Device Congress

Device Congress Track B: ReimbursementHow to Convince the Medical Director Your Product is Special

Michael Becker, GM Global Reimbursement, GE Healthcare

Michael Bihari, MD, Health Care Consultant

March 29, 2007

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Device CongressReimbursement Track -- Medical Director

Key Questions We Will Address Today•What are the do’s and don’ts in convincing the payers’ medical directors that your product is worth covering and reimbursing?

•What are medical directors looking for?

•How do they make decisions?

•And what are some strategies one successful medical company uses?

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Before We Start . . .

•What is your Reimbursement Strategy?

•Where does discussion w/Medical Director fit in your overall reimbursement strategy?

•Medical Director is just one stakeholder

•Medical Director may influence coverage decisions . . . don’t forget about coding & payment

GEHC GEHC Reimbursement Reimbursement

ProgramProgram

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Reimbursement Objectives

1. Accelerate reimbursement for new products

2. Respond to customer needs for existing products

3. Develop & advocate public health policies favorable to GEHC products

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Reduce cycle time from product launch to customer paid & patient access

Regulatory Approval

ExistingProcedure

NewProcedure

Existing Coding/Coverage/Payment

$Customer

Paid+

Improved Health

Outcomes

New Code (15 mos. min)

Expanded Coverage(1-5 yrs)

New Payment (1-2 yrs)

0-7 years

Reimbursement Objective #1

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Creating “Surround Sound” With Key Stakeholders

Professional Societies

Code application & utilization guidance, coverage support, clinical guidelines

LobbyingLobby for coverage, protect payment

Consumers/Patients

Advocate access to technology through favorable coverage & appropriate payment

EmployersAdvocate for access to technology that increases quality and lowers costs

Industry Organizations

Coverage and payment support, industry PR and collaboration opportunities

ManufacturersNew product reimbursement strategy, work w/payers on coverage & payment

ProvidersPetition for code, advocate for coverage, payment, protect payment

Coding

PaymentCoverage• CMS• Priv Payers• Legislature

• CMS• Priv Payers

• AMA• CMS

Technology Assessmt

Coverage support for payers based on clinical evidence

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We Will Be Successful, If We Can Create Positive, Ongoing Dialogue With PayersObjectives of Payer Focus•Understand coverage & payment policy

processes (decision makers, influencers, requirements, timing, communication) and where we can influence

•Gather payer input into product reimbursement strategies: clinical trial design, reimb. tactics to support coverage

•Collaborate with payers to accelerate coverage for new technology, where appropriate

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We Will Be Successful, If We Can Create Positive, Ongoing Dialogue With PayersObjectives of Payer Focus

•Develop relationship w/ major payers for open communications when favorable/unfavorable policy changes made (coverage, payment, utilization)

•Gather payer input on product development– how to meet their needs (VBM/P4P data, pricing transparency; reducing medical errors; linking claims data w/ pt. history; provider accreditation)

•Identify opportunities to collaborate on major health policy initiatives (IT initiatives, VBM/P4P, Quality)

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Meeting With Medical Director

Preparing for the meeting

•Inventory payer relationships

•Select target payers

•Research target payer policies/positions

•Assemble clinical value story (WIIFM)

•Assess existing evidence

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•Assess provider & professional society support

•Prepare agenda & presentation

•Determine/secure meeting participants

•Modify Reimbursement Strategy accordingly

•Maintain dialogue with payer

Preparing for the meeting

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Who should attend the meeting?

•Practicing physician

•Technical expert

•Clinical trials design expert

•Senior company representative

•Consultant / Facilitator

•No Sales & Marketing

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Meeting Agenda•Objectives – what is your ask?

•Disease overview

•Procedure/technology overview

•Evidence review & clinical trial plans

•Specific questions for payer

•Next Steps

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Do’s

• Must be part of overall reimbursement strategy

• Be prepared

• Be clear & consistent

• Be careful what you ask for

• Treat Medical Director as Customer

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Don’ts

• Over commit

• Raise the evidence bar

• Blow smoke

• Overstate outcome of meeting to commercial teams

Medical Director Medical Director PerspectivePerspective

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Medical Device Companies

• Capital

• Personnel - researchers & medical workers

• Disease expertise - knowledge of disease states from device development process

• Clinical expertise - insights & outcomes from clinical trials

• Influence - tools & techniques to influence patients & providers

• Devices - clinical therapy

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Things You Need to Know About Your Target Health Plans• Structure of plan – local/regional/national impacts the message

• Who is at risk and for what – capitation/P4P

• Radar screen diagnoses and # lives

• Key decision makers – bottom up vs. top down

• Competitive environment

• Political environment

• Coverage/Tech Assessment Process

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Coverage/Tech Assessment Process

Clinical vs. Reimbursement

• Usually separate process with clinical decision made first, BUT may vary with plan

• In most plans, a medical director chairs clinical committee process

• As part of process most plans use outside assessment companies (BCBS, Hayes, ECRI)

• Criteria:

- FDA approval of technology/device

- Documentation of safety

- Must be as efficacious as current treatment

- Improves health outcomes

- Independent scientific evidence

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Coverage/tech Assessment Process – What Kick-starts the Medical Director?

Outside Requests

• Most often from network providers

• Consumer Groups

• Patients

• Manufacturers

• Health plan staff

• Large employer

• “Squeaky Wheels”

Process Initiation

• Will benefit health plan members

• Technology related to high utilization service or disease

• Will significantly reduce other health care costs

• And, I need to know that it’s important!

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Things to Do:

• Appreciate the role of the medical director – I’m your customer!

• Take the time to provide me with evidence-based information and tools to help me make an appropriate decision

• Make sure what you say to me is consistent with what you say to physicians and consumers

• KNOW YOUR STUFF!

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More Things to Do:

• GET TRAINED!

• It is important that you understand how health plans function

• Learn the roles of key staff and what keeps them up at night

• Excellent training companies are available that have had extensive experience in the pharma industry

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What Not to Do:

• Don’t nag me, I’m busy. I do care but I’m juggling multiple projects

• Don’t waste my time – KNOW YOUR STUFF!

• Don’t do anything that is not consistent with industry standards and ethical and legal business practices.

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How to Influence Me Appropriately

• Surround Sound – increase the noise level- Key opinion leaders- Local influential physicians- Clinical practice guidelines- National society evidence-based protocols- Non-branded disease awareness: increase the

size of the pie—benefits all patients- Practicing physician awareness: publish, present,

via specialty societies- Work with employers and employer groups

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How to Influence Me Appropriately

• Develop a relationship with me based on trust and mutual respect

• Learn best ways to communicate with me• Be dedicated to my organization: research and know my plan• Get involved in plan initiatives• Provide “value-added” services that benefit the plan,

providers, patients Measurement tools to assess performance of care and

services in health plans- Disease management tools - Focus on appropriate outcomes – such as quality,

utilization, cost, and satisfaction

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Partner with Me

• Early involvement in product development, launch, and promotion

• Algorithms to support appropriate use

• Educational pieces

• Phase 4 trials

• Joint promotion of preferred devices

• Collaborative initiatives with plans, providers & employers

Device Congress

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Transcript of Device Congress