Device Congress. Track B: Reimbursement. How to Convince the Medical Director Your Product is Special

Transcription

1 Track B: Reimbursement How 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

2 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? 2

3 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 3

4 GEHC Reimbursement Program

5 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 5

6 Reimbursement Objective #1 Reduce cycle time from product launch to customer paid & patient access Existing Procedure Existing Coding/Coverage/Payment Regulatory Approval New Procedure New Code (15 mos. min) New Payment (1-2 yrs) Expanded Coverage (1-5 yrs) $ Customer Paid + Improved Health Outcomes 0-7 years 6

7 Creating Surround Sound With Key Stakeholders Technology Assessmt Coverage support for payers based on clinical evidence Consumers/Patients Advocate access to technology through favorable coverage & appropriate payment Professional Societies Code application & utilization guidance, coverage support, clinical guidelines Coverage CMS Priv Payers Legislature Coding AMA CMS Payment CMS Priv Payers Industry Organizations Coverage and payment support, industry PR and collaboration opportunities Lobbying Lobby for coverage, protect payment Providers Petition for code, advocate for coverage, payment, protect payment Manufacturers New product reimbursement strategy, work w/payers on coverage & payment Employers Advocate for access to technology that increases quality and lowers costs 7

8 We Will Be Successful, If We Can Create Positive, Ongoing Dialogue With Payers Objectives 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 8

9 We Will Be Successful, If We Can Create Positive, Ongoing Dialogue With Payers Objectives 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) 9

10 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 10

11 Meeting With Medical Director Preparing for the meeting Assess provider & professional society support Prepare agenda & presentation Determine/secure meeting participants Modify Reimbursement Strategy accordingly Maintain dialogue with payer 11

12 Meeting With Medical Director Who should attend the meeting? Practicing physician Technical expert Clinical trials design expert Senior company representative Consultant / Facilitator No Sales & Marketing 12

13 Meeting With Medical Director Meeting Agenda Objectives what is your ask? Disease overview Procedure/technology overview Evidence review & clinical trial plans Specific questions for payer Next Steps 13

14 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 14

15 Don ts Over commit Raise the evidence bar Blow smoke Overstate outcome of meeting to commercial teams 15

16 Medical Director Perspective

17 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 17

18 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 18

19 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 19

20 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! 20

21 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! 21

22 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 22

23 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. 23

24 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 24

25 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 25

26 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 26