Tip Your Reps: The Service Is Worth the Price

My first job with a real paycheck was bussing tables at Dino’s Italian Food in west Denver. To supplement my $1.35 per hour base, I hustled: clearing tables, cleaning highchairs, and filling water glasses for a portion of tips from the waitresses. Nearly 50 years later, I still believe that superior customer service deserves generous recognition. Yet tipping requests now surface in surprising situations (appliance repair, grocery stores, even self-serve kiosks), and adding a tip before the service completely uncouples the relationship to quality. Suddenly, tipping has become a source of anxiety for me!

Managers of orthopaedic service lines may experience similar anxiety over implant costs. Most hospitals contract with a narrow network of vendors to control costs, but a recent study noted that for primary total joint arthroplasty (TJA) Diagnosis-Related Group (DRG), implants represented 43.6 percent of the total hospital cost; for a revision TJA DRG implant, that number was 55.8 percent. Research and development drive some of the continued rise in implant prices, but one study estimated that 40 percent of orthopaedic implant costs can be attributed to sales and marketing. Is that a service charge worth paying?

The value added by industry reps
The editorial theme for this issue of AAOS Now is industry relationships. Orthopaedic implant distribution can involve complex, multi-tiered organizations, but I will focus on the person we know from direct contact in our offices and ORs: the industry representative.

These “reps” are sales professionals who develop relationships with surgeons and promote new products applicable to our practices. Most surgeons recognize how a good rep helps the scrub technician manage the back table, during setup and the actual case. A common model used by device manufacturers is to assign reps to specific institutions, allowing them to build relationships with staff and become familiar with the resources of a given OR. The portmanteau “repulator” speaks to the dual role a rep can play, not only assisting with the equipment but also supporting the circulator. It certainly helps to have someone in the room who knows where the arcane retractors are stored when you have the ophthalmology team in your room!

Teaching institutions benefit from cross-pollination of ideas via residents, but in a community practice, my best reps added that value by sharing tricks and recommendations among surgeons, even beyond their specific devices. For example, unknown to me, the OR had obtained a new wedge that easily facilitated the semi-lateral position needed to access the lateral ankle. My 6’4″ implant rep must have felt guilty, unable to help as two women struggled to position a 250-pound patient. “Hey doc,” he offered, “Dr. S uses this new foam piece. Do you want me to grab it?” I wondered why the circulator had not suggested it, but the rep had probably been in many more ankle cases than she had.

The rep’s role behind the scenes
For the surgeon, the expectation is the right product at the right time for the patient. More cases moving to the ambulatory surgery center (ASC) setting eliminates the deep bench of implants and surgical tools available at a large hospital OR, creating a challenge that requires meticulous planning for the rep. Just as a surgeon goes into a case with plan A but also has plans B, C, and D, one rep with whom I spoke noted that he always queries to “avoid surprises and appease the ortho ‘gods.’” A rep confirms with the OR the day before, arrives ahead of the surgery, and returns the following day to recover processed trays. For those handling trauma lines, their call schedule can be worse than a surgeon’s. Recognizing that even for elective cases surgeons work outside normal hours, most reps make themselves available 24/7 to their surgeons.

Most large manufacturers of orthopaedic devices require rigorous training for their sales reps. Most have at least an undergraduate degree, then train extensively on their products prior to shadowing established reps in the OR. To ensure knowledge, new product lines have online modules and in-person training with testing to ensure proficiency.

Is it worth the cost?
At a time when orthopaedic practices struggle with rising costs against stagnant or declining reimbursement, implant prices can feel exorbitant. However, the profound technology advances in orthopaedic implants over my career have also translated into faster, easier surgeries with improved patient outcomes. The reps with whom I spoke noted that 6 to 8 years ago, cost was rarely discussed if a surgeon wanted a product, but now requests for quotes and negotiations are common even at ASCs. Use of generic implants has been promulgated as a cost-control option in routine cases, but consider that additional trained OR staff may be needed to fill the role of the rep, and alternative implants may need to be on standby if a case takes an unexpected turn.

Compensation models for reps vary, but base plus commission predominates. The commission aspect can raise concerns over motivations for the industry rep to promote expensive implants over traditional ones that could offer the same outcome. Decades ago, at the large managed care system where I started my career, these concerns led to prohibition of reps from the OR. However, that policy vanished, suggesting that ultimately the value equation favored the rep.

My conversations with reps from various industry partners were enlightening and included advice on how surgeons can optimize that relationship (see Sidebar). Certainly, these detail men and women contribute to the cost of devices, but compared to yet another hospital administrator, I find their service deserving of a small percentage of the healthcare dollar. I appreciate the occasional bottle of wine or baked goods from a patient, but considering that surgeon reimbursement is not even keeping pace with inflation, I suspect payers would balk at adding an 18 percent service charge to claims. As covering practice overhead gets more challenging, is it time to put the tip jar by the front desk?

Alexandra E. Page, MD, FAAOS, is a foot and ankle specialist in private practice in San Diego, California, and the deputy editor of AAOS Now.

References

1. Fang CJ, Shaker JM, Ward DM, et al: Financial burden of revision hip and knee arthroplasty at an orthopedic specialty hospital: higher costs and unequal reimbursements. J Arthroplasty 2021;36(8):2680-4.
2. Miner HR, Slover JD, Koenig KM: Price transparency and consumer perceptions of generic and brand-name implants in orthopaedic surgery. Arch Bone Jt Surg 2022;10(9):791-7.
3. Pean CA, Lajam C, Zuckerman J, et al: Policy and ethical considerations for widespread utilization of generic orthopedic implants. Arthroplast Today 2019;5(2):256-9.

Five things industry representatives wish orthopaedic surgeons knew

1. Review plan A for your case with the representative, but also mention alternatives so they can be prepared with products you could need for plans B, C, and beyond.
2. Canceled or changed cases are frustrating for everyone; ask your office/ambulatory surgery center to include the representative in the communication network.
3. A little prep work goes a long way: Representatives are happy to demo a new product, review videos, or even do a lab case with you before showtime in the OR.
4. Honesty is best: If you do not think you will use the representative’s product, be straightforward and save everyone time.
5. Know that it is not just OR staff members who make things happen. Invest an hour in meeting the sterile processing department staff. Your effort may be rewarded when sterile processing department staff move your urgent processing to the front of the line!