A new study warns that American operating rooms may be relying too much on medical-device salespeople for technical assistance, while loyalty between surgeons and representatives may be contributing to rising hospital costs.
Researchers explored the role of sales technicians in the OR, their relationships with physicians and the impact of sales reps on a hospital's bottom line. Two former salespeople, one current sales representative and 19 surgeons participated in focus groups and individual interviews. The study was sponsored by Georgetown University.
In many ORs, surgeons couldn't use complex devices without the technical expertise that sales technicians provided, the study found. Many technicians also made sure surgical trays and tools were ready, a role that wasn't necessarily being performed by OR staff.
Reps cultivate relationships and “make themselves invaluable to physicians on a personal and professional basis,” said Adriane Fugh-Berman, an author of the study and director of PharmedOut, a Georgetown University Medical Center project focused on pharmaceutical marketing practices. In many cases, representatives and physicians alike noted that surgeons didn't always have the expertise to handle procedures on their own.
”All of the reps were clear that they were making up for a deficiency in operating room staff,” Fugh-Berman said.
But that close, often personal relationship can be problematic when it comes to pitching product and advising physicians on what devices they should use for a particular procedure. Even sales representatives told researchers that they felt uncomfortable when their companies pushed them to sell newer, more expensive products even though existing products had more extensive efficacy data.
“I often felt like I'm driving up the costs of the healthcare system. ... We used to sell an implant that has 99% survivorship at 15 years, which is great, right? We were told to not ever market it to anybody. ... If a doctor asked for it by name, we would give it to him. We want to market the newer, the better technology,” one rep told researchers.
These kind of tactics can damage a hospital's bottom line and mean less predictability in the OR, said Eric Cenac, an executive at ROi, the supply chain organization of St. Louis-based Mercy health system.
“It's a constant cycle…we may save a million on a contract, but spend more on a new product that comes along shortly thereafter," Cenac said.
Physicians tell ROi and Mercy that their loyalty is to certain products and not to the representative selling them. Despite this, the company has repeatedly seen physicians follow a surgical representative when they change jobs rather than staying with the product they previously promoted, Cenac said, which means ROi may need to spend time and money signing new contracts.
So, ROi has replaced company sales representatives with in-house device technicians in six of its hospitals, in a program that is eventually expected to be rolled out to the entire system. The direct-service model – which is also used at Loma Linda (Calif.) University Medical Center – means physicians still get the technical help they need on how to best use devices, but without the bias and upselling that comes from company technicians, said Cenac, ROi's executive director of medical-device implant solutions.
In replacing the sales representative with an individual who is solely responsible for technical advice and ordering, ROi has also taken the sales process out of physicians' hands and moved it to a contracting team that is able to more objectively evaluate new devices, compare them to competitors and ensure that they're being sold at a satisfactory price before presenting them to physicians for input.
“We're not necessarily keeping new technology out of physicians' hands,” Cenac said. “We just have better control over the process of how newer technology is received.”
The model may also help defray some of the expensive logistical fees that come when a sales representative is responsible for transporting and ordering products. During the pilot for the program at Mercy Hospital Springfield (Mo.), standardization of product used and in-house control of device inventory meant that the hospital could reduce its on-hand inventory by 54%, freeing up two rooms that ironically were converted into office space for the technicians.
ROi's in-house technicians have access to the electronic health record, diagnostic images and other information that third-party representatives wouldn't be able to access, which means they've been able to better plan ahead. That has improved OR workflows and helped surgeons make better use of procedure time, Cenac said.
The health system technicians participated in more than 1,000 procedures last year. In contrast to the traditional commission-based model that encourages company representatives to upsell, Cenac is actually looking at developing an incentive program that rewards his technicians for reducing the cost per surgical case.
“It flips the commission model on its head,” Cenac said. “That's really what we need to do.”
But industry leaders have argued that the traditional rep model isn't going anywhere. Commenting on a repless model offered by devicemaker Smith & Nephew, Stryker CEO Kevin Lobo said last year that physicians need company technicians if they intend to run a strong OR.
“Until these procedures are de-skilled, it's very hard to imagine [not having] the salesforce and the services that we provide in the hospitals,” Lobo said. “If you don't have that, the operating rooms just don't flow effectively and efficiently.”
A model like ROi's is certainly something the study authors would support, because it “increases the chances that therapeutic decisions are based on evidence rather than friendships,” Fugh-Berman said. Though physicians are trained to make decisions based on scientific evidence, they're only human.
“We're all susceptible to social psychology techniques that are used to manipulate physicians in different settings, and the relationships between surgeons and device reps can be very close,” Fugh-Berman said. “We're all susceptible to friendship and flattery.”