Reimbursement Planning and Implementation

Boston Healthcare has worked with established and emerging companies to create innovative market and reimbursement strategies. Below are summaries of typical project case studies:

Reimbursement Assessment for Product Launch
An international pharmaceutical company needs an initial reimbursement assessment of both the inpatient and outpatient environments for their target product. Boston Healthcare is engaged to provide the full range of reimbursement services necessary to support product launch. Boston Healthcare conducts an internal reimbursement infrastructure needs analysis. Boston Healthcare develops a white paper to educate payers and increase awareness about a specific disease area, conducts field force reimbursement training, and develops a data capture system to profile major U.S. payers for peri-launch activities. Detailing the critical path and timeline for the relevant coding process, Boston Healthcare develops coding stakeholder relationships and enlists coding advocates in anticipation of submitting for a novel code. Conducting a reimbursement hotline needs analysis for the target and two additional products, Boston Healthcare develops key criteria for evaluating hotline vendors and interviewing and evaluating hotline vendors. Boston Healthcare was able to execute many of the tactical elements of the reimbursement plan and develop the subsequent U.S. reimbursement strategy for the target product.

Pre-Launch Market Analytics for a Specialty Pharmaceutical
Boston Healthcare was engaged over a period of three years to act as the market analytics arm and generate and assimilate the market data needed for a targeted market launch of a specialty pharmaceutical in the gastroenterology market space. Over the course of the engagement, Boston Healthcare conducted a product/market opportunity assessment, a reimbursement assessment and strategy, a KOL evaluation of the product, qualitative and quantitative positioning and messaging research, market sizing, including the creation of a forecast model, and evaluation of sales material and collateral. In addition, Boston Healthcare worked with the company to test and obtain market input on several iterations of a risk management program. The research methodologies used ranged from telephone interview to in-person research at facility and web-based designs (including internet surveys and tools such as Webex in combination with a telephone discussion). A range of stakeholders were included in the numerous research projects, including physicians, patients, payers, infusion nurses, and hospital pharmacists.

Assessment of US Reimbursement Environment for Specialty Pharmaceuticals
A large oncology care provider needs to assess the evolving market for specialty pharmaceuticals. Boston Healthcare examines the approach payers take to manage specialty pharmaceuticals, and organizes these payers into a series of strategic “buckets” denoting their timelines and approaches to aggressive management. Boston Healthcare determines a key distinction between oncology agents, supportive care agents, and other specialty drugs with regard to levels and timing of management through specialty pharmacy or other options to physicians “buy and bill.” Boston Healthcare delivers a dollar volume projection of management strategies in a five year pro-forma.

Implementation Strategy to Influence Technology Adoption and Increase Reimbursement in Multiple Sites of Care
A medical device company wants to launch a new device for conducting an existing surgical procedure. The device offers numerous clinical and operational benefits, including the ability to visualize the surgical field more effectively and complete the procedure in approximately half the time it takes to operate using traditional technologies. However, since the technology is utilized in both inpatient and outpatient hospital settings and freestanding ambulatory surgical centers, it is impacted by multiple coverage and reimbursement systems and is subject to geographic and payer-related variations in payment rates. This highly complex reimbursement environment is negatively influencing technology adoption. Boston Healthcare is engaged to assess the situation and develop a strategy for securing appropriate and consistent coding, coverage and payment throughout the United States. Boston Healthcare works to develop an interactive cost effectiveness model to demonstrate the financial and operational impact of adopting the new technology. After introducing the reimbursement tools developed by Boston Healthcare, the client company realizes a greater than 30% increase in sales of its product in the United States.

Reimbursement Strategy for Novel Breast Cancer Test
A diagnostic company needs a reimbursement strategy and assessment for a novel breast cancer test. Boston Healthcare is engaged to implement a strategy to achieve appropriate coding, coverage, and payment. Boston Healthcare performs primary research with key stakeholders including physicians, payers, and laboratory directors. Boston Healthcare also performs research with key coding decision-makers to understand the appropriate coding and how the codes may change over time. A strategy is developed which aligns the clinical message with the best coverage and payment opportunity.

IVD Business Development Strategy
An IVD company with a novel cardiac risk marker needs to identify the critical path to achieve maximum value based on optimal business partnering and reimbursement pathways. Boston Healthcare is engaged to identify benchmarks that are critical for maximum success and to identify risks and rewards for different partnering models. Boston Healthcare uses primary and secondary research with blinded technology profile and discussion guides to assist in testing various business models with key stakeholders. Boston Healthcare constructs laboratory payer mix model which estimates the average reimbursement and profit expectations for various laboratory markets. Boston Healthcare analyzes the difference in implementation support needs based on various partnering options and finds coding application, cost impact modeling, lab partner support, and payer engagement to drive necessary coverage.