Background: Medical economics have significant impact on the entire country. The explosion in surgical techniques has been accompanied by questions regarding actual improvements in outcome and cost-effectiveness, such as the da Vinci^® Surgical System (dVS) compared with conventional video-assisted thoracic surgery (VATS).Objective: To establish a medical fee system for robot-assisted thoracic surgery (RATS), which is a system not yet firmly established in Japan.Methods: This study examines the cost benefit performance (CBP) based on medical fees compared with VATS and RATS under the Japanese National Health Insurance System (JNHIS) introduced in 2012.Results: The projected (but as yet undecided) price in the JNHIS would be insufficient if institutions have less than even 200 dVS cases per year. Only institutions which perform more than 300 dVS operations per year would obtain a positive CBP with the projected JNHIS reimbursement.Conclusion: Thus, under the present conditions, it is necessary to perform at least 300 dVS operations per year in each institution with a dVS system to avoid financial deficit with current robotic surgical management. This may hopefully encourage a downward price revision of the dVS equipment by the manufacture which would result in a decrease in the cost per procedure.