Thursday, February 18, 2010

Low Growth, Pricing Pressures, Government Cutbacks? What the Hell is Going On?

Why is everyone complaining about the state of healthcare in the U.S. ? A declaration must be made that the state of the healthcare industry is alive and breathing. The patient has been misdiagnosed. It's time to take 'em off the ventilator, and get back to doing what we do best, delivering the most advanced and complex healthcare delivery system in the world. Now I didn't say the best, I said the most advanced and complex.

Let's take a look at hospitals. On a recent business trip, TSB was mesmerized as to how many hospitals were adding new additions, new parking lots, new specialty centers, and expanding patient services to make their respective hospital the publics facility of choice. Marketing, marketing, marketing! TSB thought that healthcare was in trouble? It was even funnier when the Materials Manager/Purchasing Director was requesting that the company comp the facility free product so that the surgeon could evaluate the technology intra-operatively, in addition to having the product assessed by a product evaluation committee. So in my politically correct manner, TSB asked the purchasing director if the hospital's intent was not to charge the patient, nor their insurance company for utilization of the product? Duh!!!! In my most politically incorrect manner, I asked the Purchasing Director if I needed emergency care would the hospital allow me to evaluate their services by having whatever my initial medical needs be, addressed for free? What is it about hospitals and the "business people" that work in them that make us wonder whether they are not the source of the industry's problem? Maybe part of the problem is that we have too many MBA's spewing their theoretical BS in order to justify their existence? I thought we lived in a free-market economy. I thought competition was good, and that free-markets would determine the winners, and sort out the losers? I thought that the Purchasing Directors job was to negotiate and purchase product at the best available price in order to minimize cost, rather than "shake down" a company? Today, we hear that facilities on the West and East Coast are beginning to initiate a policy where they will only allow three major vendors to be used at their facilities. When did the purchasing director become an integral decision maker in what the physician can or can't use? If the excuse that we hear is that there are too many companies to deal with, maybe it's time that we start shutting down some hospitals considering that there are too many of them that offer the same services? Maybe, this is why healthcare is so out of control, there are too many cooks in the kitchen stirring the gravy.

Let's look at Physician Owned Specialty Hospitals (POSH). TSB thought that physicians were all in an uproar that they weren't making enough of money. Yet, in various pockets across the U.S., POSH (and I'm not talking POSH SPICE) facilities are opening with the justification that if you become a specialty-centric hospital, the hospital will be run financially efficient with better outcomes. If Physicians are complaining about reimbursements, where are they getting the capital to build some of these facilities? Obviously, any facility that focuses on providing care to one or two specialties, i.e. Orthopaedics or Neurosurgery can be profitable when you pick and choose the patients that you opt to operate on, while sending the patients that do not have coverage to your local public or non-profit hospital. Aren't you sending the message that its better for the government to take care of these people? So what's the beef? TSB, wants to know what our readers have been experiencing in the field and how it's effecting your ability to sell product?


  1. Fantastic commentary.

    Keep it up TSB

  2. Preach on MSM! I can't begin to tell you how many times the hospital that according to had net revenues of $107,995,718 in 2009 request free product because they are going broke.

  3. The issue is that there is no shortage of campanies willing to cower to every whim of the hospital. Free sets, loss leader pricing, byzantine contracts - there are plenty of companies out there, small and large, that are willing to play ball no matter what.

    This is one example of why the ongoing hypercompetition in the spine market is a bad thing for the industry as a whole. It helps to further empower hospitals and purchasing managers to get away with shenanigans that would otherwise not be tolerated.

    This is why there must be consolidation in the industry. Fewer, but stronger, players could tip the balance and benefit everybody. Consolidation, however, is difficult and expensive. So far no one has been willing to step up to the plate and buy out the smaller players to create a larger, more politically powerful entity. Until that happens, it will continue to be a "race to the bottom" where everyone loses.

    So here is my prescription to cure the spine industry:

    I would bet that for less than the cost of Medtronic's (admittedly absurd) Kyphon acquisition ($3.9B) in today's market, you could buy and consolidate every decent independent U.S. spine company.

    At the same time, FDA can be lobbied to tighten the 510(k) process for spine products and raise the bar of entry for new garage companies.

    The consolidated company will pick up a ton of patent rights in their acquisitions and will now have the fincinces to enforce them agressively - again to keep out the upstarts.

