Wednesday, May 25, 2011

Let The Games Begin

The Martin Memorial Health Systems in the State of Florida issued a memorandum dated May 6th, 2011 to all of its providers of medical devices and supplies.  The reference on the memo was regarding PODS. Here is a reprint of the Memo as provided to TSB by one of our bloggers.

Martin Memorial and its affiliates believe that the growing influence of physician owned intermediaries in the medical device and supply industry is inconsistent with the spirit and intent of the federal anti-kickback statute, creating what the OIG has characterized as a "strong potential for improper inducement between and among physician investors, the entities, device vendors, and device purchasers.  The OIG has stated that these ventures should be closely scrutinized under the fraud and abuse laws.

PODS are beginning to appear in hospital supply chains as middle man entities, typically organized as a product distributor or a group purchasing organization, that gives physician investors an opportunity to receive profits from the sale of certain medical products or supplies to hospitals in which the physician investors provide professional services.  After reviewing various recent publications and legal opinions on this subject, Martin Memorial has concluded that it shall be its policy to refrain from entering into business relationship with supply chains that involved physician owned intermediaries. A snapshot of five bullet points follow;

1. Martin Memorial prohibits purchasing items or services for use in patient care including but not limited to pharmaceuticals, implants, instruments and other medical devices from any supply chain that involves a physician owned intermediary with which any affiliated physician or immediate family member has a financial relationship or which otherwise involves physician ownership in excess of 5%.  Exceptions to this rule may only be approved only by the Martin Memorial Audit Committee, in consultation with the CEO, the Chief Legal Officer, and Chief Compliance Officer.

2. No Martin Memorial entity will enter into any agreement for the purchase of medical devices, supplies, pharmaceuticals, or any other item or service if it determines that the transaction is intended to influence the referral pattern from a physician who has, directly or indirectly, a financial interest in the utilization of the item purchased.

3.  Where relationships with physician owned intermediaries is necessary, the relationship must be consistent with fair market value and satisfy all other applicable legal standards.

4.  Vendors of all medical devices and supplies shall be contractually required to disclose to Martin Memorial all financial relationships, whether directly or indirectly, involving physicians who are either employed by Martin Memorial or who serve on the medical staff of Martin Memorial.  Such disclosure shall include non-monetary benefits if the value exceeds $350 annually.  In, addition, contracts with vendors shall contain an ongoing obligation to disclose such future financial relationships,  and shall contain provisions for the prompt termination of the business relationship in the event of a failure to disclose or the disclosure of a prohibited financial relationship. The provisions of this section shall also apply to financial relationships with such physicians' immediate family members.  For the purpose of this policy, the term "immediate family member" shall be defined in the same manner as it is defined in federal regulations related to the anti-kickback statute.

5.  This policy shall be broadly construed such that whenever possible business relationships are avoided where supply chains for medical devices and supplies involve a potential conflict of interest of any kind. If Martin Memorial concludes that any vendor has engaged in an effort to circumvent the spirit and intent  of this policy, Martin Memorial may in its sole and absolute discretion, elect to exclude such vendor from doing business with Martin Memorial or take such other corrective action as it deems appropriate under the circumstances.


  1. No, missed it. I was watching the season finale of "America's Most Wanted, White Collar Crimes." Show was titled, "There's a POD in all of us"

  2. There must be nothing to do in Arkansas tonight

  3. This isn't the first. Check out Scripps in San Diego. They excluded PODs almost a year ago.

  4. "There must be nothing to do in Arkansas tonight" that made me laugh...and no theres not

  5. All it takes is a catalyts... Unfortuntely, everyone loses in the Spine industry when the PODs coming crashing down.

    Yes, several surgeons will lose licenses and perhaps spend time in club-fed, but most insurors, hospital administrators, and patients will lose the trust in spine surgeons in general(Once they see the scope and reach that the PODs have made across the country).

  6. I LOVE THIS!! Everyone, and I mean everyone, knows these entities are unethical AT BEST! Surgeons who participate on PODS are scumbags. Period.

  7. Everyone loses when terrible 3rd world hospitals like Martin memorial bastardize device pricing...Russia,Haita,and Pakistan would pay more for hardware! Scum like their systems will take spine and future technology backwards to the stone age. We all need to band together or parish. There has to be a floor and a time when we all find our balls and say enough! Oh get a cookie martin memorial for your ethics....have to start giving out character awards to mob bosses breaking knee caps of street vendors as well. I hope your hospital falls into the ocean....or better yet the "Corleone family" takes it least they"ll pay something you cheap bastards.

  8. 9:05pm, what are you talking about? You're totally off topic, brotha'.

  9. Can anybody shed some light on WHY my husband was charged $8,000 per AlphaTec 6.5mm spine screw (32K total) plus 6,900K for the set screws? And...$19,478K for the AlphaTec spine cage? Surgery performed in Santa Barbara, CA. Is there any recourse on these costs? PLEASE Help with suggestions.

  10. You got billed 2,560,600 for an alphatec construct! If my math is right, that's highway robbery.

    Sorry- couldn't resist. If your math is right, it's still ridiculous.

  11. I'll shed a flood light...IMPOSSIBLE for your husband to be charged that amount. NO hospital would ever pay $8K for a pedicle screw or the other prices you have listed.

    I call BULLSHIT!

  12. 9:29 - its based on the index that the hospital charges. If medical device company charges them $1, they turn around and attempt to charge $3-4. Been their game for many years.

  13. a LG II infuse at my largest account bills out at 19K thanks to indexing...

  14. Hospitals charge at least 3x to insurance what device companies charge them, especially the Cottage

  15. The Martin Memorial Health Systems in the State of Florida

    "Exceptions to this rule may only be approved only by the Martin Memorial Audit Committee, in consultation with the CEO, the Chief Legal Officer, and Chief Compliance Officer."

    Translation : POD's may be allowed as long as it benefits the hospital. Which by the way makes you look as if you don't support POD's on the outside but wouldn't mind allowing a few as long as they follow protocol and benefit the facility. Got to love the wording.

  16. Martin Memorial is THE WORST abuser of Nazi pricing and vendor hate. Their poor surgeons have had their sack stepped on so many times, they may as well have taken InFuse. The only reason they published this memo is they HATE anybody else making a dime while they light their cigars with 100's. If you want a family member treated with technology from the Nixon administration, take them to Martin Mem. Dirtbags.

  17. Martin Memorial is a good example of what happens in a small town with a 1 hospital monopoly. Service/excellence/technology all go down, and the poor rural residents who don't know any better get screwed.

    Remember, don't steal because the government hates competition. And don't make a profit at your hospitals because the fat, lazy drones in administration are greedy.

  18. Martin memorial will ruin technology/healthcare. I know a rep that did a 30 screw case there for 8800.00 dollars!!! What the F is wrong with you people agreeing to this? I know we all will be cleaning toilets down the road....just didn't think 6months down the road- if this pricing gets out....I'm going to get a pay increase and be a bus driver or dog walker....who cares about pods or industry is melting,,, ! Away with lower and lower pricing!!! Make it stop!! Somebody wake me up from this nightmare.

  19. Huntsville Hospital in Huntsville, AL has figured out what Martin Memorial can't ... Huntsville Hospital as been in bed with the SpinalUSA pod for years. Yes this is the same Huntsville Hospital that paid the stiffest penalty for fraudulent Kyphoplasty billing.

    But, of course, the reps make too much money.

  20. If it is not clear 9:29, You are being charged at 3 to 4 times what the hospital is charged for the implants. It is called a mark up. Are products are expensive but it becomes ridiculous by the time it gets to the actual consumer. The truth is the hospital is just using the implants as its way to justify its bill. Then they complain to the implant manufactures that our prices are too high. Funny right? The hospitals should just show you what the implant costs actually are and then show you that they are charging you an extra $50,000 for their professional services. Sorry but that is as close to the truth as I see it.

  21. 8:21 pm can you share some link to that story about Scripps?

  22. Does Nuvasive sell through PODs?

  23. Nuvasive does not but Depuy has no problem hiring wives as sales people in one hospital cities like Carson Tahoe. This has been going on for years! When is this madness going to stop!Could this be the next trend? Stay tuned

  24. Thank you to those of you who responded to my inquiry about my husband's AlphaTec implants (see above posted 5/25.) The correct math is $32K total for 4 AlpahTec screws, $6,900K total for 4 set screws, $19,478 for the Novel TL Cage. All this ads up to $58,378K. That DOES NOT include $22,601 for BMP Infuse Bone Graft Material, and $6,650K for Actifuse Bone Putty. Total Hospital Bill $156,000K with all the other charges. MY CONCERN is the hardware costs and what I might be able to do about it. This was ONE fusion. This is frightful and impossible to understand. Is there a POD involved? would that explain it. And is there any way to research if your surgeon is involved in POD? Please respond. Thank you

  25. This comment has been removed by a blog administrator.

  26. Steve Hochschuler says PODS are legit and industry is illegit. I totally believe him. He is such a stand-up guy.

  27. Ever wonder why some people look at our industry with disdain? It takes less energy to be nice to someone that doesn't understand something, than it does to be crass.

