 3%. Management has decided to perform robotic procedures.
13. So, what do you do? This question should be answered an in essay format with a clear beginning, middle and end. You should use transitions between paragraphs and be readable to a knowledgeable business person. This means you will need to discuss the IMA Code of Ethics and how it applies to this situation. This question should not exceed 5 pages double spaced. With that said, a one page answer will not suffice either.