    Now will anyone have the guts and to do it, or will we continue to all ride the sinking tide downward?

  4. Spine Sales (3:43pm): Keep in mind that revenue does not equal profit nor cash flow positive.

    TSB: I think you're implying that most hospitals are squeezing device prices and piling the extra profit into their Scrooge McDuck-style money silos. Most hospitals have razor thin margins and a third aren't even turning a profit ( I find it funny how your definition of "free market" means anything that makes a Spine rep more money but doesn't apply to surgeons, hospitals, manufacturers, etc.

  5. That non-profit garbage is nothing but a total farce. It's also amazing to me how the most difficult accounts to deal with are those that have endless layers of useless bureaucrats who all believe they are better educated than the surgeons regarding what's best for the patient. The problem is these people have been awarded financial incentives to be the obstacles they are.

  6. So why aren't the hospitals profitable? I find it funny how you don't even know me, and you imply that I am only concerned with free markets and how they affect the spine reps earnings. I have always believed that physicians are underpaid for their craft, and have lobbied on behalf of physician reimbursements. Unfortunately, most physicians in general are bad business people witnessed by how mismanaged their practices are. But I also don't believe that physicians should be concerned about how much money I nor any other sales rep makes, considering that whatever they earn is not any of my business. On the other hand when you stick your nose into my business that's where I draw the line. There is a clear distinction those two points of view. I don't really care about hospitals squeezing me on pricing, I care about hospitals squeezing me for free product when they are billing the insurance carriers after getting comp'd for the free product. If physicians want to claim that they are good business people let them run a hospital that treats every patient equally regardless whether they have coverage or not and then they will find out how easy it is to be profitable. Thanks for your opinion and commentary, your voice like everyone else's must be heard.

  7. Just as the hospital can ask for free trial products, you're more than welcome to tell the hospital no. THAT is the free market at work, TSB. (I read your response several times and wasn't able to figure out what the "two points of view" are that you're talking about. Somehow you jumped from hospital profits to physicians being bad business people and sticking their nose in your business? I don't get it. Are you talking about PODs now??)

  8. I am responding to the multiple points made by Anonymous regarding hospitals not being profitable, my definition of free markets, and how it only applies to spine reps and not physicians. When I say "sticking your nose in my business, I meant why should a physician care how much I earn, when I really don't care how much they make. I am not discussing POD's.

  9. PS: I did tell them No in a very nice way without offending their ignorance.

  10. Just as you have the right to say no to the hospital's request, the hospital can say no to yours. Choice is the essence of a market-based system. The only real payor here (the hospitals) can ultimately choose what they will and wont pay for. A few private insurers will cover implant costs but many (including the biggest payor - Government) dont. Instead the hospitals get one fee out of which all expenses must come out. What will happen when this is also bundled with MD payments?

    One of the commenter talks about building horizontal monopolies as a cure for the implant industry. A) Monopolies are difficult to manage, lose their innovative drive, and most become inefficient overtime. B) Its very difficult, if not impossible, to take a commodity (like spine implants, trauma implants, and total joints) and turn it back into a unique product.

  11. But is it the hospitals choice to say no, if the physician wants to use your product? Choice is the essence of a free-market, but if your price is in line with the competition and you are not increasing cost, just because a surgeon utilizes the facility to perform their surgery does not give the hospital the right to take away the surgeon's freedom to choose. Purchasing job is to contain cost, it is also their job to deal with vendors, not limit vendors. I thought you believe in free-markets? Where in the chain of command did the hospital industry start thinking that a purchasing director should be shaking down a company for free implants. This is the essence of what we are fighting in the current battle. No different than the hospital forcing reps to pay a fee to sell its products in its facility, or have to register with Status Blue.

  12. MM,

    Status Blue and other "credentialing" companies are a cancer to the sales industry. Many will not guarantee or even affirm that all of the private personal data that you supply to them will be properly protected. I'm curious to your thoughts on these companies as well as if you believe some sort of restraint of trade lawsuit against facilities that demand you utilize these services would fly. Thanks.

  13. First of all, TSB believes that these credentialing companies are nothing more than a money-making scam by the hospitals and companies that attempt to initiate or enforce these programs. When in the past did the hospital have to be concerned with vendor credentialing? Didn't we always have to follow protocol? How many regulatory standards can we enact to the point of paralyzing the industry? Haven't we always been concerned with the patient's privacy and our own safety? And, what about our own safety? Everyone is concerned with violating the patient's rights, what about protecting us from the patient?

