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Sales reps for surgical hardware companies are becoming a common presence in operating theatres – selling medical devices, sometimes without the consent of unconscious patients. By Mike Seccombe.
Sales reps have infiltrated operating theatres without patient consent
They are not doctors. Despite this, they are ubiquitous in hospital operating theatres in Australia, alongside surgeons as they install new hips, knees, heart pacemakers and other pieces of medical hardware.
There is no requirement that patients consent to them being there. Most patients are unconscious when they arrive. They are sales representatives for medical technology companies.
Kerin Fielding, president of the Royal Australasian College of Surgeons, says they have become an indispensable part of the process of installing medical prostheses in patients – providing the various necessary bits of hardware and medical supplies, advising on and sometimes assisting in procedures.
“I’m a rural orthopaedic surgeon. I do hip and knee replacements,” she says.
“The reality is that I wouldn’t go into theatre without one at the moment ... I don’t know any surgeons that would say that they weren’t an integral part of the team.”
Fielding says that over the past decade, and particularly since the Covid pandemic, “the whole landscape has completely changed”.
She cites a number of reasons for this: the added stresses of being increasingly on-call, longer shifts, staff shortages and a more itinerant medical workforce, a resultant reduction in the “skill base” of hospital staff and the “expertise of a lot of our operating room nurses”, and the greater range and complexity of medical devices being used.
“This technology is quite advanced. And we want people that understand the equipment and we don’t want any mistakes,” she says.
“I think that you would really find it very hard to find an orthopaedic surgeon or a spine surgeon, for example, doing lots of implants – any surgeon doing a lot of implants – that didn’t want to have the device assistant available.”
Rachel David, chief executive of Private Healthcare Australia (PHA), the peak body for medical insurers, does not call these medical technology industry representatives “device assistants”. They are first and foremost salespeople, she says, and their primary purpose is to make money for their employers.
“Everyone else there, their first duty of care is to the patient,” she says. “But for that person, their duty of care is to the company.”
To underline her point, she provides The Saturday Paper with copies of recent recruitment advertisements for big device suppliers.
“Are you an energetic target driven sales representative?” asks one, which seeks applications from people with “a proven track record of influencing sales, whether this is in retail, hospitality, customer service or another sales role”.
The job would involve building “strong working relationships with key hospital contacts to maximise business opportunities”.
A successful applicant would be “[p]resent in the operating theatre to assist surgeons and theatre staff to maximise the use and application of products”.
According to PHA, there are almost as many “frontline” sales and marketing reps as there are surgeons: about 5000, compared with about 6000 registered surgeons. While they don’t earn the same incomes, they are still well remunerated. Average base salaries, says David, are in the $120,000 to $140,000 range, and often come with other perks.
Another of the ads she provided included a $22,500 car allowance, as well as “generous commission incentives”.
While most recruits to the business come from a health or science background – that ad preferred “experienced Scrub Nurses, Physiotherapists, Chiropractors, Osteopaths, Exercise Physiologists, Podiatrists or Paramedics” – David and the PHA cite representatives as saying the job had attracted former police officers, accountants, hospital porters, photocopier salespeople, former athletes and personal trainers.
In fairness, it should be noted the sales representatives get training from their employers. One company, according to a briefing note provided by the PHA, had offered Australian recruits a six-week intensive course in the United States that included schooling in anatomy, full product training as well as sales training, “including in-theatre selling role play”.
The insurers’ concern about the proliferation of marketing reps within the hospital system is not so much about their qualifications as it is about the ethics of them being there at all. They are also concerned about the usefulness and safety of the products they are paid to sell and their cost to the health system.
As to safety, David points to examples of products that have been pushed by marketers, and adopted by surgeons, that have been found to have no clinical benefit or to be harmful.
The worst example, she says, was pelvic mesh, “which was only ever tested for use in hernia repairs in men”.
“It was subsequently very heavily promoted for pelvic organ prolapse of women, for which it wasn’t properly tested. There was a lot of encouragement from reps for surgeons to try this, and it turned out to be a disaster.”
Pelvic mesh was ultimately withdrawn from use in Australia, and led to the largest product liability class action in Australian history, with the maker, Johnson & Johnson, having to pay $300 million to women who suffered chronic pain, psychiatric injury and internal injuries from the product.
More recently, the insurers have been campaigning against the use of electronic implants called spinal cord stimulators, used to treat chronic back pain. They want the devices removed from the market. These devices cost between $60,000 and $75,000 and fail about 40 per cent of the time. Spinal fusion surgery, David says, also is ineffective and can cost more than $100,000.
By law, private health insurers are required to pay a benefit for a product if it is on the federal government’s Prostheses List, which covers thousands of items and sets a price for each.
The PHA’s complaint is the set price is too high. Device makers run on inordinate high profit margins, even as they compete to sell what are in many cases essentially generic products.
“We’re lucky in Australia because, for joint replacements, we’ve got a registry which shows very clearly which knees, for example, get the best outcomes. But unfortunately, some of the ones that get the worst outcomes are actually priced higher because of historical pricing errors.
“Australians still continue to pay 30 to 100 per cent more for generic medical devices than any other country in the world.”
According to David, these costs are a major driver of health insurance premiums.
It appears the federal government has come to accept this. Average prices were reduced by 20 per cent last year – and are to come down another 20 per cent this year.
“They have slowly let the air out of the balloon and reduced prices to be more in line with global market prices,” David says. “This is something that should have happened years ago. Ideally, we would have moved away from list pricing and to bundle pricing years ago.”
The government has also made moves to control health insurance premiums. Last month, Health Minister Mark Butler announced he had approved an average industry premium increase of 3.03 per cent – well below the general inflation rate of 4.2 per cent.
He noted that was a long way short of the increase in other insurance products, which was about 17 per cent in 2023.
Then again, the private health insurers can afford it. According to the government, industry profits rose 110 per cent last year, from about $1 billion to well over $2 billion.
Much of this came from investing their members’ premiums at the current high interest rates. Even if you strip out this contribution to their profitability, the figure was still over 50 per cent.
The Australian Medical Association noted the proportion of hospital insurance policy premiums returned to patients in the form of benefits for hospital treatment fell to 81.6 per cent in 2022-23, down from 88.02 per cent in 2018-19.
Bottom line, even as they squabble about costs, all parties are doing well in the health industry: surgeons, sales reps, insurers, device manufacturers.
All except patients. According to data released by the Australian Prudential Regulation Authority in February, in the December quarter last year out-of-pocket payments for hospital episodes increased by 10.2 per cent compared with the same quarter for the previous year.
Those same patients are also in operating theatres where – without their knowledge – sales representatives are upselling their surgeons on spinal cord stimulators and other medical devices.
This article was first published in the print edition of The Saturday Paper on April 20, 2024 as "Theatre ticket".
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