  28. Hey 9:29, as to whether there is recourse, the answer is yes, but it is practical, not necessarily legal. The bill the hospital issues can be seen as a starting point, sort of like a ridiculously high list price on a car. It's not the price you necessarily have to pay. What the insurance company actually pays the hospital is based on their contracted rates with them, and usually the implant costs are bundled in. For a lumbar fusion, this amount, depending on the state, insurance company, nature of the procedure, etc. could be anywhere from $15k to $50k, but based on the charges that you're quoting, it's likely to be much less than the bill they sent you. So your insurer will probably pay a set amount for the procedure, and then you'll pay whatever coinsurance you might have. (Part of the reason for the ridiculously high list prices, is that in the event of a lawsuit settlement, or a wealthy international visitor, etc., the hospital will actually collect the full billed amount.)

    If you don't have insurance, ideally you would have received an estimate from the hospital up front that you could somewhat hold them to. But even without the estimate, the hospital will usually offer a substantial discount for "cash pay" or "private pay". They will also be considering what they would usually receive had you had insurance, and you can ask them if you can settle the bill with them for an amount that is consistent with, or perhaps a small percentage over what they typically receive.

    Bottom line is that if you're insured, step aside and let your insurer handle it. If not, talk to the folks in the hospital and ask for a discount.

    Good luck!

  29. There is a Nuvasive rep in Fort Worth, Texas and her husband is a surgeon that uses Nuvasive exclusively. The funny thing is that she keeps her maiden name on her name badge. Everybody knows who she is though, and the huge diamond ring she wears doesn't help the cause!

  30. 9:14

    I apologize that you have not received an answer to your question. I applaud your tenacity. The bill you are holding is an excellent example of what is wrong with healthcare. I have read this blog for a year and have seen little mention of the devil in the details. As you may have gathered hospitals are driving the cost of implants to all time lows. However, they are still billing the patients for "list price". For example. I sell a screw to a hospital for 700$ that "list" for 1400$. While the hospital only pays 700$ dollar per screw, they actually bill and add a 3-5% multiplier or "index" as I am seeing it calls on this post, to the higher price. The benefit of this is obvious. This is, in my opinion, fraud, on the part th hospitals. Your cheapest option is to contact your local paper and five them a copy of your bill, or, if you have the money, hire a lawyer. This is one of the biggest issues with healthcare today. .......

  31. Sorry for the typos. Dammyautocorrect!

  32. Thank you for your feedback. It really is nice to know others are willing to shed light in the darkness of those uninformed. This thank you does not include the crass comment that was removed by the blog manager. Your comments at least give my hope. I am NOW considering getting certified as a Medical Billing Advocate. I think I shall wear my ID badge to EVERY doc appt I go to and drop by the billing office just to say "hi". I would love to be part of helping other seniors who don't know how to stand up and ask questions. thanks again everyone!

  33. I was with Spine Tech/Zimmer for over 8 years. I saw the good and the bad (well let’s say horrible). 4 Spine Presidents in 4 years. One that lasted about 2 weeks. Terry Slaughterback was the first one out of the gate and he was out of his element with Spine and Minneapolis. Hell he didn’t even have a home there, he would come in for mtgs. Then David D tried to run things from his chair in Warsaw and that was a mess. There has been no solid leadership there for over 7 years, hence why a total joint company should stay just that..a total joint company. We went from having great National Sales meetings to have "break out" sessions to go over what?? BAK C cages and a stupid portal from Endius. Now if that doesn’t get you excited, than what will! Who knows what their next move will be but if I were them, I would dump spine on an actual Spine Co. They have been stumbling for years trying to get Dynesys approved and only to have a product that is still used off-label as a high priced pedicle screw system.

  34. 9:14
    You have a right to obtain the hospital's Chargemaster. The idea of going to the paper is a good one, but prior to that you should ask for the Chargemaster in its entirety which by CA law now they must provide to you, and request that the implant charges be limited to a 20% increase in what they paid, or you will be taking this further with an atty and the local press. You stated that the hospital was in Santa Barbara but not which one, Cottage most likely. What they charge you however will not be what they paid for these implants. They paid most likely in the neighborhood less than $900 per screw including the Hex. As far as whether your husbands surgeon is in a POD, he must have signed a disclosure, or he better have, and in this disclosure will be some very special verbiage about how ethical he is and that he is a member of this society that upholds ethical conduct etc.. and that he is disclosing the following financial arrangement that he gets paid for because he is such a great designer and speaker etc.. This is where they are to disclose the nature of their arrangement with a POD. Good luck.
    As an example, if this was Cottage, reading from their Chargemaster they currently charge patients: $19,400.00 for an ALIF Cage, $18,200.00 for a TLIF Cage, $9,381.00 for an Anterior Cervical Plate, $1,455.00 for a Medtronic Legacy Hex Screw, $9,126.00 for a Medtronic Legacy Polyaxial Screw, etc. They have Allez as well as Alphatec and I would never use those companies unless I was getting paid as I would not want to feel left out.
    By the way, Cottage also charges $1,500.00 for Sterile Maggots. That's right, they are making a comeback for wound debridement.

  35. That portal from Endius had great potential. It is a shame that it never got out of the block at ZS, but that was more related to the timing (Endius acquired in Apr-07, DPA handed down from FedGovt in Sep-07, Z has internal seizure for years afterward). This DPA induced organizational seizure also exacerbated the already risk-averse environment of the Z organization and many of its people. It takes commitment, drive and belief to make new products work...that portal never had a chance in Z, during that time.

  36. mm
    My crass post was meant as a joke, because I do not believe the poster was for real. I think it is a trouble maker trying to stir up trouble about how much manufactures charge for their products.

  37. 10:34 I would have to agree with you! Its prob another rep just stirring the pot! I will tell you from my experience as not only a rep but also having a 360 done on me in 2003 for treatment of L5 Spondy. The paper work that I received from insurance had no indication of 1. Manufactures name 2. What size screws were used, plus she said she was charged x amount for a set screw and 3. I would question if it was through insurance who cares?? If he chose to have the surgery without insurance covering it, well then that’s his bad! Come on what insurance co out there gets that detailed? I can bluff like everyone else.

  38. I must say that it was refreshing to read 9:29's post and the subsequent follow up (props to 9:37), as it was a significant change in what has now become a rather routine and mundane blog site.

    As 15 year veteran of the implant industry and one who does have familiarity with health systems in Europe and Asia, I have consistently found myself agreeing that we do indeed have the best healthcare system in the world. However, I've always felt that statement was unfinished in some way. 9:29 highlights what most of us know and fills in the gap.

    The United States has the most robust, technologically advanced healthcare system in the world. Problem is, it is likely (when compared to resources) the most inefficient system.

    Gross inefficiencies can exist in markets that can absorb them and grow. Rightly or wrongly, the US economy can no longer support the burdensome inefficiencies the health care system (public and private) creates. And that's why TSBs site has become the back water of angry, fearful insiders and any topic outside of consolidation, PODs, and shady competitive tactics is likely to be ignored.

    My forecast is this site will reflect the market and amble on as it has with the typical, redundant insider gossip, fraternity trash talk and occasional pearl for, hmm...say, the next 2-5 years.

    From that wreckage will come something positive, new business models / technologies, and I sincerely look forward to it.

    Until then, some one should figure out how to get paid, wasting time talking @#$! or at least put that time and typing skills into something productive (e.g. learning how to Sell or refreshing the ole resume).

  39. 10:47
    My thoughts exactly. I perhaps should have used logic like you instead of a cheap joke. But I thought it was pretty funny.

  40. 10:22 thanks for your post. I was the one that posted the comment about ZS. You are correct, the Endius port is a great idea. Zimmer just screwed it all up with that DPA. It's a shame that Zimmer decided to purchase a company all the while knowing that they were under investigation with the DOJ. That DPA effected not only the Recon division but really hampered the Spine reps that had nothing to do with it at all! Again, this is why Recon companies should leave spine alone! I left ZS last year after 8 years and they have done everything possible in my old territory to lose every single customer I worked my ass to get in that time. They have a half ass distributor "running" the line now and it's just a shame to see all the hard work put into the territory gone!

