Originally published in EP Lab Digest May 2017
Those of us who choose and implant medical devices shoulder responsibilities that extend well beyond typical patient care. Device implant decisions carry lifelong impact for our patients, but they also have major implications for our staff, hospitals and the vendors with whom we partner. Doctors need to use a principled approach to get these decisions right. Given the stakes involved, there are few areas in doctor/industry relations that carry more meaningful impact than pacemaker and ICD selection.
Early in my career as an electrophysiologist implanting cardiac rhythm devices, I developed a set of principles in vendor and model selection, and these have served me well in almost 20 years of practice. I’ve also learned that it is critical for us to fight to retain control of these implant decisions, and make them in a disciplined and ethical fashion. We, the front line caregivers, are uniquely qualified to best serve our patients’ interests. By responsibly taking charge of vendor selection, we are best suited to maximize benefit and value to both our patients and the healthcare system.
Device selection must carry an inviolable first principle — the patient gets the appropriate device for his or her indications and specific circumstances. All negotiation occurs in the gray areas in which there are alternatives. Pacemakers and ICDs should never be treated as interchangeable commodities supplied to us by the directives of hospital purchasing departments. Doctors, for their part, should not make implant decisions based on personal whims, friendship-based loyalty or self-serving deals. For these complex devices, doctors should fight for multi-vendor arrangements with MD control over the decision. Healthy competition elevates service and promotes innovation. Using multiple vendors also amortizes risk of product recalls across the practice, and gives our patients a broad array of options. How many vendors should serve us? That’s a question worthy of discussion, but I’d argue “one” is the wrong answer.
At the point of product decision, a doctor should consider four principles before choosing the device or vendor: product, technical support, price, and value-added service. The device decision hinges upon a balance of these factors.
It is intuitively obvious and principled that MDs should implant the best product for their patient’s needs, but that need not always be the top tier model from the doctor’s “favorite” vendor. Given the complexity of pacers and ICDs, model selection can prove to be a challenging decision fraught with tradeoffs. Each patient has unique needs. One patient’s priority may be a particular diagnostic tool; another may most benefit from maximal battery longevity or ease of remote follow-up. Reliability is important to all, but difficult to predict. The “perfect” device today may be next year’s recall. By rotating among vendors, the doctor reduces overall risk to their patient population. Doctors need to work hard to educate themselves on all of these tradeoffs and choose responsibly. Vendors need to know that if they create great products, this will influence their share of the business.
The requirement for lifelong technical support distinguishes cardiac rhythm from most other other medical devices. Healthy MD/vendor relations are critical for optimal patient care, even in hospitals without direct in-hospital rep support. Many industry models exist for device technical support in the office and hospital. Each of these models has merits, but all must be handled within ethical and legal bounds. Other expensive medical devices such as coronary stents or valves do not have this lifelong support need, and hospital purchasing departments need to appreciate this critical distinction as they consider the value of their purchases. If a doctor makes it clear to the vendor that they must earn their business each day, they will be rewarded with exemplary service. Doctors who treat their reps as “box openers” will have their negative expectations reinforced with substandard support. In our system, we treat industry reps as partners, and consider them as part of the hospital implant and support team. The quality of their work becomes a factor in device implant decisions. The vendors’ rational response is to compete on these terms, and our patient’s realize this benefit.
Simply stated, we doctors need to seek the best value for our patients. Because device price decisions typically do not impact the MD or patient directly in the US health system, it has been historically tempting for doctors to ignore cost. Doctors do this at their own peril. If a vendor recognizes this blind spot, the MD may be leveraged into an arrangement unfavorable to the hospital. This will not be sustainable. Hospitals will protect their financial interests and seize control from price-insensitive physicians. To maintain choice, MDs need to directly insert themselves into hospital pricing discussions, and also make it clear to the vendors that price is important to them. We need to have the discipline to walk away from unfair arrangements favoring the vendor. On the other hand, doctors who are complicit with aggressive purchasing departments and consultants in a “we win/you lose” race to the bottom will eventually find they get what they pay for in loss of product, support, and/or service. They will also find those unhappy vendors less receptive at next contract negotiation.
Value-added service that deserves vendor recognition benefits our patients, not the doctor’s wallet or ego. The key here is for all to understand this distinction. When an industry rep goes the extra mile to support the healthcare mission, these actions should be noted. Examples might include patient counseling, office staff education, and MD access to experts. Indirect benefits such as research and consulting opportunities might benefit the overall mission, and could be considered in proportional terms, strictly adhering to ethical and legal standards. Doctors need to guard against being “bought” by industry. Nothing a vendor does to earn business should be construed as an overt or potential quid pro quo.
Key to making all of these vendor relations work is transparency and consistent follow-through. Vendors need to know the rules, and doctors need to enforce them. If a vendor slips in their service responsibility, they need to understand this may affect their share of the business. If a vendor has an exciting new product, the alternative vendor may be able to compete on price or support. The doctor needs to respond to these levers in a predictable fashion.
As doctors, our primary mission is to provide high quality healthcare to every patient we see. Responsible device selection must serve this mission. Vendor selection must be a transparent and principled process. Once it is determined the array of device options available to a given patient, the doctor can apply the four principles discussed to finalize the decision. If the vendors understand the rules of the playing field, natural competition on product, service, price, and support will create the optimal environment for doctors to deliver care.