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.

Assessment and Strategy for Coding and Coverage of a New In Vitro Diagnostic
A diagnostics company is preparing to launch a new in vitro diagnostic test. Realizing that gaining reimbursement will be critical, particularly with Medicare, the manufacturer engages Boston Healthcare to assess the situation and develop a strategy for coding and coverage. We carefully document the current situation including competitive product strategies, and suggest a proactive educational effort with key Medicare contracting carriers. Based on this analysis, we partner on behalf of the client with the appropriate medical specialty society to submit a request to the American Medical Association (AMA) to revise the current CPT coding to ensure that our client’s technology will be included in the code description. The change to the coding is secured.

Reimbursement Assessment and Strategy for a Biotech Company’s Development-Stage Cancer Vaccine
A biotechnology company is developing a personalized cancer vaccine and is preparing to enter Phase III trials. Since the procedure to manufacture the vaccine requires a cell harvesting procedure in addition to the vaccine administration, attaining coverage, coding and payment for the product must incorporate the process to acquire the cells as well as to the final product. In addition, the patient population is primarily covered by Medicare, and issues pertaining to Medicare reform and payment reform for drugs and biologics covered by Medicare will impact distribution of the product and Medicare coverage and reimbursement. These issues will also influence private payers.

Boston Healthcare develops 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 addresses questions likely to arise in the technology assessment process by physicians and payers. Boston Healthcare recommends timing for initiation of other reimbursement activities and tactics to be completed prior to launch.

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

Situation Analysis and Implementation of Reimbursement Plan for Greater Utilization of FDA-Approved Product for Small Pharma Company
A small pharmaceutical firm with an FDA-approved product has 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 is engaged to conduct a situation analysis to define the causes of the low levels of utilization and reimbursement. We develop a strategy and plan for increasing awareness and maximizing reimbursement. Functioning as the national accounts component of our client’s sales force, we confirm or achieve coverage for the product in 152 MCOs and PBMs accounting for over 21 million lives. Additionally, we organize and spearhead a successful regional effort that results in our client’s product being added to the new VA National Formulary. Reimbursement status at key payer organizations is communicated to field sales representatives to facilitate greater utilization by providers and patients.

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.