  41. 10:34 & 10:37....WRONG, WRONG, WRONG. Born and raised in SB CA, heavy equip engineer for 42 years. Do you think we are stupid and didn't know how to ask for an itemized (in laymen's words not insurance codes). I can quote you every single mfr that supplied the hardware...the size and how many were used. No REP in this household and not bullshitting any of you. Send me your email and I'll send you a copy of the bill!
    10:19 Thanks for the suggestion... I will be requesting the ChargeMaster before we go into negotiations. I'm not afraid to ask the hard questions. Your'e cool! By the way my name is Kathy.

  42. Hey 8:59 pm, is providing medical care a business? If it is, then the Doc's are only doing what smart business entities should do. If it is not, then there should be set prices for services (like medicare and medicaid) and you sales guys are not needed. Each hospital should hire a staff that manages inventory on products that are available for the system. As doc's cannot consider the financial impacts of their decisions ( after all, it is not a business) the selection for the implants, products, etc. will only be based on outcomes, or price. There will be no room for face time with spine reps, as their input will be meaningless. So what is it, a business or not a business? If doc's are also businessmen, why would they not want to cut out the middleman? But you are right, the system is not designed to be a business. That is why we as a society are willing to pay $900 per titanium screw that cost less than $25 to manufacture. Before you spout off about ethics, think about that scenario.

  43. 10:34 & 10:37... and by the way.... it's a non-issue as to whether we have insurance or not. (by the way we do) The stupidity is in you implying so. Why do I want to pay the difference on a pumped up $32,000 in screws? 80/20, or 70/30 or 50/50..... the patient gets the screws and gets screwed when the cost is inflated to meet the beauty of the palm trees in Santa Barbara.

  44. I'm a rep and one of my docs showed me a copy of a pt's bill that they had provided him with. This was probably 5 or 6 years ago. I charged the hospital $1300 per screw at the time for this case. The hospital turned around and charged the pt $6000 per screw. I asked the surgeon if that was normal and he said yes. I then learned that another hospital in the same city was charging patients $4500 for each screw that I sold to them for $1150 each. All true. I saw the copy of the bill. I was told by the doc that it really didn't matter what the hospital upcharged the pt (to a certain extent) because the insurance only reimburses the hospital a set amount for each surgery anyway and if the pt had no insurance that the hospital would lower the charges.

  45. 9:29???

    What 9:29??

    Was it about Globus going public?

  46. This is 12:36. Not saying anything I said was right or ethical, just saying that it is all true.

  47. Kathy,

    If the true manufacturing cost of a screw is $25 (not including sales, marketing, admin costs), and the screw technology is old ( R and D costs have long been recovered), how much should the companies be charging the hospitals? 3 times cost, 4 times cost?

    Of course the Hospitals are marking up the implants. The Hospitals need to make money on paying patients to make up for the tremendous amount of un-insured and non-compensated care.

    But this situation does not occur with the product vendors. Hospitals will always pay for these products utilized by the patients regardless of the ability of the patient to pay the hospital.

    As stated in my post at 12:12 pm, the medical system is not a true business. Hospitals and Physicians cannot demand payment for emergency surgery before the procedure. In trauma hospitals, often times the patient does not pay for the hospital fees or physician's fees as they have no money. But the medical product vendors always get paid. Maybe it is OK for a hospital to charge 3x the cost, as a significant time they do not get paid. But is is OK for the screw manufacturer to charge more that 3 times costs, as they always ge paid?

    Kathy, you may be angry at the wrong set of people.

  48. 12:12. Let's see you put together a full line of implants and instruments, charge $25/screw and make a profit. You are obviously the worst business person on earth. What you are describing is are a fool. If the hardware is so profitable why did NUVA just become profitable. You need to go back to school and take some business classes.

  49. 12:12 - Yes some screws, not good ones, can cost $25 to manufacture. But, that's much less than half the story. Add the cost of FDA clearance, add the un-fathanable cost of liability insurance, the cost of inventory to include instruments that have no opportunity for revenue recover, cleaning and maitaining inventory, the un-believable cost of required government documentation, all a part of cost of goods and this is the short list. That the real cost, and it ain't $25. Add sales and admin expenses; there's not much left.

    So, before you make an ethics statement related to cost, please make sure you tell the whole story, not just what's convenient to be controversial.

  50. 12:40, This is kinda fun. Something to do while waiting for turn over in the OR. YOU just made my point. With true manufacturing costs so low, spine hardware has become a commodity. The old model of spending lots on R and D to replicate the same technology, spending a fortune on buying a sales force, spending a fortune on developing "quality relationships" with doctors, will not work in the future. You still do not get it. The reason we as a Society was willing to pay so much for medical care is that someone else paid for it. Medicare established in 1965, was for people over the age of 65. At that time, people only lived to 70.9. They paid 1.45% of their salary to get that benefit. Now people live to 79. Disabled people are also covered. They never paid the 1.45%. So everyone thinks they paid into the medicare system, but in the reality, they did not. Some one else is paying for these $900 screws, not the medicare recipient. Likewise, health insurance is paid as a benefit. We feel we earned it. In reality, again someone else is paying for the $900 screw. Well guess what, no one wants to pay $900/screw. In fact, we want to know why a screw costs $900.

    I am glad I am retiring soon. Thank goodness I have an MBA, as the hospital has asked me to help them transition for this new environment.

    12:40, what are your plans?

  51. help I need a band aid.May 26, 2011 at 1:06 PM

    12:38 is right Kathy. Why are you angry at the reps and question us about what YOUR and I repeat, YOUR insurance has charged??? Did you question the car dealership when you purchased your car? Did you know that the too, marked up that car they purchased from the manufacture? Hummm....??? I can go on from there if you like? There are blogs that you can find to bitch at the right people not the ones making a living just like you do or did. Ask for the charge sheet all you want, but you wont find any pricing on that. The ChargeSheet (as you like to call it) will only express what was used , like that $75 band aid used to cover the exposure after your mate had surgery. Maybe you should be barking up J&J window as well then?

  52. 12:38... not angry just disheartened...after just reading post 12:36, I'm even more so. Two hospitals just down the street from each other conflicted in the charge for the same screw?! And, after reading anonymous 9:14 regarding my right to ask for the ChargeMaster plus an estimate of the probable cost of $900.00 per screw from mfr even Donald Trump or Newt "Tiffany" Gingrich would ask the same questions I'm asking.
    I am most interested in seeing the medical system cleaned up and equitable. We are "working" stock portfolios, just a union retirement, S.S. and some savings. I don't want to pay the hospital and docs for everyone else's care. I'd rather choose who I help. T.Y. Kathy

  53. 1:12. I'm not specifically mad at the reps.... I suspect there are POD's involved every which way and the docs are running to the bank with the inflated mark ups and kick backs. I've done my research, read legal articles by attny's who help make investments for docs and even they are down on the POD gig.

  54. 1:12pm
    I would recommend printing out this blog and show it to the hospital and your insurance company. You should not have to pay a percentage of the inflated price. Instead you can negotiate with the hospital to pay your PPO % of the actual cost that the insurance company paid for each implant. Otherwise send this information to a newspaper such as WSJ or NYT or your congressman. It is outrageous that the hospital demands cutrate pricing from the spine companies but then demand that patients pick up the balance with super inflated pricing. If you were in an HMO, there would be no charge to you. Only in an PPO, there may be lots of out of pocket costs.

  55. What's disheartening is that someone who apparently stumbled onto the blog looking for answers to a very reasonable question (Why is the hospital charging me so much for these spine implants, and is there anything I can do about it?) was beaten down and derided rather than just given some advice. For those of you who think it's a prank, okay, but until that's established what's the harm in going along with it just in case it isn't? It's not like it's out of our field of interest.

  56. 1:06... Absolutely I question the car dealers when I buy a car and I negotiate usually to my advantage. WHY in the WORLD did you state and imply that I am questioning what my "INSURANCE" charged? My husband's surgery was performed in a hospital and they are the ones that charged us. Are you so misinformed and confused that you think an insurance company determines the charge? Ins sets parameters as to what they will pay and then leave the hospitals and docs to collect the difference from insured people. Winning! Duh!

  57. 1:46 Thank You very much for your kindness. As I said.... I AM NOT a prank. I will send a copy of the itemized bill (in English not codes) to anyone who is interested. My concerns are reasonable and I really like this blog site. I may join for the education and entertainment of it all.

  58. I believe you becuase as I said, I've seen a patient's bill. For those speaking against the implant companies, it's not their fault that a hospital buys a screw for $900 and sells it to a patient for $6000 or $8000. It's horrible, I agree. And it's the plain truth of what happens. How does anyone on here not know this? I thought it was common knowledge that hospitals up-charged patients 5x or 6x. As a side note, notice all the new hospitals being built?