    First it was Blood Borne Pathogen Certification, then they were concerned about the patient's rights, then they wanted the companies to run criminal checks on our backgrounds, now we have to pay to get into the operating room subsidizing the cost of enforcing this platform. I think you get the picture. The system is out of control and needs to be dialed down, if we spent as much time and money are enhancing the delivery of healthcare in this country as we do legislating and enacting ridiculous guidelines, everyone would be better off. Just what healthcare needs more bureaucracy.

  14. We all have a choice in the matter as well. We can choose to work at one hospital or another. If a hospital unilaterally makes a purchasing decision against the wishes of the surgeon, that surgeon can take their business elsewhere. If a hospital is not being fair in its treatment of implant representatives, then those companies can do business elsewhere.

    What we are seeing, though, is an alignment of hospital-provider incentives. Either through gainsharing, physician ownership, or physician employment, this is becoming more common.
    Given that this combined physician-hospital entity is making purchasing decisions as the primary payor, it should not be surprising that they have leverage over a commoditized industry.

    One of the only truly innovative technologies is BMP-2. While many of us may not like the company that controls its distribution, this is one of the few products that is unique, works well, and is an improvement with data to support it. Not surprising that they can turn around and leverage the hospitals.

  15. (I'm the poster of 4:41 & 6:58)
    Yes, choice is usually a benefit of a free market, but free market doesn't mean you can have whatever you want. I WANT a chateau in the south of France, but France won't give it to me. Is the free market broken? A doc may WANT the $2k pedicle screw, but the hospital wants to reduce their costs. Given that the hospital, and not the doc, is buying the screw, the hospital is really the only one playing in the free market in this situation. As you've said yourself many times, there are a 100 screws in this commodity market; why should the hospital be willing to pay significantly more for the screw the doc likes (and, as you know, it's probably not the screw he likes as much as other factors -- most of which have little to do with patient outcomes)? And, this may surprise you, but I'm on the side that would benefit from higher screw prices. I just prefer to understand, face and adapt to reality rather than shake my fist at the sky and curse hospitals, docs and manufacturers as being unfair/unethical for doing the same thing I am (and you are) -- trying to make a buck.*
    * (Of course, within the constraints of patient safety, etc.)

  16. Hospital the ultimate payor??? I don't think so. DRGs are paid by insurance companies and medicare/medicade/mediCal. These dollars come from my insurance premiums and my taxes. Nice try, I used to work for a hospital. Full disclosure of ALL hospital employee salaries, bonuses, "financial arrangements", subsidies, endowments, and financial data should be FULLY disclosed at all hospitals. A poster made a great point earlier, the constant construction and upgrades cost millions. The money is coming from somewhere. If the government was smart, they would contract directly with implant companies and eliminate the entire DRG system. Your SMAT and VAT and whateverAT committees are a big joke. There is rarely anyone capable of understanding scientific data on your committees, and most are RNs with MBAs or just MBA's. Hospitals are corrupt.

    DOJ-Investigate hospitals (start with HCA, CHW, etc).

  17. Unfortunately, you are not reading what I wrote. I stated that as long as the product is not increasing the cost and is equivalent, why should the purchasing director deny a company the opportunity to do business at the facility? That's as bad as some insurance clerk denying a patient access to medical care when they are entitled to it. Besides, I don't shake my fist. Too much energy, I just move on to the next popt-o-call. Peace

  18. J Galt,
    I contend your point about the hospital being the only one playing in the so called "free market". Unless it's different in other parts of the country, the hospital only purchases the screws after they've been implanted. They can then mark it up 300 to 400% and immediately bill it to the insurance carrier or the patient. Since the rep delivers the implants the night before, the hospital never incurred any inventory carrying costs. I've seen this before when a patient comes back to the surgeons office with an itemized bill for 22K in pedicle screws & rods when I know I only charged them 6K for those items. It must cost the hospital a fortune to steam autoclave those implants!

  19. Yes, the hospital typically purchases the screws after they've been implanted, but presumably there is some type of agreement in place ahead of time that outlines pricing. I'm not following your point.

    What!? The hospital charges more than their costs!? They dare to make a profit? Say it ain't so! I hope you don't charge the company you work for more than enough to cover your gas costs. You make $100k you say? It must cost you a fortune in gas to drive sets around.

