Reimbursement and
Market Access

Carefully targeted reimbursement and market access strategies are the key to successfully launching new medical products in today’s cost-conscious health care environment. Our keen understanding of the often conflicting objectives and motivations of health care system stakeholders allows us to create actionable reimbursement strategies that support the range of reimbursement activity — from planning through implementation and ongoing support.

Boston Healthcare has a strong understanding of reimbursement/funding processes for pharmaceutical products, diagnostics, and medical devices, as well as the changing trends in the delivery of health care throughout the US, Europe, and other global markets (including emerging markets).

To aid our clients in gathering the necessary evidence for demonstrating a product’s clinical and economic value, we provide access to key stakeholders and decision makers (both medical and pharmacy) through our panel of global market access experts and government and commercial payers. Our research panel contacts provide insights to help assess and drive positive coverage and decision making and include private managed care organizations (MCOs), preferred provider organizations (PPOs) and indemnity insurers, pharmacy benefit management organizations (PBMs), technology assessment firms, and Medicare and Medicaid as well as hospital and provider organizations, physicians, KOLs, and patients.

Summary of Services (+)

Reimbursement Assessment and Strategy

  • Analyze existing coding options
  • Identify payer coverage and reimbursement policies and drivers
  • Examine payment levels for relevant product and procedure codes
  • Develop a reimbursement pathway for a new product outlining coding, coverage, and payment activities and timelines

Policy Monitoring

  • Evaluate changes and trends in health care policy that affect your technology

Reimbursement Implementation

  • Prepare and support CPT, HCPCS coding applications
  • Coverage management
  • Private payer engagement
  • Public payer engagement (including Medicare, Medicaid, VA / DOD)
  • Reimbursement training
  • Reimbursement education for staff and management tools

Health Economics

  • Payer-focused cost-impact and cost-effectiveness modeling
  • Provider practice-focused cost-impact tools
  • Publication strategy support

Case Study 1:
Reimbursement Assessment for Product Launch
(+)

Objective

An international pharmaceutical company needed an initial reimbursement assessment of both the inpatient and outpatient environments for their target product. Boston Healthcare was engaged to provide the full range of reimbursement services necessary to support product launch.

Boston Healthcare Approach

Boston Healthcare conducted an internal reimbursement infrastructure needs analysis, developed a white paper to educate payers and increase awareness about a specific disease area, conducted field force reimbursement training, and developed a data capture system to profile major U.S. payers for peri-launch activities.

Outcome

Boston Healthcare detailed the critical path and timeline for the relevant coding process through our stakeholder relationships and enlisting coding advocates in anticipation of submitting for a novel code. Boston Healthcare developed the key criteria for interviewing and evaluating hotline vendors by conducting a reimbursement hotline needs analysis for the target product and two additional products. Boston Healthcare was able to execute the tactical elements of the reimbursement strategic plan and develop the subsequent U.S. reimbursement strategy for the client’s target product.

Case Study 2:
Assessment and Strategy for Coding and Coverage of a New In Vitro Diagnostic
(+)

Objective

A diagnostics company was preparing to launch a new in vitro diagnostic test. Realizing that gaining reimbursement would be critical, particularly with Medicare, the manufacturer engaged Boston Healthcare to assess the situation and develop a strategy for coding and coverage.

Boston Healthcare Approach

Boston Healthcare carefully documented the current coding and coverage environment, including competitive product strategies, and suggested a proactive educational effort with key Medicare contracting carriers.

Outcome

Based on the analysis, Boston Healthcare partnered on behalf of the client with the appropriate medical specialty society to submit a request to the American Medical Association (AMA) for revising the current CPT coding. Boston Healthcare enabled the client’s technology to be included in the code description and the change to the coding was secured.