  59. Hey Kathy, sorry to contradict what 1:29 and others are telling you, but I wouldn't bother with the adversarial "How dare you charge so much?" approach to the hospital. The practice of marking everything disposable they use in the OR up by 300-400% on the bill is common, not unique to that hospital, as old as time, and arguing against it isn't going to lead anywhere. Plus that's only addressing the implant costs. Everything else they are charging for (OR room, X-ray services, disposables, etc.) is inflated prices as well.

    First off, you have insurance. So your insurer is going to have a negotiated price with the hospital that you are most likely contractually obligated to pay your portion of. And that amount is almost certain to be much lower than the bill you are looking at. Call your insurer and find out what that amount is. They can tell you. If you're still unhappy, you want to team up with your insurer to get your bill reduced, not go it alone. But because the hospital has already likely negotiated with the insurer for a price, anything you do is likely an exercise in futility. If you do go at it alone though, just be careful that you don't do anything to allow the insurer to back out of their share of the bill. There may be provisions in your contract with the insurer that prevent you from negotiating with providers separately.

    Good luck!

  60. ... and let me correct your statement in 1:48. In almost all circumstances "balance billing" (i.e. collecting what insurance pays and then charging the patient for the remainder) is illegal. Generally the process is that the hospital will settle with the insurance company first, and the insurance company will tell the hospital two things: what's the total amount that will be paid, and how much the insurer and how much the patient will be paying. The hospital then reduces the bill by down to the sum of those two amounts, credits the payment from the insurer, and bills you for the portion that is your responsibility. That's not the balance of the total, but rather the portion that your insurance policy dictates you're responsible for. Thus the total that the hospital receives is the amount that the hospital and insurer agreed upon.

  61. I can understand the hospital marking up products that they purchase and stock. But when they are marking up a product that a rep. has to bring in the day before, be there for the case, and pick up the next day. Other than washing, wrapping and moving around, they haven't really added a lot of value to the product. Between the hospitals doing this and the intentional mark up for the insurance companies, it is a scam.

  62. I agree. And while they're decapitating implant prices do you think they're passing along the savings to the patient?

  63. 12:57

    Your argument applies to only a fraction of hospitals. What your describing is certainly the case in a inner-city level one Truama center, but those aren't really the problem are they? Let's include the reality of the spine boutiques(surgery centers,spine hospitals etc) in our discussion shall we? Do they exist for the greater good? Our their cups overflowing for the benefit of mankind? Or are they highly profitable joint venture between the hospitals and DR's that have never proven to benefit anyone but the investors of those hospitals. Your argument is based on generalities my friend. As we say in flyover country, your putting lipstick on a pig....

    I hear alot of talk about POD's on this blog. What about the other 3 letter nightmare the RFP? Hospitals(profit centers) have become masters at driving down the cost of implants through the most antagonistic process available and yet, the patient still gets raped in the end, and we get another spine hospital ..........

  64. I have been in a dozen RFP negotiations in the last year. In every case, we mentioned 3rd party billing which would remove the cost/burden of implants from a hospitals books. In every case they refused to even consider it. Why we asked? "well,......because we profit from the implants so much". Come on, St least lie to me before you.......

  65. Back to sit around for another turn over time.

    Kathy, we have the best healthcare technology in the world here in the USA. But, our methods of delivery, and the incentives to be efficient in our delivery is perverse.

    Back in the 1980's , when I was training. We only had Steffee plates and screws, and CD hooks. The cost for a large construct was about $2,500. This was considered much improved technology to the Harrington rods, Luque techniques and Zielke instruments. It was safer, with somewhat more predictable outcomes. But since then, there has been a tremendous amount of research, and development with minor advancements in overall success rates. Unfortunately, this technological advancement comes at a tremendous cost.

    At one time, I thought the United States had infinite wealth, and therefore we can afford all these changes. That's why our government plans covered all these modern advances, and naturally, the employers demanded the insurance companies cover these benefits for the employee's.

    Well, we are now out of money, and the employer's no longer want to pay for all these expensive treatments. The costs are now shifted to the patients. That is why you are seeing these big co-pays and deductibles. As people figure this out, less people are using these benefits. Why? BECAUSE YOU NOW MUST PAY A SIGNIFICANT PORTION OF THESE COSTS!

    Unfortunately, you are caught in the middle of this transition and probably was not warned of its implications.

    Believe me, 6-9 months ago, I was doing much more surgery. Now, with patients having bigger costs, many patients have decided the pain is not that bad.

    For us spine surgeons, and thus for the Spine Sales Rep, these are anxious times as well.

    I hope your husband gets better. My suggestion is to talk to your union leaders, or company representatives to see what they can do. Unfortunately, the Hospital is obligated by its contract to the insurance company to collect what is due. This is part of the "negative incentive" built into the system so that you decide whether you should have the treatment.

    We physicians unfortunately do a poor job of relaying this information to the patients. Unfortunately, we have no incentive to tell you how much the hospital costs will be (otherwise, you might decide against surgery). And often times, we do not know that information.

    As for you sales reps, get over it, the times are a changin.... but you all went into this to do good for the patients right?

    BTW, HMO's have had tremendous recent profits because of this lower utilization. Keep fingers crossed, maybe, the premiums should then drop? Unless you have HMO stocks in your 401K, then, you do not want the premiums to drop.....yes?

  66. 2.57pm, that is call competition, and that only happens when your products become a commodity.

    Didn't any of you guys go to business school? I guess 12:40 pm still wants to know which school I attended.

    The room is ready, have to go....Thanks for letting me vent.

    I will keep it anon, but you can call me Old Spine Doc

    BTW, Kathy, I hope you find a solution to your problems. Everyone here shares your concerns in their own ways.

  67. One should be more upset having Alphatec implants in them. "I whip my hair back and forth!"

  68. Kathy,
    Crass poster here. My apologies if you are legit. My real point was that all products used in a hospital are marked up very high, but as one poster pointed the uninsured cost hospitals a lot of money that they don't get paid for. I am a manufacturer and I can assure you my company is not making a killing. We are fairly small and just barely survived the recent downturn. As many posters have commented in the past, our cost of doing business and risk is very high, so please don't be mad at us. Just trying to make a living like you and your family.


  70. 3:49 p.m. Oh goody.... what am I suppose to do with this info besides have nightmares? !
    3:41 p.m. Can you explain further your opinion of AlphaTec. We trusted the surgeon who is suppose to be the best in Santa Barbara.... long time Ortho Practice. Do you think the doc may have known about these warnings prior to using them on my husband. Not a good thought!

  71. 3:41 comment of AlphaTec.... never heard the phrase...." I whip my hair back and forth" Can you expound?

  72. K, don't worry they're only warnings.

    However, you'll have nightmares if you read the history of this blog.
    "The Truth, Just Causes, The American Way." ~ TSB

  73. Old spine doc,

    2:57 here

    Pleasure debating with you, you are the better man, I yield. However, I would like to offer a parting thought to this spirited debate. ........if my implants have become a commodity....they are but a tool same as any other, how soon until the serviced provided by the surgeons that use them become a commodity?

    Thank you for participating in is blog, your input is appreciated.

    Midwest Rep

  74. 6:32.... good I need nightmares... where can I find the blog: The truth, just causes and the american way? Guide me.

  75. All you people are missing the point...CFO's at hospitals make 5 million dollars for working at hospitals and being retarded. Point 1. Point 2 if you have a problem with our healthcare system get your spinal fusion done in india for 100 bucks case...sure my poodle knows more about spine surgery but that's your choice. If not shut the f up. Hospitals are the enemy! You need to understand- their greed is destroying our industry and the future of healthcare.... For the most part they're a glorified warehouse... The docs, all the products, hand soap to toilet paper comes from us! Everything!!!! And 6 months to every year
    they squeeze our nuts in a vice and line their pockets! And instead of working hard and knowing how to sell you fing monkey hor yourselves out and slice the industries futures neck! Stand the f up! Say no to 500 cervical peek why we still have jobs! and you spoiled f's that don't know what I'm talking about the pain is coming to you too. We are all screwed, nothing matters more, nothing should be talked about more on this blog then to stop the pricing Holocaust.

  76. Kathy

    Go to Orthopedics This Week and Orthoworld. For $250 per year you could read press clippings from Google, Yahoo Finance etc with there own spin. Everything is beautiful, emerging technology is on the rise, surgeons are everyone's best friend, but what they fail to tell you is the truth. That's why people from the industry read the blog and comment on this site, this forum has given the people a voice,

  77. Kathy,

    id like to see a copy of the bill.

  78. 7:57 request. I will scan ONLY the charges.... not any personal info. Expect a copy tomorrow. May I ask why you want to see it? You still think I am a rep incognito? Or are you truly curious and/or interested?

  79. Curious/interested.

    Thanks you..just started checking it out..ridiculous.

  80. As a lot of people have said, im well aware of the 3-4x hospital markup of implants that is customary, but $8k for an Alphatec screw and $20k for an Alphatec cage?

