In the operating room, surgical masks and matching scrubs can make it hard to tell who is who — at least for outsiders.
A patient may not realise that salespeople on commission are often in the operating room and at times advise clinical teams during surgery.
Who are these salespeople, and why are they there?
These sales reps often will be working for a medical device company such as Stryker or Medtronic. Surgeries in the field of orthopaedic trauma and cardiovascular procedures, often require the implementation of artificial joints or other medical hardware that has been manufactured by sales reps company.
The answer to why6 they are present in the operating room differs depending on who it is that you ask.
Those who condemn sales reps being present say it is so a sales rep can strengthen relationships with particular surgeons, therefore, persuading them to choose a particular brand or artificial joint, stent, or pacemaker over a potential competitor.
However, sales reps argue that their presence is needed as they are experts on devices and the accompanying toolkits. These toolkits often include hundreds of wrenches, screws, and all other types of hardware to aid device installation. Device reps have often observed surgeries with a particular piece of equipment and anyone surgeon. Having that depth of experience can be helpful, especially if the device is new or has been recently upgraded.
"I can't keep my socks together through the dryer. You can imagine trying to get 100 pans or 300 pans of instruments all set up correctly," - Michael Christie of Nashville, hip replacement specialist.
Even though device reps have been attending surgeries for many years the practise is coming under heavy scrutiny. There has been expediential growth in device-dependent procedures such as total joint replacement, and insurers have had to start to crack down on health care costs, often telling the hospital that they will only pay a fixed price known as the “bundled payment” regarding certain medical procedures such as hip and knee replacements.
The cut down of insurance backing has meant hospitals have had to look at the price tag attached to these new medical devices and the sales reps attached to them pushing the latest models. Hospitals are "starting to figure out what these reps make for a living. They feel like they're making too much money, and I think that's why they want them out," – Brent Ford, a former sales rep who now works for Nashville-based HealthTrust, a firm that handles contracting and purchasing of supplies like hip implants for 1,600 U.S. hospitals.
Sales reps are far more likely to have studied business than biology however, they train for these jobs as if they were going to have to perform these surgeries themselves. An education centre in Colorado teaches future reps how to saw off a hip bone and implant an artificial hip.
Sales reps corporate training now often involves topics such as cadavers to help them get used to unsettling sights that they will have to see and hear regularly in the operating rooms.
"Before we're allowed to sell our products to surgeons, we have to know the anatomy of the body, go through tests of why physicians use these types of products and how we can assist in surgery," says Chris Stewart, a former rep for Stryker.
Large companies such as Stryker have developed detailed policies for their reps regarding behaviour in operating rooms. Some hospitals have banned selling in operating rooms and only allow reps to be present to provide support for surgical cases.
Many still maintain that reps are still useful in operating theatres in the smooth running of the procedure. For example, delivering trays of ancillary tools making a busy surgeon a steady customer.
Keeping up with technology
It is becoming increasingly difficult for hospital staff to keep up with the constant design changes for artificial joints and other implementation devices and or systems. The speed of these innovation causes levels of concern for some researchers. The biggest concern is safety, including the occasional violations of sterile protocol. As part of research studies, using anonymous interviews, reps said they are instructed to always push the latest, most expensive products, even when the previous version is more proven.
The rise of surgical costs has been the more prevalent reason for not wanting to welcome reps into the operating room. The effect they have is hard for hospitals to quantify, but hospital executives now have a new incentive to keep reps away as insurance companies have changed their reimbursement formulas.
In 2016, the US government-run Medicare programme began to change in how it pays hospitals for hip and joint replacements from a traditional billing-for-cost model to a fixed-dollar amount for each surgery. This was a cost-control move as a joint replacement has become the main reason for inpatient hospitalisation for Medicare patients.
Hospitals are starting to feel the pressure of these new payment caps. Hospitals are looking at costs and thinking “I want to understand everything that drives cost in my OR.” This is causing the hospital to look at sales reps and realising the cost associated with their presence. However, removing all sales reps may also have hidden costs.
Many of the tools needed for surgery have been meticulously placed often by reps. Logistics is a huge part of a sales rep's job. Logistical roles are filled by the manufacturers instead of hospitals in recent decades, leading reps to be the most trusted in the room being their first call when scheduling to ensure they are ready to move forward.
Surgeons may also have their own financial ties to the manufacturers collecting royalties for helping in the design process of new implants. As of 2013, these payments were made to be publicly disclosed showing surgeons being paid over $100,000 to manufacturing companies alone in a single year.
A spokesperson for the industry trades group defends the close relationship to improve products and gain hands-on training for surgeons.
"Those are two areas where it's key to maintain a close, collaborative relationship, with the appropriate ethical limitations," says Terry Chang, associate general counsel for AdvaMed.
Filling a personnel gap
Overall clinicians are happy to have reps in the room.
"You say 'sales rep,' " says Marley Duff, an operating room manager at TriStar Centennial Medical Centre. "I look at them more being somebody that's expertly trained in their field to provide support for the implants that they happen to sell.”
Hospitals are reluctant to remove in fear of irritating their surgeons who in a typical circumstance do not work for a hospital directly and could move their cases to an alternative institution. A hospital that has experimented with going “rep-less” have done so in a noticeably quiet manner and have had to hire additional staff to pick up the slack.
One of the first in the country to try, Loma Linda University Health, 2015 boasted of reducing costs for total knee and hip replacements by more than 50 per cent by going rep-less.
However, a hospital spokesperson has spoken out saying that the medical centre has abandoned the effort, though she refused to discuss why.
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