Reimbursement &
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, Boston Healthcare provides 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 Studies

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.

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.

Reimbursement Assessment and Strategy for a Biotech Company’s
Development-Stage Cancer Vaccine
±

Objective

A biotechnology company was developing a personalized cancer vaccine and was preparing to enter Phase III trials. Since the procedure to manufacture the vaccine required a cell harvesting procedure in addition to the vaccine administration, attaining coverage, coding, and payment for the product needed to incorporate the process to acquire the cells as well as the final product. In addition, the patient population was primarily covered by Medicare, and issues pertaining to Medicare reform and payment reform for drugs and biologics covered by Medicare impacted distribution of the product and Medicare coverage and reimbursement. These issues were also influencing private payers.

Boston Healthcare Approach

Boston Healthcare developed an implementable strategy for preparing to secure appropriate and consistent coverage, coding, and payment through research with physician stakeholders, Medicare Carrier Medical Directors, and cell collection providers to assure that data captured in the course of the Phase III trial addressed questions likely to arise in the technology assessment process by physicians and payers. Boston Healthcare recommended timing for initiation of other reimbursement activities and tactics to be completed prior to launch.

Outcome

The biotechnology company incorporated findings from Boston Healthcare’s recommended strategy into their ongoing Phase III trial and engaged Boston Healthcare to conduct follow up research to incorporate updated distribution models and to account for the impact of a recent Medicare legislation in commercialization plans.

Situation Analysis and Implementation of Reimbursement Plan for Greater Utilization of FDA-Approved Product for Small Pharma Company ±

Objective

A small pharmaceutical firm with an FDA-approved product had been unsuccessful in achieving strong sales and reimbursement, despite early targeting of private managed care organizations (MCOs) and the VA, the two groups identified as key payers for the product. Boston Healthcare was engaged to conduct a situation analysis to define the causes of the low levels of utilization and reimbursement.

Boston Healthcare Approach

Boston Healthcare developed a strategy and plan for increasing awareness and maximizing reimbursement. Functioning as the national accounts component of our client’s sales force, we confirmed or achieved coverage for the product in 152 MCOs and PBMs accounting for over 21 million lives.

Outcome

Boston Healthcare organized and spearheaded a successful regional effort that resulted in our client’s product being added to the new VA National Formulary. Reimbursement status at key payer organizations was communicated to field sales representatives to facilitate greater utilization by providers and patients.