    Im looking at it..

  81. To 9:26 p.m. When a hospital is the only gig in town....they damn well do what they want. It is sinful and shameful.

  82. Id like to know what this hospital is paying for this metal...and if it is indeed a POD situation.

  83. To 7:08

    One must not be too retarded to make $5 million year.

  84. 2:57

    Yep, all medical services are becoming a commodity. That means, essentially, the service and products are interchangeable.

    Regretfully, I have come to that conclusion when I started seeing the medical tourism industry blossoming. You can go to India or Korea and get high quality care, by US trained MD's with predictable outcomes.

    The only factor that prevents the complete change is that people do not want to travel out of the US. But the reason they are now willing is IT IS CHEAPER, and THESE SURGERIES ARE ELECTIVE.

    We have also tried to turn medicine into a business with all the sales and marketing. Well guess what? That means anyone can also market and advertise. That means people will now begin to price compare, that means people now want to know why it costs $900/screw, a hospital day is minimum $1500, and why to spine surgeons charge $15k for a 70 minute ACDF.

    We created this by our slick marketing and advertising campaigns. Initially it worked. We made a profit. In economics, it is called a "supra-normal profit". There is minimal barriers to entry into this field, so others now are competing in this arena. Yes, that is the ankle biters, the POD's , hospital based practices,and now the Medical facilities in overseas.

    Let's face it, we are, for the first time, actually following the natural history of economics. The buyer is now "shopping". We need to compete on price, quality, convenience and true innovation.

    Through this crisis, some will prosper. Most will fail (the kinder word is to say "be acquired").

    Compete well everyone.

  85. Old Spine Doc

    You raise valid points about product commoditization. However please don't forget that service cannot be commoditized. A huge component of high implant prices is the reps and service infrastructure that surgeons demand. If lower prices are to become reality, surgeons are going to have to accept no reps in the OR. In the vast majority of cases, I don't see that happening. You can't have it both ways.

  86. Let me guess the hospital is like every hospital, "We don't make money off spine, we need a discount" I personally have seen spine specialty hospitals charging 10x actual implant cost. Never discount, charge list for everything.

  87. there will be a time where there are no reps in the OR. that will be the next phase after this 2-3 years of consolidation. The pricing agreements will not allow for commissions.
    Scrub techs will be trained and be held responsible for knowing the nuances of the screw drivers, inserters, etc.
    Less trained surgeons will have to understand how to reduce a spondy without a rep talking him through
    Spine for the most part will consolidate back to larger institutions and academic settings. It will be like 1995 all over again.

  88. 5:31

    Remember, I am just the messenger. Before the 1:1 sales rep to doc era, we often did not have the sales rep.

    And lets be honest, for a simple ACDF, or a routine TLIF screw case, why do we need a rep in the room? WE (that includes me) think we are indespensible. But lets be real, we all know that is not true. As the saying goes, the grave yard is full of men who thought they were indespensible.

    OF course we need a sales and marketing force. That is one of the ways we get information about modifications and improvements. But lets be real, the technique on how to insert metal should be known to the doc and staff. If they do not know, that is because you have enabled them to be like that. I assure you, if they knew no one would be there, they would learn the process......or not use it.

    In the future, if the trends continue, there will be less "complicated" spine surgery. Less fusions and hardware. You know that is true, and my recent income certainly reflects that truth. Again, this is all because the purchasers of the medical care (government, or employers) are no longer willing to pay for our prices and outcomes. The consumer of medical care (patients), while complaining loudly, are not willing to become the purchaser of the services. This is the new reality.

    BTW, for you guys that want to protest the decreasing reimbursements of hardware (and therefore your income), you sound like the internet version of the Wisconsin Teacher's Union. You are proposing collusion. If you successfully collude, the DOJ will knock on your doors. A few years back, Doc's tried that by forming Unions. Did not work. Now, we are faced with take medicare, or drop out. In area's with lots of spine docs, take the rate, or do not participate. We have become commodities as well.

    Now that I do not have any more fusions authorized, I may just become a blogger. It does not pay the bills, but it allows me to vent.

    Great debates guys.

  89. I liked 1995. No war, prospering economy, weighed 15 pounds lighter. Managed care was really not too burdensome.

    Bring back 1995.

  90. Old Spine Doc. Please give me a break! I am from the West Coast and find it very hard to bleieve that any of my surgeons could do "a simple ACDF or TLIF screw case" as you put it, with out me or another rep standing there to stroke their egos "oh yes doc that 12mm screw looks great" or better yet "can I get you some lunch after this $800 single level ACDF that I just stood for 4 hours for" Most of these surgeons have their own sweat wipers that come in for them too. To quote Mr. Jack Nicholson from A Few Good Men "You don't want the truth because deep down in places you don't talk about at parties, you want me on that wall, you need me on that wall. We use words like honor, code, loyalty. We use these words as the backbone of a life spent defending something. You use them as a punchline. I have neither the time nor the inclination to explain myself to a man who rises and sleeps under the blanket of the very freedom that I provide, and then questions the manner in which I provide it. I would rather you just said thank you, and went on your way, Otherwise, I suggest you pick up a weapon, and stand a post. Either way, I don't give a damn what you think you are entitled to.

  91. damm 7:17 you hit in right on the head bro!

  92. 7:17

    Wow, I think I am hitting a nerve. Fascinating. Do you really think spine surgeons need sales reps to "talk them through an operation"?

    I question your thought process, but, if what you say is true, why are you aligning yourself with these surgeons? Oh, I forgot, it is about the patient. It has nothing to do with your commission.

    If you have the guts to show your comment to your local surgeons, I wonder how they would react?

    Get over it friend. Adapt, or perish. Getting angry about the truth does not make the situation better.

    Like i said, no surgeries makes blogging a pretty fun way to pass the time. Is that what you are doing?

  93. hey spine "doc". I think it’s you that needs to check yourself. You continue to jump on this blog between "turn over’s". Don’t you have some add on codes that you need to get dictated. Or is that micro disc that you just did taking up to much of your time? Most of my real Spine Docs (the ones that perform and treat real spine complexities) don’t have time between room turn over’s to be surfing the internet yet, posting on some spine blog. If you are looking for intel on how you can join a POD, I am sure one of your reps could help you with that.
    And while I am at it...YES I know for a fact that I have surgeons that need us to walk through an operation! I have a major teaching hospital and the residents are always left alone when it comes to the instrumentations and have to basically walk them through step by step how the instruments are used and how fricking far to counter sink a pedicle screw. What would happen in that case? It would require the attending to be present in every room and every case. Not a chance at this hospital!

  94. OSD,

    Good ones dont of course. Back in "95", as another opined to return to, my surgeons routinely did cases with me in the room. But, there are plenty who most definitely do.

    Its not the surgeons that cant do without the rep, its the hospital. As reviled as the sales rep is, and as badly as we are treated, just short of being fingerprinted to get in, we have spoiled them to a degree, where they dont have to do much of anything. Hell, most hospitals dont even call when cases are scheduled.

    Ive heard of hospitals going this no rep route in general orthopedics and it being a complete failure. The hospitals would be the ones in for a rude awakening.

    Could it be done, sure, but it aint easy.

  95. i meant "without" me in the room.

  96. 8:02

    That was yesterday. No cases today. Just blogging.

    As 7:17 pointed out "you don't want the truth".

    You all provide these services because your livelihood depends on it. You are competing on pricing because the consumer is now shopping. Your services are important, but at some point, you may not be compensated for these extra services. At that time, doc's, OR staff, residents will learn the nuisances of the hardware, because they will have to.

    Get your head out of the sand boys.

    BTW, most spine surgeons I know, also share my experience of declining surgeries. Or, if they can justify it, are changing their indications.

    Either way, the payers are not authorizing the more controversial indications, and the patients are not willing to pay out of pocket.

    Happy Blogging.

  97. Old Spine doc,

    Great posts. To everyone on this forum - this guy is relating to us. He's dealing with similar issues that are presenting themselves in different ways.

    He has a declining # of surgeries, just like we do because we have more ankle bitter companies, POD's, etc to compete against.

    Patients going overseas - that's bad for all of us

    Pricing issues - docs make less than they used to and so do we.

    I am also really glad to see Kathy on here, looking for answers about her husbands surgery, taking matters into her own hand, and fighting for what she believes in.

    And to MM - way to keep up with the posts. The new content has been flowing!! much appreciated and as always; well written and relevant.

  98. Could 'Kathy' redefine the mission of TSB's site?

    Industry, Providers and now Patients!

