EXPENSIVE ADDITION More than half of an implant's total cost goes to the service and support provided by the vendor rep.

Looking for a way to cut implant costs and prevent new and expensive devices from entering your OR with little oversight? Try going repless. More facilities are buying implants straight from the manufacturer to remove vendor reps from the equation. Eliminating the middleman saves you money and gives your staff ownership in maximizing the profits of your joint replacement procedures.

Why go repless?
A large part of an implant's total expense — an industry insider says it can be as high as 60% — goes to the service and support provided by the vendor rep. This support includes everything from helping to prepare pre-op paperwork to managing the facility's supply of implants. "But some facilities and administrators are recognizing that they don't need or want the support," says Christopher D. Provines, MBA, the CEO of Value Vantage Partners and an adjunct professor of supply chain management and marketing sciences at Rutgers Business School in Newark, N.J. "So they're trying to unbundle those services and separate the implant from the rest of the package."

Typically, the bulk of vendor support is focused in the OR, where the rep gives the surgeon instruction on implanting the device. It's an important role, says Mr. Provines, but one that may be better filled by surgical techs or assistants who don't benefit financially from their relationships with surgeons.

Since different total joint implants tend to result in similar patient outcomes, the choice of which one to use often comes down to surgeon preference. That preference can be at least partially driven by the doc's relationship with the vendor and its rep, says Mr. Provines. And if that rep has a flashy new implant available, he may upsell it to the surgeon even if it offers little advantage over cheaper alternatives.

"From a purchasing standpoint, you realize more objective buying by going repless, because it's less about relationships and more about the quality, price and innovation," he says.

Those benefits are a few reasons why the Santa Rosa (Calif.) Memorial Hospital recently revamped its total joint program with the hope of eventually moving to a repless model. Though the move away from vendor reps is only one part of the program's overhaul, David Ziolkowski, MHA, chief operating officer of St. Joseph Health—Sonoma County, which oversees Santa Rosa, notes that administration sees it as a way to get implants at a low cost, while also better regulating which devices are used in the OR.

"There's a general concern that as reps develop relationships with surgeons, there's a constant pull to try the latest products or supplies that may not be necessary," says Mr. Ziolkowski. "We want to go through an evidence-based review to see whether the implants they offer are clinically superior, or if they're 99% the same with a significant mark-up."

Replacing the reps
While the benefits are certainly appealing, reps do play an important role in your joint replacement service line that can't be overlooked. "Whatever the rep was doing before, now someone else has to do it," says Mr. Provines. "You can either assign staff to take over, or bring in a third-party consulting company."

Though the repless model is still fairly new, several big-name manufacturers now offer implants both in a traditional sales model and in a "no-frills" repless format that features a limited selection of implants, says Mr. Provines. For facilities that opt for the stripped-down repless program, manufacturers may attempt to replace reps by offering new supply chain management technology. For example, Mr. Provines points to one company that recently started offering low-price implants along with an iPad app to track devices used in individual patients, a role traditionally held by sales reps.

He says surgeons often miss the OR support offered by reps when facilities go repless. That's something many third-party consulting firms are attempting to address by training surgical techs on how to use the implants, or by contracting out their own assistants at an affordable price.

Santa Rosa worked with a consulting firm to introduce surgical first assistants (SFAs) to its total joint cases. SFAs are mainly physician assistants and nurse practitioners who are trained and contracted out by the consulting company to help surgeons perform total joint replacements. Unlike a rep that cannot touch the patient in the OR, SFAs are allowed to be hands-on and help place the implant or use tools as requested by the surgeon. Since the introduction of the SFAs, Mr. Ziolkowski says the joint program has seen a major increase in OR efficiency, resulting in a cost savings of $250,000 in the first year alone.

Vendor-physician relationships may go back years, which can make the repless model a tough sell to your surgeons. But a SFA is able to take over a rep's responsibilities in a practical and affordable way, says Mr. Ziolkowski, making it a "win-win" for you and your docs.

In addition to offering an extra set of hands, Mr. Ziolkowski says his hospital got physician buy-in by letting the orthopods take an active role in the OR overhaul, even asking them to narrow down which vendors and supplies the hospital would use. "They helped to drive the priorities of the program," he says. "I took a step back and let them self-govern and manage themselves, and so far it's been very successful." OSM