  20. "If the government were smart, they would contract directly with implant companies." Now, I hope that's something we can ALL agree is a terrible idea.

    (And I didn't say the hospital was the one ULTIMATELY paying the bill. Just the one paying THAT bill.)

  21. Making a profit isn't a problem for me as long as those doing it under the auspices of serving the community freely admit to it. The rub is that so many of these facilities are so called non-profit organizations that have some pretty sweet tax advantages. The free market for hospitals argument is BS in this state. No new hospitals can be built without the legislature approving a CON (certificate of need). Since the existing hospitals lobby like hell to keep any new ones from entering the market they're able to maintain the monopoly that they have. That ain't no free market slick. So your John Galt Atlas Shrugged business philosophy doesn't apply here. You and the Hospitals are the "looters" when you're up-charging implants 300 to 400% for keeping them on your shelves for 10hours.

  22. First: I agree; needing a CON to build a new hospital obstructs the free market. That should not be the case. Second: I don't work for a hospital nor do I personally care how much they make. I'm just pointing out the Rep vs. The World hypocrisy. Third: You think X% markup is too much for the services they provide (keep in mind, the avg profit margin of a hospital is just 3%)? If you're consistent, you also believe that manufacturers should charge $100 for a pedicle screw and, et sequitur, your commission should be less than $10/screw. Does that sound about right? Or did I name thy hypocrisy too closely?

  23. I don't see your correlation between the two?

    A manufacturer must purchase raw materials or outsource that to a third party, ensure the product meets all regulatory requirements, hire a sales force to market that product, and maintain specific records for potential recalls etc, etc, etc.

    The hospital sterilizes the implants and puts them on a case cart for 10 hours and justifies a 400% mark-up to the patient without ever actually owning the inventory?

    I'm not anti-hospital, but I love using this real world scenario whenever Materials Management starts their holier than thou crap about doing what they do for the benefit of the patient.

  24. One thing that hasn't been mentioned is that the hospitals have to eat the cost of the implants if the patient doesn't have insurance (or has charity-level Medicaid). That helps to at least partly explain the big markup in implants. This is the same reason we see the famous $10 Tylenol - "cost shifting."

    The surgeon and hospital get nothing but the liability. I wonder what the average rep would think if every fourth case they did was for free - even if they were up all night for it.

    The reps and implant companies get paid whether the patient has insurance or not. This is a huge luxury that the industry has - that most people commenting here seem to have forgotten.

  25. Bravo SpineDoc1 for your well stated point. It might also be mentioned that who cares that the hospitals mark them up 300-400% (if that really happens?!), they certainly do not collect from the payors this amount. It's all a scam; from the raw material to the manufacturing per the surgeon developers golden input to the packaging, delivery, and delicately provided to the OR by the white gloved butler (the REP) ...........hmmmm...........kinda sounds like Madoff, in a way. Every layer needs to make their piece of the pie. Where's mine?

  26. Your right about that Doc. We do get paid either/or. However most, but not all, hospitals operate as some type of 501C3 non-profit organization. This gives them a tremendous advantage in being able to write off those losses and not suffer on the bottom line.

    That is unfortunate for the surgeon. Maybe some of your professional organizations should lobby Congress to get the benefit that the non-profits have.

  27. Your piece of the pie is out there when you decide to man up and are willing to work for 100% commission. Until then take that safe & secure little paycheck and keep punching that clock!

    The 400% mark-up is very real as I have been confronted by an angry surgeon who thought this was what I charged the hospital. His patient had come to him on follow-up obviously upset with bill in hand. Both of us were shocked to see this as I showed him the original PO from that case.

    This was one those those poor souls who either had no or very inadequate insurance. How compassionate of the hospital to screw over the person that could least afford it.

  28. It's always easier to beat on the little guy than take on the establishment! As TSB has stated in the past, challenge the anti-trust laws, take a stand with the insurance industry and vote the lazy old "fat cat" politicians out of office. Isn't it interesting how the insurance and banking industry work hand in hand on the state level. It's the old pyramid scheme, pit the bottom of the pyramid against one another, and the top continues to exist.

  29. Hey 1:12pm, do you hear the walls tumbling about you? Stop hiding behind its's someone elses fault. You are PART of the problem. Your blog even permeates your angst to others infringing your lifestyle. Who made you God!