    'Something's happening here
    Ah what it is ain't exactly clear
    There's a man with a gun over there
    Tellin' me I got to beware

    I think it's time we stop
    Children what's that sound
    Everybody look what's going down'

  99. Seems grandma has discovered this blog, so let's keep it clean boys.

    "Solutions for the Aging Spine". Indeed

  100. Old Spine Doc, Kathy, MM, Globus Going Public, and the numerous anonymous posters who make
    this blog informative and entertaining, have a great Memorial Day weekend! And while doing it, remember those who have made it possible for us to freely share our opinions on this blog. We may bitch about PODs, bash the competition, whine about surgeons / reps / hospitals being greedy and making too much money. But in the end, its great to live in the USA and have the freedom to earn a nice living doing what we want to do while openly raising concerns about our industry.

    While Lee Greenwood may not be The Boss, I think he puts it in perspective well.

    I'm proud to be an American
    where at least I know I'm free,
    And I won't forget the men who died
    who gave that right to me,
    And I gladly stand up next to you
    and defend her still today,
    'Cause there ain't no doubt I love this land
    God Bless the U.S.A.

  101. 8:55 a.m. Not a grandma yet.... I'm the proud holder of several triathlon team medals. You can be 64 and not withered away! Kathy

  102. Spine Rep from CaliMay 27, 2011 at 10:05 AM

    Spine Doc could you please give us your feelings on were you think the market is shiffting? What new technologies are you most interested in now that there are over 2000 cervical plates and 5000 pedicle screws out there. What is next? Being that there is more than one way to skin this cat.
    I can rememeber being in a Spien Conf mtg not just 7 years ago where Dr. Vaccaro himself said that "we are still in the stone age when it comes to treating the spine". Just wanted to get your feelings.
    Byt the way...I am the Rep that made the Jack Nicolson quote. Nothing but love for ya Doc.

  103. Kathy, you go girl!!!

    MM, we should make Kathy the Honorary Patient Advocate for this site. She has rebutted all the crassness, criticism and ignorance with class and grace. Each time, putting a knucklehead in his/her place without so much as a frowning "smiley face" to add! Besides the greed that exists in every discipline, Kathy and her husband are the reason we do what we do. Providing a service that yields a positive outcome! At the end of the day we should feel very satisfied that we do have the best healthcare system in the world!

  104. 9:29
    I read your post and immediately just scrolled to the bottom to respond.
    I DO believe your claims. AND, I can bet a lot that the insurance was Work Comp or a really good private insurance. ... No way it was Medicare/Medicade.
    I do believe you have recourse. You should call your congressman, your insurance commissioner and the insurance company. Also, call the CEO of the hospital and call him out on fraud. You're totally getting bent over.

  105. On the other hand, you live in Santa Barbara. So WTF. You're rich. Who cares.

  106. Hello Guys and Gals. New to the Spine blogger and enjoying it so far.

    I am trying to reach out to the Reps that are from California on here to see pick their brains as I am trying to locate a fellow rep that I have known for years that has just dropped off the radar and soliciting your help.

    He was with Zimmer Spine up in the Northern California area. I would post his name but don’t want to solicited back lash. If you are from N.CAl you probably know who I am speaking of.
    Thanks for the help. And all have a great Memorial Weekend

  107. 8:27, Kathy and 10:05,

    I really have enjoyed the debate and appreciate any kind and civil words.

    Yes we are all in this together. My original reason to post on this blog is secondary to the comment about "scumbag Doc's in PODS".

    As 8:27 eloquently stated, physicians are also in the same boat as you. And from a pure business standpoint, we are also looking for ways to preserve income. I am not it a POD, but I have been tasked to explore various options that may be attractive for the coming debates on Accountability Care Organizations. That is why I, just like most Materials Managers, and Hospital purchasing people look at all these blogs.

    Face it, we the physicians are fighting for the same dollar you are. In a zero sum game, someone getting more, others get less.

    POD's are direct competitors to the sales team. Interestingly, the manufacturers supply to both the POD's and the sales team (how's that working out for you Alphatech guys?). So, in effect, the doc's are competing with you.

    I guess you can try to form DOP's (Distributor owned Physicians) to compete, but you tried that already. The "old fashioned" consulting deals are now under scrutiny. I doubt if you really want to hire your own spine doc's so that they can use your products.

    The real challenge to both the doc's and the sales reps is the next iteration of the business cycle.

    As Doc's get bought out and join the hospital, the hospital does not need a POD. The contracts can read that a share of savings of revenue by cost management (lower implant costs) is divided with the physician.

    That is the true beginning of the end.

    As far as new products, you have correctly defined that screws and plates are now commodities.

    There has to be a new paradigm. Maybe biologics that work? Diagnostics that better define who needs surgery is also the holy grail. If you can do a test that will tell you if a patient needs surgery, then the insurance company will pay for the procedure. The workers comp people will believe you, and the auto insurance company will more likely settle with you. If the test is normal, then everyone saves money.

    Here in Florida (am I giving too much info?) we have the infamous Laser Spine Institute. While i do not agree with many of their protocols, they are making the true minimally invasive options more appealing. If we can develop MIS techniques that can truly speed recovery, and return to work, patients and payers will pay for these treatments.

    I am afraid the days of the mega thousand multi-level constructs are coming to an end.

    Thanks for letting me vent. I hope I have more cases next week. I am running out of things to say.

  108. 10:20 a.m. NO, NO and NO...My husband was born in SB to parents who were caretakers living a financially minimal lifestyle. We got financially chased out of SB when my husband took his 42 year retirement working his ass of as a heavy equip operator. No time in that trade to toast docs at lunches for taking on your fav products. No memberships to health clubs and spas, No golf trips to kiss butt....just 42 years of 4:30 a.m. - 7:00 p.m. days.... raising four fabulous sons and sending them all to college through knuckle busting work. Now live out of CA completely.. existing on union pension which has shrunk in the last few years. NO this IS NOT a work comp case nor Medicare. Have a drink for me at your next pow wow! Kathy

  109. Kathy I still think you are barking up the wrong tree my lady. You are speaking at a bunch of rep's and I have NOT seen a posting response from any of the "DR's" on this blog. We charge what the hospitals will allow us to charge, some more, some less depending on CAP pricing. You need to take that bill to your insurance co which I know you have and have it out with them. All your doing here is bitching and complain for something WE as reps have NO control over. Yes, I would have LOVED to have had the 30% commissions on that total bill your husband has. Maybe nextime "buyer beware". Go to your surgeon and ask him/her how much their cut was and see if they will tell you? Probably NOT!

  110. 8:02

    BTW, I would not tell anyone who you are. I am sure Kathy would be shocked to hear that you are teaching the residents how to put in screws on live patients while the attendings are elsewhere.

    I bet the hospital admin, The state licensing board, the insurance company and HHS would also want to "question you".

    A few years back, a few residencies almost got canned for the same issues.

    I guess you do work hard for your commission. But in your case, you should probably charge a surgical fee as well.

  111. again Old Spine Doc side steps any of the questions presented to him. Are you still preforming Cloward ACDF's as well man??? Or r you just "assisting" now?

  112. 8:02 here Spine Doc. I am sure Kathy would be shocked to hear many of the things that we as reps have been asked to do either in or out of the OR. rememeber this is a blog so WTF. Let me ask you, how many times have you asked your Rep to tie your gown up for you? To move the C ARM a little to the left or right? To move the monitor for you? Or better yet "hey can you answer my cell phone and tell my wife I will be running a little late"?????????? How many times has your rep found that missing Pinfield 4 that the scrub tech missplaced before he/she went on a break. Or helped you figure out how to remove some random pedicle screw construct because you neglected to figure out who's system was in that patients back before you cracked them open?

  113. 11:25

    I guess my previous post did not make it. I appreciate the new cordial tone of the conversation.

    As 8:27 pointed out, we are in this together.

    But now the business climate has changed. We are now in a zero sum game.

    If someone makes more, another will make less.

    Doc's are also struggling with reimbursement issues. Naturally, we want to preserve our income, just like you. Well now, we are competitor via the POD's. Interestingly, the manufacturers are willing to supply both of us (hows that working out for you Alphatech reps?).

    To compete against POD's, maybe you should form DOP's (Distributor owned Physicians). I guess you tried that in the past. But those "consulting" arrangements are now under scrutiny. I guess you can try to hire your own spine doc's to put in the hardware?

    The next iteration of the business model will happen when the Doc's are bought out by the hospitals and employed. You will no longer need POD's. The hospital will build in a contract where cost savings (spine hardware, etc) are shared with the doctor. In that scenario, there will be no issues to the DOJ. Scared?

    As far as the future, screws, plates and cages are now commodities.

    The future may be in biologics, but it will also definitely be in diagnostics. If there is an assay or test that confirms the pain is from the hip, or knee, or spine, then insurance companies will be willing to pay for surgery, workers comp will believe the worker, and auto attorneys will get their settlements. If the test is negative, it is negative.

