But it's unclear how many manufacturers are willing to give up their sales reps' coveted one-on-one relationships with surgeons. That access can allow manufacturers to influence surgeons to use more costly products. Still, hospital initiatives in recent years to reduce the costs of medical supplies—which make up a hospital's second-largest expense after labor—and a push for more transparency about doctors' financial relationships with manufacturers have started to limit surgeons' choices about the products they use.
At Loma Linda, about 90% of roughly 400 hip and knee replacement surgeries performed each year are handled through the direct-service model, which was started in spring 2013. Two in-house orthopedic device technicians received training on the devices at the headquarters of the manufacturers, which Loma Linda officials declined to identify. The employed technicians begin managing the implants as soon as the shipments arrive.
“We have better people servicing it who have better familiarity with the doctors and the operations and the OR,” Freed said. “They're not up-selling. And the quality doesn't change.”
But some observers question whether the rep-less model can be applied to most U.S. hospitals. Others worry that it could affect patient safety if not executed well. “If hospitals are not looking at safety and effectiveness as well as cost, then you might have a recipe for disaster,” said Lisa McGiffert, director of Consumers Union's Safe Patient Project.
Sales reps long have played a major role in providing technical assistance to surgeons. Sales reps often bring implants to the OR before a procedure or suggest what devices should be used during surgery. A standard orthopedic surgery may have 10 to 15 product trays, each with hundreds of instruments.
The orthopedic implant sector of the medical device industry uses the most sales reps. It's a highly consolidated market, with five manufacturers—Biomet, Johnson & Johnson's Depuy Synthes unit, Smith & Nephew, Stryker Corp. and Zimmer Holdings—controlling about 95% of the worldwide market share for hips and knees, and further consolidation is underway. Experts say there are few clinical differences between the hip and knee implants or many of the spine surgery devices sold by different manufacturers.
The rep-less model is being driven by pressures on hospitals to lower costs—declining reimbursement rates, lower patient volumes, financial risk arrangements with insurers, and employers and consumers seeking lower-cost procedures. The hospitals most likely to employ this model are academic medical centers, which have some of the most stringent policies on sales reps' access to clinicians and operating rooms. Other hospitals moving to this model include those that work under risk contracts or serve a high percentage of uninsured, Medicare and Medicaid patients.
Some hospital officials say they favor the rep-less model because they are tired of paying “selling, general and administrative,” or SG&A, costs as part of the price of an implantable device. Those costs can make up nearly 40% of the price. Another reason is that they believe sales reps have become too heavily involved in clinical procedures.
In shifting to the direct-service model, hospitals have to make an investment through additional salaries and training for the in-house service technicians taking on the role of the industry rep. But “over time you come out clearly on top with the lower costs of hips and knees,” Loma Linda's Freed said.