  30. Hey anonymous, its my blog, not 1:12 p.m's. No one claims to be the Golden Oracle. This blog allows us to discuss what's good and bad about the industry and healthcare in general. Each and everyone of us is not only PART of the problem, we could be pro-active and be PART of the solution. So before you go calling anyone GOD, think about who is calling the kettle black.

  31. I don’t mean to come off as captain obvious here but this is just business altogether. Wrong, right or indifferent…it’s just business. Do medical device companies charge $2000 for a screw that cost $45 dollars to manufacture? Yes, why? We all know why. It’s the cost of business: R&D, packaging, shipping, regulatory, insurance, commissions and a plenty of other factors. Do hospitals up charge implants? Absa’freck’n’lutely! Why? Is it because they are maximizing margins on percentage reimbursed DRGs? Duh. Margins are razor thin because of bad business and waste. But this is not the point. It’s about the cost of doing business to be able to turn a profit. We all do it, it’s how we put food on the table to feed the little ones or make the payments on the Lexus. This makes us competitive and creative.
    Just as manufacturing companies are driving revenue so are the hospital entities. GPOs, IDN and company acquisitions, supposed new technologies...everyone’s just being competitive to earn a buck. Its capitalisms my friends; let’s not be so naive or displaced in thought of who’s to blame for the failure in the health system. We’ve done it to ourselves in making bad business deals, exploiting the system and competing with each other instead of partnering and working together. Whenever big money is involved people and entities will naturally exploit and get theirs too. It’s no different in auto, tech, telecom and commodities.
    In my humble opinion, we’re all in the same massive patient care boat at different positions clamoring for control, money, opportunity, etc. No harmony, no unity…really no direction floating in a sea of greenbacks as we all shout aloud “better patient care, better pricing, FOUL!” It’s kind of funny when you look at it because the bankers and insurance providers are looking down from the safety of their hovering helicopters watching the mutiny take place while government stands ashore blowing it’s time out fog horn…just because they can.
    What would it look like if the hospitals and manufactures partnered together concentrated on fair market instead of free market? I’m not taking about socialized…okay maybe a little bit but think of the impact on health care (even control for that matter). We are all resolute and unified in doing our respective part instead of slitting each other’s throat for existing floating dollars…OH WAIT A SECOND! Now both hospitals and manufactures are shooting Batman Cables from their hips up to bankers and insurance companies? Holy Insanity Batman! We’ve just linked up with the Joker, Riddler, Penguin and Two Face. Oh what the…! Is that Cobra Commander flying the gun ship?
    Pardon the juvenile references, but it’s kind of comical when you think about it.
    When are we going to stop fighting each other and start making strategic partnerships that make sense with the right entities? Some companies that don’t add value will go away. Technology will be managed and priced appropriately. Hospitals can clean up the inefficiencies in their system and actually get paid what they bill (this means higher physician payments too). And Docs can do what they do best…patient care. We all do clean and appropriate business with each other as we together steer the healthcare boat back in the right direction under our control without the need of Uncle Sam coming in to regulate and put us in time-out. Let’s learn from the auto industry, you let government come in…you’re going to get slapped and eventually bankrupted because they will spend your money to reform and regulate everyone of us.

  32. Either Anonymous @ 2:48pm is MM in disguise or someone is vying for the MM moniker and take his mantle, and lead us to the promised Land!

  33. Anonymous 12:18pm: Your "real world scenario" that you use to counter the Materials Manager is to say, "All you guys do is sterilize my sets" ??? You DO understand that a hospital's function is more than just sterilizing sets, right? Just as a manufacturer has all the operational costs you mentioned, a hospital also has significant operating costs (like covering the unpaid liabilities that SpineDoc mentioned). Now that you understand that, which do you prefer: ONE, you're OK with hospitals marking up screw prices because you admit you didn't fully understand how the sytem worked or TWO, manufacturers sell their screws to hospitals at-or-slightly-above cost and you're out of a job (but not a hypocrit)?

  34. Hey Anonymous 3:11 p.m. we don't need another MM considering that I'm not interested in leading you to the promised land since I could not promise you anything. Besides the Ark that I'm building can only hold my immediate family. But I do have a question to ask our readers , "How did we segue into a rant on pricing when I was asking why does everyone think that there is a healthcare crisis when you look around at hospitals around the country and everyone is expanding their facilities?