    I am in Florida. I do not agree with much of the Laser Spine Institute protocols. But they have identified the fact that patients are willing to pay for outpatient MIS procedures. In the future, technology that allows faster return to work, via outpatient surgery will still grow and prosper.

    Don't get offended guys.

    I hope I have more cases next week. I am running out of things to say.

  114. ... btw Kathy, don't worry too much about the FDA warning letters. While no company likes to get them, and they do indicate that somewhere in the sales, marketing, QA, etc. process they've made a misstep, it's not necessarily associated with an actually defective product. Even big and reputable companies receive them following FDA inspections every now and then. For example, here's one a Johnson and Johnson company recently received:

    AlphaTec has been around a while and I wouldn't worry about there being some sort of defect with the implants your husband received. And no, I neither work for them or am affiliated with them in any way.

  115. Hey 11:30, aside from your last point for which a rep can be a truly invaluable resource, every one of the things you listed can be done by circulators at a fraction of the cost of a rep. Why are we paying reps to stand there and do a job that a much "cheaper" person can do? We don't pay surgeons to do a nurse's job and turn over a room?

  116. Kathy,

    The earlier poster was exactly correct when he/she said you are mis-directing your anger. I have had a hospital actually say to me, "whoa, do not drop your prices too much, we can only mark it up 5x and at your quoted price we will be leaving money on the table".

  117. 11:50 this is 11:30. My point was explaing to Mr. Old Spine Doc that we reps are asked to do many things that are "not allowed" in the OR, aside from telling the residents how to place pedicle screws...oops watch out for the Dura. He tried to point out that this "kathy" would be suprised that I am actually explaing to the residents how to place screws when this is jsut a small fraction of what WE as reps are asked to do on a daily basis.
    Sure they circulators can do our jobs, but then who will they have to make themselves feel better when they bitch at us for walking in the wrong door or not wearing a stupid badge or standing just too close to the table...?

  118. 8:02, or is it 11:30

    This is what you posted.

    ...YES I know for a fact that I have surgeons that need us to walk through an operation! I have a major teaching hospital and the residents are always left alone when it comes to the instrumentations and have to basically walk them through step by step how the instruments are used and how fricking far to counter sink a pedicle screw.

    I am glad you clarified. Refund the surgical fee. And yes, if you were not in the room, someone else would do those functions.

    My longer posts are not being published. But, I think you have an idea how I would respond.

    Have a Great Memorial Day everyone.

  119. OSD - Thanks for contributing to the BLOG! You are both relevant and civilized.

  120. Kathy
    Don't get too upset until you actually see what the insurance company pays and what you are asked to pay. In my state, the insurance companies negotiate a price they will pay, regardless of the charges. The patient is not responsible for anything more than the negotiated price minus what the insurance company pays, which may be a percentage of the ALLOWEDcharge or a fixed copayment. The amount they charge has to do with future reimbursements from insurance and Medicare in many instances. However, unless it is work comp, they NEVER expect to get paid what they charge.

    My wife had a minor procedure, the charge was $21000, the insurance paid $1200 and my copayment was $300 and that was the end of it. Just hold tight, charging outrageous amounts is nothing to call your congressman about. However, if you get a collection letter for the full charge, then start writing!!!!

  121. 11:05 & 11:59...ok guys and dolls, I'm calling a truce! Because the heading of this blog opens with: "The people's blog site where news, ideas, job opportunities and what's been heard on the street can be discussed in a professional manner." My very first blog on this site was, "Can someone shed some light on this matter...." I got some really kind advice and some f___ off's. I only asked for some assistance. All responses since have educated me. I NEVER said I was angry at reps though I do know that some reps have more involvement in POD shenanigans then meets the eye. I'll say it one more time.... I'm only DISHEARTENED. If the hospital only charged a 3 x markup on a $900 screw instead of an 8x on the screw our out of pocket pay be a heck of a lot more manageable. 30% of $3000.00 per screw would not have been as shocking as 30% per $8000.00 per screw. As of yet we have not received (been 6 months) a bill from the surgeon but from a database our insurance company posts on pending claims... the surgeon charged the insurance company $53,000.00. I'll wait for the mailman to deliver the news...Meanwhile... I think I'll go listen to Springstein holler, "Pay me my money down" "If I was Mr Gates, Pay me my money down, they'd haul my money away in crates, Pay me my money down.

  122. the really good news here is the old gain sharing model coming back to light. Hospital buys direct from Spine Co USA at a discounted rate and splits the profits with the surgeon. OIG endorsed BTW. still cutting out the middle men reps and distributors. Docs still profiting from surgeries. OIG endorsed BTW. AND Guess what?? something else for you slack jawed reps to boo hoo about on the Dear Abby of the spine world. but nothing you can do about it this time becase it's OIG endorsed BTW!

  123. WOW! 2:29 are you the fat bitch that sits at the front of the physiatrists office? I bet you would rather be eating a donut than working the keyboard with your sausage-fingers. You must be out of breath BTW!

  124. Found out today xspine has no loyalty to distributors "watch your accounts keep them away from your surgeons and trust no one"

  125. 2:37 great F-ing post my man! I say go ahead and purchase direct from Spine Co USA, please plase please then we can create another blog called "and another hospital f*ucks it up for everyone" or better yet "there was this nurse in the OR that didnt inform the scrub tech to set the depth gauge when the surgeon was drilling and now my husbands a quad. Seems like she was to busy with all the other shit she has to do, like gossip about the rep standing next to her earing 2x her best month". Now thats a funny blog BTW! And I got your OIG right here...

  126. Pretty sure he has a bunch of stuff going on with the red headed fat guy out of phoenix and can't be trusted!

  127. hey what does AIG have anything to do with this? Didnt they go belly up? ;)

  128. Old tired ass- skills eroded spine doc. I'm pretty certain I've been in cases with your ilk.
    If you're doing an ACDF and you take longer than an hour you got no reason to be operating. Not to mention as long as 12 hours. That's right. Been there done that... and plate crooked... screws all jacked up. I mean seriously, WTF.
    Plus, anyone who has worked in the University settings know that we teach the residents. (not to mention shabby fellow programs) I was in on a case many years ago... as usual, the attending didn't even show up... and the resident was closing and didn't even remember to put the bone graft in... so, a gentle touch on the back, a nod and eyebrow up... "oh yeah, thanks"... and so it goes. Good reps increase the value with good service.
    Drop dead all ready you fucking butcherer. I hate you for what you do to people. I hope the public DOES find out about SpineBlogger and they see what scum this industry really IS... reps/companies/doctors... the whole lot. WHORES. Fuck off and I hate you all.

  129. LMAO @ 7:52!!!!

    The last line was pure gold, I wish you all could have seen it before it got wiped off the blog! I seriously laughed out loud....thank you sir!

  130. 7:52 right on right on right on BRO! See this is what I am talking about! I mentioned many hrs before about the University setting and what WE reps have to do to save some asses. The gent puts it into words I have to echo. I can’t tell you bro how many x's that has happened to me and still does. Resident almost forgetting to torque down the sets screws or asking US "does that cage look counter sunk to you". WTF. We earn every $$ we get and then some. If you haven’t worked in a University setting then shut the f*ck up. You go try standing in the OR for a single level ACDF case that last 4-5 hrs then with a room turnover of another 3 hrs waiting for your next case to start, only to find out that they can’t even find the f*ing patient and now the whole case is canceled.
    But I will argue I don’t like the word WHORE, I prefer Male Gig my brothers.

  131. To 7:17 and 8:02
    If you feel you are indispensible, I would like to introduce you to my friends the buggy whip maker, corona typewriter salesman, polaroid camera manufacturer, travel agent, and soon to be friend newspaper deliverer.
    No one is indispensible in good times or bad. business models constantly evolve as new entrants challenge the status quo. This is the nature of business.
    All of you should read a classic 1979 HBS article entitled Porters 5 forces which defines the competitive intensity and attractiveness of a given market. Then put it into context of the spine market.
    I am a surgeon who does not belong to a POD and I disagree with their basic premise. However, what you are seeing is the first disruption of a supply chain that can not withstand current economic forces. PODs will go away as the power is taken away from the surgeons. However, as the business model evolves to address margin compression, where will the model be compressed? The model may evolve into bulk purchase commitments at significantly reducing pricing structures. The power lies in the manufacturer and the hospitals. Be aware of what is heading your way.
    I happen to enjoy my local reps and I try to feed many of them. I don't begrudge what they make but am concerned that most of them are business naive and akin to those poor people on the beach in Thailand who were stunned to find the ocean retreat only to be overrun by the tsunami.
    To old spine doc, it is clear that this country can not economically afford thousands of fusions at a high price structure. You are the nidus of a large cost center to all insurance carriers. I learned to do my own lumbar epidural/facet injections to participate in a greater continuum of care years ago anticipating this economic change.
    signed, middle aged spine doc. MD/MBA

  132. Middle Aged Spine DOc this the the rep that made the comments about the University settings. I could no agree with you more!! You made some very vaild points and I as well as your Reps appreciate your business.

