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The idea of so-called "demand matching," or technology-appropriate utilization, as I prefer to call it, is not new. First endorsed in a 1992 position statement by the American Academy of Orthopedic Surgeons and updated in 1996, the concept holds that while final authority for selecting implants belongs to the treating physician, orthopedic surgeons should nonetheless work with hospitals and fellow physicians to adopt criteria for selecting implants based on individual patient needs.

"These patient implant needs should be matched with appropriate implant design, and orthopedic surgeons and hospitals should develop strategies for cost containment in purchasing appropriate implants," the academy said.

Although some momentum was generated around the idea of better implant utilization after the academy’s statement was released, much of that forward motion has been lost in the intervening years.

Yet matching technology to the patient’s lifestyle, physical demands, age and medical history has never been more important as the costs of hip and knee replacement technologies continue to push ever-higher. It is not uncommon to see 10 percent price increases in existing technology, year in and year out, with newer iterations of older technologies frequently touted as revolutionary or ground-breaking.

In many cases, average implant costs are now running at between 60 percent and 70 percent of Medicare reimbursement. I have even seen instances in which the implant consumed upward of 90 percent of the reimbursement. In almost every case, hospitals will lose money when the implant absorbs such a large chunk of total procedure payments. Generally speaking, the implant expense should not exceed 40 percent of reimbursement.

Many observers may wonder why physicians need any help in figuring out which technology makes the most sense for a particular patient, but as the types of available orthopedic implants proliferate, identifying the ideal piece of equipment can be a confounding experience.

More to the point, physicians – like everyone else – are susceptible to the natural human tendency to want the "latest and greatest" technology. This is especially true in orthopedics, since the actual procedures for installing competing technologies – be it a "next-generation" device or something less – are virtually the same. It is true that new, minimally invasive techniques hold for the promise of better patient outcomes with less surgical trauma, but they’re not likely to alter the interchangeability of various implant devices.

The problem of physician-technology overreach is made worse by a sales process that leans heavily on the individual relationships formed between the sales representative and physician. This kind of approach has its benefits, but too often it gives the salesperson undue influence in the device selection.

Materials managers can help gain better control of implant procurements by spearheading the development of implant criteria at their hospital. Enlisting the support and cooperation of the service line manager (if such an individual exists at your institution) is an important first step. By presenting the manager with historical information about the utilization and price points of various implant devices, a clear understanding of program costs can be created and a baseline for improvement established.

It then becomes the responsibility of the service line manager – or, if none exists, the chief medical officer or hospital administration – to enlist orthopedic surgeons in developing the actual utilization criteria. Physicians will naturally have their own ideas and preferences about which technologies are most appropriate for specific kinds of patients and a fair amount of back-and-forth can be expected before a consensus is reached.

Nonetheless, by considering implant longevity and performance versus a patient’s age, physical demands and medical history, a list can be developed to match the appropriate technology with a variety of patient types and requirements. For example, a professional athlete is going to have very different needs than an elderly, less-active individual. As part of this process, it is important to inform physicians about the relative costs of each technology so that they become sensitized to the financial implications of their decisions.

One point to make with physicians that should stimulate cooperation is this: A well-conceived implant criteria developed jointly by physicians can serve as an important defensive weapon in the event a patient sues over the type of technology used. By developing the criteria, the physicians and hospital effectively have created a standard of care for the community and thus are less vulnerable to legal attack.

Once an agreed-upon criteria has been established, the materials manager and service line manager can follow up by tracking utilization by physician each quarter with the objective of ensuring guideline compliance. Naturally, the criteria need to be revisited on a periodic basis in order to take into account significant technological advances.

After the orthopedic utilization program is well-established, the materials manager should look to other service lines where technology appropriate utilization would be beneficial. Ultimately, the overarching goal is to establish relationships with key surgeons and the hospital leadership aimed at jointly tracking quality, cost and outcomes on a continual basis. This is just one more step in that process.