how the US medical technology giant is setting up in French hospitals

"Integrated health solutions" offered to health facilities; ultra-high-tech operating rooms delivered turnkey, as well as a real business plan to develop their turnover and optimize their management; Offers of "partnership" ranging from price discounts on medical devices to the supply of equipment financed by the manufacturer: this is how Medtronic, the world leader in medical technology, pushes the doors of French hospitals.

The "Implant Files" survey, conducted by the international consortium of investigative journalists (ICIJ), whose research unit of Radio France is a partner, badyzed the Medtronic strategy. It reveals counterparts and shows that this policy is not disinterested.

Methods challenged by the American justice

Medtronic's know-how is celebrated around the world. The American giant manufactures medical devices that help control diabetes or relieve Parkinson's disease. The company was born in 1956: the founder of Medtronic then invented in his garage the first battery-powered pacemaker, the size of a smartphone. Since then, the manufacturer has become the world's leading medical technology manufacturer, inventing a wireless pacemaker, fat as a vitamin pill, defibrillators and state-of-the-art insulin pumps. Present in over 160 countries, Medtronic generates $ 30 billion in revenue.

But to rise to the highest level, the medical devices giant has used methods challenged by the US justice. The list is long. In 2006, Medtronic was ordered to pay $ 40 million to the US government. He is believed to have paid bribes to more than 100 surgeons in the form of fake fees for advice or exotic travel. In 2008, the group received a $ 75 million fine. Justice accuses him of having pushed some hospitals to carry out unnecessary care reimbursed by Social Security. In 2011, he spends $ 23 million to stop the prosecution of the US government for failing to pay doctors for scientific studies, while Medtronic wanted to encourage them to put his implants. Same in 2013, with a fine of $ 10 million, and in 2015, $ 4.4 million. The multinational would have lied about the origin of some of its products by claiming that they were made in the United States, while they came from China or Malaysia.

Interviewed by the ICIJ consortium, Medtronic headquarters denies any wrongdoing and claims that it is now strictly complying with anti-corruption laws.

Gifts and other trips to doctors would not have been limited to the United States. In France as well, these practices would have taken place, but they would be done by outside agents that the company had recourse until 2014. A former technical-commercial executive of Medtronic testifies: "The sales agents had some sort of gift rack that they could offer depending on the type of pacemaker that was implanted." It was not complicated: you could pay for a vacation before or after a convention when it was held in the United States. In the United States or Canada, for example, the agents had a credit at a travel agency, and the doctor could change or cancel his flights freely. "

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These practices would have stopped because, according to this former Medtronic executive, "The risks were getting too big and the lawsuits in the United States made them lose a lot of money." When asked about these practices, Medtronic denied any allegations of corruption.

From "partnerships" to immediate benefits

In 2016, change of strategy. To conquer the markets, Medtronic's CEO, Omar Ishrak, is now offering "integrated health solutions" to healthcare facilities. To offer these services, Medtronic has a structure, the "Integrated Health Solutions" department, which has so far signed 80 "partnerships" around the world, including a dozen in France.

The Rouen University Hospital inaugurates in 2017 a new state-of-the-art rhythmology room dedicated to the treatment of heart rhythm disorders. It allows to reconstruct a 3D image of the heart chamber to understand the origin of the arrhythmia. Medtronic is funding 800,000 euros over five years. In exchange, the hospital pays the manufacturer a percentage for each act performed. The partnership also plans to increase the activity of the hospital. This involves optimizing the beds. According to our information, the contract goes so far as to envisage a goal of five-year savings. According to our sources, 900 nights, the equivalent of 200,000 euros for the hospital. A marketing strategy is also planned on social networks to improve the "attractiveness" of the hospital.

For the hospital, the benefit is primarily economic. He would realize 700 000 to 800 000 euros in purchasing savings, which is why he receives the"Trophy of hospital purchase" for "this innovative partnership", an event organized by the Hospital Purchasing Network (Resah) in Montrouge. "This room will facilitate access to care for all"says Professor Frédéric Anselm, a cardiologist in charge of the CHU's cardiology unit. "This public-private partnership was unimaginable a few years ago.The public hospital can only be sustained by putting others in place with the private sector"enthuses Professor Alain Cribier, former head of the cardiology department of the University Hospital Center.

Equipment of a level that CHUs could not pay

Further south, in Toulouse, the Pasteur Clinic, one of the leading private sector in Europe, recently equipped eight new cardiology operating rooms with state-of-the-art imaging equipment. One of these eight rooms, Room 8, is funded in part by Medtronic for 750,000 euros, for 250,000 euros over three years.

In Plessis-Robinson (Hauts-de-Seine), Marie-Lannelongue hospital, one of the leaders in the treatment of cardiovascular diseases, also turned to Medtronic to finance a hybrid room. It allows to perform both conventional surgical operations and more complex procedures without having to operate the patient open heart. The principle is the same as the University Hospital of Rouen: Medtronic finances the room up to two million euros, and the hospital gives him a percentage on each act. According to facility management, this new room has reduced patient waiting times, and to develop Tavi's activity [Transcatheter Aortic Valve Implantation, une valve aortique percutanée posée sans opération à cœur ouvert, dont les implants valent très cher], major for the hospital ".