  133. I am neither a surgeon nor a rep. You reps are idiots to think surgeons need you. Many in you don't even have college degrees and you are comparing yourselves with people with much higher aptitude as well as decades of education. If a surgeon needs you so badly, why do you sacrifice your pride and integrity everyday, being a yes man while you set new brown nosing lows struggling to win their loyalty? If you had any value other than a simple courrier service, you wouldn't be so desperate to establish your worth to them.

  134. 9:34 - Right on!

  135. Hey 9:34, if you’re not a Rep or a Surgeon then you must be some fat nurse that either pissed she missed the boat or a fat ass office "clerk". Either way I don’t care about your opinion until you pick up a bag and go out there and try this business on for size. You have absolutely NO idea what you are talking about if all you think is WE have no college education and are "just a courier service". There is so much the general public (this means you and your fat ass nursing staff), doesn’t see what services are provided by us reps. Sounds like you are just tired of earning that $12.75 hr paycheck and pissed that Uncle Sam took 27% of it. Get real. I have a BS for UC Berkeley and I would challenge half the surgeons I work with to an aptitude test. And did you say "decades of education"...please, please inform yourself a little better.
    We are not saying the surgeons need us so badly, I am saying the whole system needs our services and that not just to drop a set off show up for a case and "brown nose". Do you even know where the Transarticular facet joint is located? How about an easier one, the f*ucking TP's???

  136. I've been in over a thousand cases... with multitudes of surgeons with varying disciplines. I've also been in training with top tier companies and excelled to train surgeons in labs myself on various techniques, etc.
    Compare this to one surgeon, who trained under one Fellowship, and has had limited exposure to any other technique, company, etc.
    We ARE the experts. And, the EXPERTS will survive... as we do provide a valuable service. Cocksuckers and brown-nosers will become extint. Thank the good lord.

  137. It cracks me up to hear reps that think the patient would be harmed or the surgeon could not function unless the rep is there for every case.

  138. Hey Guys, I think we definitely touched alot of nerves. Be careful what you say about Old Spine Doc. He may be your "favorite spine doctor" that you call on.

    I am like Middle Aged Spine Doc, old to me is finishing fellowship in spine in the early 1990's.

    I went through all the consulting deals, and drank the poison. I helped with the "training courses" that some of your surgeons and, also many of you sales guys attended.

    I sat with many of your champions surgeons on panels. I chuckle about the comment on Alex Vaccaro. What else is he going to say? Of course there are lots of technologies coming out in the future. Seven years ago, that meant more consulting deals.

    There is alot of conspiracy scenario's about the "military-industrial complex". Well, you guys are pawns (as the doc's) in the "medical-industrial complex". The companies are extracting $$ from the public via government plans, insurance plans, and paying us pawns a few pennies on the dollar.

    I also do my own ESI's, and find that non-surgical care is often times better.

    That does not sit well with you, the hospitals, and of course your masters at the "complex".

    BTW, I do not have ownership in a POD, but I am tasked to see how we can use similar models for employed physicians, similar to the comments made by 2:29. That is why I am on this blog site.

    I am not employeed...yet, but we all know that is coming. I hope to semi-retire by then. In the meantime, I have to help shape the "new world of cost effective medicine".

    Compete well everyone.

    From the sales guys perspective, understand that it is only business. It is nothing personal. IF I had to chose between you getting the deal, and me getting the deal...well you know the rest of the story.

    BTW, if you are paid ony $50k a year to be a sales rep, would you still do all the things you say you are doing?

    Too hot here in Florida to do anything else this afternoon. I guess I needed to respond to your kind comments.

  139. 9:45, 9:34 here. Just because you had a crash course in anatomy, don't think you are at the level of any if the hospital staff other than the custodian.

    I earned $400k last year as I am the CEO of a spine device company. I may be mistakenly employing you. What is your name?

  140. 1:04 or Mr. CEO of some spine device company. My "crash course in anatomy" comes in way of a BS in Human Kinesiology and I am a rep, of 12 years might I add. That my friend makes me somewhat of an expert in the human anatomy. Where do you get off trying to flex your money muscle of $400K a year? Does that make you proud or some expert? Please give me a fucking break you pathetic piece of shit. I have a name for you... Mr.Blow Me! You need to take a reality pill my fellow rep, cause thats what you are right? Or did you work your way up the corp ladder blowing your way there?>

  141. 9:12, I see you avoided the question... Lame ass...Isn't your degree what you get if you want to be a high school PE teacher?

  142. Hey look at me, look at me I make $400K a yearMay 29, 2011 at 8:55 AM

    ok Mr. Big Shit CEO of some Spine Device Co. Tell us your name??? You seem to want to rip this other rep with a degree in kinesiology? Isnt a CEO position a job for a washed up old rep that couldnt make his quota, so they decided to feel sorry for you and make you a CEO of some "spine device company" that is probably in the back of your car. How does it feel pushing that pieace of shit metal you call a spine device? Please inlighten us your wholly one?? And just what was your question for the bunch?? All we saw was a bunch of blah blah and you saying something about making $400K a year? I am sure the patients and hospital staff that read these blogs would love to know how much you are making. so please go on....

  143. ... yes folks, I think we have reached a new low in TSB history. Bumfighting anyone?

  144. What is bumfighting?

  145. ... no urban dictionary needed. Just means paying bums to fight. For an only mildly humorous Daily Show parody check out

  146. your bum hanging.

  147. Back to the issue.Where did PODS come from and why is Martin Memorial really issuing this decree? Truth be told,PODS are a direct reflection of the frustration reps and medical device manufacturers have been dealing with for years. These biobyproducts include poor reporting,shabby supply chain management and requiring the rep to monitor inventory in the field while being a product expert and drum up new business all while hitting sales quotas that are butting up against ridiculous capitated pricing. Don't forget the family that never sees him/her with the garage full of product and enough packing material to suffocate the pink elephant in the room we all call Obamacare which translates to "Tax the Man" and make the rep pay for it. The result, inflated pricing, hammered commissions and capitated hospital pricing, so what happens then? The reps best friend (the surgeon) joins the rep hand-in-hand because after all he can't get reimbursed for a damn thing, and they start a POD and send it right back to ensure their cut in the game is covered. The hospital is pissed because now it is an integrity issue that may affect their future bottom line. Next CMS gets wind of all the money being pissed away on their dime. Here's the solution you are all avoiding for whatever reason (I guess they got use to feeding the cat rather than putting it out of its misery).First off you will NEVER get rid of the rep in the OR,he/she is as important as the light you use in that room to stop from bumping into each other looking for the handle to the widget thingy. Hard knock education or not they are the expert on the product that has done more cases with patient and surgeon or on cadaver than anyone in that room. So what can we do to make everyone's life more profitable so the rogue rep doesn't go on a POD development spree using the greek alphabet as a red light on a dirty new alley everyone despises. Stop making him chase inventory, outdated PO's and a courier that can't afford a GPS. Start investing in technology...throw a tracking system on the inventory so you don't lose it and he doesn't have to account for it, automate sales reporting through an IPAD or the like, make it easier to fill in a charge sheet with drop down menus and a send button, burn ALL fax machines, simplify REPtrac, give him an education grant if its in question, invest in his future, give his family stellar benefits as a thank you, and love him/her like your favorite teddy bear because he/she is making sure that everything you truly need for surgery is in that room present and ready-to-use - why? because the hospital staff doesn't have a clue nor the time to keep up with every new widget thingy.To the Manufacturers...flush the red tape and run more efficiently. Lose the egos and stop the riff between the sales wing and the inventory guys...invest in tech and save the trees...automate everything. The upgrade is long overdue...please pull the trigger! Ship less and save more, can a guy hold on to a tray for a few more days? Look around, everyone cool is doing it!In a modified version from the Ol' Col. Jessup to those who question the rep's role in the OR..."And my existence, while grotesque and incomprehensible to you, saves lives! You don't want the truth, because deep down in places you don't talk about at parties, you want me on that wall! You need me in that OR!We use wordslike "honor", "code", "loyalty". We use these words as the backbone of a life spent defending something. You use them as a punchline! I have neither the time nor the inclination to explain myself to a man who rises and sleeps under the blanket of the very freedom that I provide, and then questions the manner in which I provide it! I would rather you just said "Thank you," and went on your way. Otherwise, I suggest you pick up a lead jacket, a surgical mask, and stand a post. Either way, I don't give a damn what you think!"

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