WORTH THE EFFORT Rep-less arrangements may lead to clinical savings that surgical facilities can pass on to patients.

Medical device reps have long played a vital role in the OR by advising surgeons on implant usage during total joint cases, but something's wrong with this picture when vendor reps make more than the physicians they're assisting. A growing number of facilities have replaced vendor reps with highly trained in-house techs. The new approach is called "going rep-less." Is this staffing model as promising as it sounds?

To find out, we talked to leaders at Loma Linda (Calif.) University Medical Center and Wayne County Hospital in Corydon, Iowa, about their decision to go rep-less. Represent-atives from implant manufacturers no longer have a permanent place at the surgical table in those facilities, and the bottom line may be better off because of it. By going rep-less, you work directly with the implant manufacturer, meaning you pay no costs associated with "rep services." Because you're paying only for the implants, you should be able to significantly reduce overall ?case costs.

How? By turning the supply chain on its ear. Third-party companies offer to provide your facility with FDA-approved implants directly or connect you with a manufacturer of generic implants. Cutting out implant manufacturers bypasses pricier options inflated by the costs of marketing, distribution and managing a sales force. Companies following this model will also train and certify surgical techs and supporting OR personnel on site to perform the functions traditionally handled by reps.

Some of the companies in the space suggest they can reduce a facility's cost per implant by as much as 80%. Daren Relph, CEO of Wayne County Hospital, can't confirm that number, but says going rep-less has helped his hospital create a more cost-competitive joint replacement program. Wayne County started down the rep-less road about 3 years ago after key implant vendors refused to negotiate on price. About that time, a company came calling with a direct-purchasing model to cut implant costs and train OR techs to assume the duties traditionally handled by vendor reps.

Mr. Relph wanted to know what the company's training program involved and what kind of support the company offered after the initial educational sessions were completed. "In very short order they had the techs trained to be on par with the reps that had been coming in through a traditional program," says Mr. Relph.

Wayne County Hospital now does the majority of its total joint cases using the rep-less model, though some complex procedures still require assistance from implant manufacturers. "We don't do a lot of revision work, so when we do, it's good to have reps involved," says Mr. Relph. "If we need a specific part or implantable device that we don't carry in inventory, we want them in the room."

VENDOR SUPPORT
Common Roadblocks To the Rep-less Model

EXPERT EYE Reps bring plenty of expertise to the OR and some level of comfort to the surgical team during complex procedures.

Considering the potential upside of doing away with implant reps, why aren't more facilities deciding to cut out the middleman? There are a few reasons why facilities might be hesitant to take aim at one of surgery's sacred cows.

It's controversial. That's an understatement, admits Gary D. Botimer, MD, of Loma Linda (Calif.) University Medical Center. Those who spearhead efforts to go rep-less may face an uphill climb, he says. He offers this caveat: Expect "phenomenal" resistance from implant vendors, who wield a great deal of influence with surgeons.

Physician opposition. Younger, less experienced surgeons may feel more comfortable with the vendor rep in the room, but most surgeons just want to know someone will fulfill that role, says Daren Relph, CEO of Wayne County Hospital in Corydon, Iowa. "As long as the tech in the room is up on the training, the surgeons don't recognize a big difference," he adds.

Other surgeons may oppose the model for a different reason, according to Dr. Botimer: They don't want to risk forfeiting any "secondary gain" as a result of partnering with key implant vendors.

Vendors have value. Kelly A. O'Brien, COO of Medarva Stony Point Surgery Center in Richmond, Va., says her facility relies heavily on implant vendors when they have a problem with a piece of equipment, when they bring on a new surgeon, or when they need a device very quickly. The close relationships the center has with vendors also open up opportunities to negotiate on pricing and service contracts.

Vendors also provide a valuable safety net, of sorts. "If you've chosen to go rep-less, where is the relationship if something breaks down?" says Ms. O'Brien. "If there's an urgent need, or if you're in the OR and something's malfunctioning, you're an island. It's you against the world."

Cost considerations. The expense to train OR staff to assist surgeons can be significant and may eat into potential cost savings the rep-less model provides, says Dr. Botimer. Also, performing procedures without the aid of an experienced rep could extend case times, especially early on. Lastly, if going rep-less causes any spikes in negative patient outcomes, the resulting costs would likely offset — or even surpass — any savings on the implants themselves.

— Bill Donahue

Down the rep-less path
Gary D. Botimer, MD, chair of orthopedic surgery at Loma Linda University School of Medicine and an orthopedic surgeon at Loma Linda University Medical Center, is regarded as one of the pioneers of the rep-less movement. He led the medical center down the rep-less path starting in 2013.

"Most routine equipment in total hips and total knees has not changed much over the years, and I've seen no studies to show any particular implant is providing better patient outcomes in most cases," he says. "There's also the issue of cost. Two-thirds of the cost of these products is associated with things like marketing and staffing and managing a sales force, not the actual manufacturing."

VENDOR VALUE Manufacturer reps help manage needed supplies and provide a valuable safety net in cases of urgent need.

Loma Linda contracted with an outside firm to teach 2 of its most proficient OR techs how to provide support for surgeons during joint replacement procedures. The medical center does as many as 90% of primary total knee and total hip cases using the rep-less model.

"You have to do the training and buy the [implant] inventory, and it takes a year to recoup those costs," he says. "Because we have our whole inventory on the shelf, there are no problems with implants coming in unsterile. You have to give your people the dedicated time they need to do the job right, and you'll face some increased costs there, but it's minimal compared with the savings."

Dr. Botimer says implant costs have dropped considerably under the rep-less model — from a high of more than $4,000 per implant down to $1,500 and $1,900 for total knee and total hip implants, respectively. These savings could be just the tip of the iceberg at Loma Linda, says Dr. Botimer, who notes that similar savings are possible in other specialties such as trauma and spine.

Loma Linda currently works with 2 implant vendors: 1 for total hips and 1 for total knees. Cost, though important, was just one factor of vendor selection. "We tried several brands, and we didn't pick the least expensive implants we could find," says Dr. Botimer. "In fact, we're paying twice as much as we could have paid. One of the main reasons we went this way was to maintain quality patient care."

Gaining momentum
Although vendor reps will remain permanent fixtures in most ORs, the rep-less route seems to be gaining steam. Many surgical facility leaders, even those who consider vendor reps invaluable, are intrigued by the model's potential cost savings. At the same time, some of the industry's most established implant vendors have piloted rep-less models as a way to reduce implant prices and lower their own operating expenses.

Dr. Botimer believes going rep-less is morally imperative, especially when the model is focused on slashing healthcare waste instead of cutting patient-centered services. "You need very strong physician champions and administrative leadership to pull it off," he says. "You also need really thick skin, because you'll be taking heat from a lot of directions."

So, is it worth all the effort? "Absolutely," says Mr. Relph. Although the rep-less model may be a fringe movement at the moment, he believes it will gain more adopters going forward. "As payers continue to compress payment on virtually everything we do, working to create better value is the only way to continue to be here and fulfill our mission," says Mr. Relph. "It's good business from our perspective, and it's a value proposition for consumers and payers, too."

"Sales reps do an excellent job, but you're often paying them more than the surgeon is paid to take care of the patient," says Dr. Botimer. "That's not the best use of healthcare dollars." OSM