These partnerships include offers ranging from price discounts on medical devices to the provision of operating rooms funded by the manufacturer. Among medical devices sold by Medtronic to hospitals, a heart valve, the Corevalve (or Tavi) that can be implanted without operating the patient with open heart. The Medtronic valve costs 16,000 euros, that of its competitor Edwards 14,580 euros. according to The worldFor Health Insurance, this is the most expensive implant, with 186 million euros reimbursed in 2017 for just 11,000 interventions.

According to several surgeons we interviewed, the badessment for the institutions is very positive. "Medtronic makes high-quality, exclusive equipment available at short notice, difficult to finance for a hospital, and patients are the primary beneficiaries"explains the cardiology department head of a CHU. Another advantage: this type of contract allows the hospital to increase its turnover. "It's important because with activity pricing, it's the bonus to whoever does the most"continues the doctor. In the case of Rouen University Hospital, the contract provides for it to become a reference training center on the use of a new and innovative cardiology vest. "It has value for the hospital, not just a market value, but a notoriety value"insists the former employee of Medtronic.

Counterparts difficult to refuse

The other side of the coin is the possible counterpart required by the manufacturer. This is what worries Eric Vicaut, professor at the evaluation center of the medical device of the Public Assistance-Hospitals of Paris (AP-HP). "That an industrialist proposes to a health facility to equip a cardiac catheterization room, can be an excellent opportunity for this hospital to acquire a modern equipment, in delays that do not allow him in general the credits allocated to the hospitals ". But, adds the professor, "There must be no compulsory counterpart on the use of medical devices sold by the manufacturer.It must at any time, the choice that can be made for the health of the patient is dictated by the best risk-effectiveness ratio and is not dependent on the manufacturer who equipped the room ".

These counterparties do exist. According to our information, Medtronic's contracts with private and public hospitals contain minimum quotas of Medtronic implants to purchase. "The goal of Medtronic is to regain ground on its main competitor, Edwards, whose Tavi (the percutaneous aortic valve), the first marketed, captures 60% of the market", badyzes Chloé Hecketsweiler, journalist specializing in health economics on a daily basis The world, also a partner of ICIJ.

Rouen University Hospital, for example, is required to purchase at least 1.9 million medical devices a year from Medtronic, or 9.5 million euros over five years. The contract also provides for a minimum number of implant poses, otherwise the CHU must pay a penalty to Medtronic. When questioned, the CHU management did not wish to comment on these figures. It ensures that this is not an exclusive contract on medical devices and that the contract allows for "mbadification of purchases" more efficient.

At the Marie-Lannelongue Hospital in Plessis-Robinson, according to our information, the Medtronic contract provides for the purchase by the institution of a minimum of percutaneous aortic valves (Tavi) for each year of the contract, ranging from 90 to 145 per year between 2016-2017 and 2021-2022. Below this quota, the establishment pays a penalty to the industrialist.

Ditto at Pasteur Clinic in Toulouse, where the management recognizes that Medtronic has imposed a counterpart. "One day, confirms Dominique Pon, the general director of the clinic, Medtronic came to see us saying 'here it is, a world offer'. They pledged to finance part of the new hybrid room over three years, saying: 'we pay, provided that the market share of our medical devices is such a percentage', that I can not reveal to you ". This percentage, we got it, it is 60%, and it was achieved in 2017 at the Pasteur Clinic, according to management. Professor Assoun, CEO of the Pasteur Clinic, insists however: the choice of surgeons is free. But an old Medtronic setting tempers: "Once the manufacturer is in the place, why would the hospital buy a device from a competitor rather than from Medtronic?"

These counterparties granted to Medtronic are confirmed by a former executive of the group. "In tenders and in contracts, Medtronic's share of Medtronic implants purchased by the facility is indicated, the goal is to exceed 30% of orders to arrive at between 40% and 60%", she says. The former employee confirms. "For Medtronic, the value of these partnerships is to build customer loyalty, develop market share and sustain them over the long term"she badures.

Loan of staff made available under the guise of training

In its "global offer" to hospitals, Medtronic also offers staff loans, salaried technicians and trained by the manufacturer. "The technicians are present at the block in a logic of training and support of the medical team, including the surgeon, the installation of complex implants"Says Chloé Hecketsweiler, a journalist in health economics at World. Sometimes this block presence can become more permanent once training is complete. Questioned by The worldNicolas Dumonteil, a cardiologist at the Pasteur Clinic in Toulouse, in a contract with Medtronic, says that the clinic uses it only occasionally, "during holiday periods". "So we have an industrialist who is at the bedside of the patient and who participates in the procedure, and who, even if he does not touch the patient plays an important role during the operation", the journalist continues Chloe Hecketsweiler.

This practice is very common, according to Laurent Sedel, former head of the orthopedic department at Lariboisière Hospital in Paris. "As we have fewer and fewer staff able to help us use these medical devices, a new profession has emerged, it is the instrumentalists who work for industrialists and who come to the operating rooms to help us"he says. The problem according to the doctor is that this presence has become a marketing element that weighs in the choice of medical devices. "We select the manufacturers who sell us the prostheses according to their ability to provide us with competent personnel, so there is a close relationship between the manufacturer and the surgeon", adds Laurent Sedel.

Asked about these practices, the Minister of Health, Agnès Buzyn, recognizes that she discovers the file: "It is not normal for non-hospital staff to enter an operating theater". The minister is committed to taking action."The charter of the medical examination which is being negotiated between the Economic Committee of health products (CEPS) and the industrialists will prohibit these practices". This charter provides for financial penalties for industry and should apply in 2019.

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