    In addition, the point of my commentary about purchasing was why did anyone believe that a hospital has the right to "shake down" any company big or small for free implants? I didn't bring up anything about marking up the cost of implants, did I?

    The most fascinating aspect of writing is that you learn that readers tend to read what they want to read, rather than what was really said, and I say that respectfully because I myself am guilty of that when I read others blogs or news articles.

    I learned a long time ago that its easier to react to what's in front of you, rather than worry about what potentially lies ahead, and that my friends is my argument that we have become result oriented in the short-term rather than worry about our long-term viability. Change is a bitter pill to swallow, but its coming whether we all like it or not.

  35. TSB, the relationship between hospital mark-ups, pricing discounts and free "trial" implants is: hospitals want to minimize costs and maximize revenue. So, my response to "what gives hospitals the right to ask for free implants" is "because they want to minimize costs." It's no shake down. It's not illegal. It's not even unethical. It's just normal business.

    I don't follow your logic of "how can there be a healthcare crisis when hospitals are expanding/remodeling?" First, the two are unrelated; the crisis is that healthcare costs are quickly escalating, not that there is less money or fewer patients in the system. Second, and more importantly, hospitals remodel/expand to (1) attract more customers in order to make more money and (2) scaling up the number of customers they can serve should similarly scale up their revenues and profits. In other words, they don't remodel/expand because they enjoy dumping money into useless endeavors; they do it because they believe it will make them more money. (Yes, you could always cite cases of mismanaged hospitals, but that's beside the point.) When you ask, "why is the hospital asking me for free screws and deeper discounts when they can obviously afford to expand?" you have it backwards. They can afford to expand BECAUSE they are able to lower implant costs (among other cost savings).

    (I can also explain the fallacies in your Physician Owned Specialty Hospital arguments, too, if you like.)

  36. As I stated, IF I CAN PROVIDE A PROVIDE AT NO GREATER COST THAN WHAT THE COMPETITION PROVIDES, IF NOT AT A LESSER COST, how does that justify asking for free product? Besides, I never stated that it's illegal or unethical did I?

    As to asking whether there is a healthcare crisis when everyone is expanding, I'm being facetious. If you have read any of my "more serious" blogs in the past, I probably was one of the first writers in spine, if not the first blogger in spine that has written expose's on the escalating cost of healthcare. Just out of curiosity, what do you expect the ROI is for many of the facilities that continue to expand? Just because you believe there's more money, doesn't necessarily mean there is.

    PS: There are no fallacies in my explanation in POSH's considering that the TRUTH is, (because of having managed in a POSH) is that they 'cherry pick" their patients and the reality is that they want the "paying" patients and not the "charity care." At this point all I can reference you is to the Hippocratic Oath. Since this is a democratic blog, I will let the people's voice determine how the majority rules. When 67% of Americans say that we need a public option and that the system is broken, just because you don't agree with my opinions doesn't mean you're any more right in your opinion than I in mine.

    Peace and thanks for your commentary, and keep on reading, your opinion counts.

  37. Yikes! This is an argument that neither side can win. It is obvious that our healthcare system is truly dysfunctional.

    I have worked many years on all sides of the equation, for a big spine company, with physicians and for hospitals. All that I can say is that while I spent many years with a spine company, I spent nights in plush resorts for surgeon "training", worked in lavish surroundings, and experienced more extravagance and waste that I could have ever imagined. All the while, the company continued to bring in huge profits. It is a business, and I do not have a problem with businesses being successful.

    The hospitals that I have worked in are fraught with dysfunction and ineptitude, but are trying to do the best they can while working on a shoestring. They may be building new facilities, but what patient is going to choose going to a dirty old dump for their healthcare? It still is a business and hospitals have to do what makes sense to survive and/or thrive. Why the double standard for hospitals trying to run their business in attempt to thrive?

    Think about it...The docs pick whatever implant they want, generally having no knowledge what anything costs. The hospital has to pay the bill to the device company for whatever the doc wants, without having much or any say on what they select. That just doesn't work, something has got to give. Hospitals are grasping at straws to have some sort of control over their costs while still dealing with the entire myriad of issues on their plate of government regulation, increasing indigent and Medicare population, unions, nursing shortages. etc...

    With all of that said, until some of the goals between manufacturers, surgeons and hospitals are aligned, our conundrum will continue.