Experience

Our work often integrates with clinical, regulatory and marketing operations with the intent of reducing the technology’s market adoption risks. The case studies below describe our experience and possible integration scenarios.

Fortune 500 Company

Payer policies affect the location of sales reps

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Mid-Tier Company

Institutional investor uses payer data

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Emerging Company

Securing codes prior to product launch

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Start-Up Company

Reimbursement planning begins in the R&D phase

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Incubators & Accelerators

Reimbursement affects regulatory & clinical plans

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University-based Company

Payer interviews give insight for university corporate licensing

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Fortune 500 Company

The Client’s Business Needs

This case study illustrates the use of payer and reimbursement data for decisions related to a company's sales and marketing operations, specifically the location of its U.S based sales representatives. The strategic objective of this case study is we believe companies may want ro consider selling their products based on how they are covered and reimbursed by the Payers, and focus less on how their products are sold based on internal plans.

The company's technology platform was comprised of an integrated camera and conferencing system capable of conducting real-time, simultaneous telemedicine sessions with multiple individuals located in different locations. The telemedicine platform integrates with major patient Electronic Medical Record (EMR) enterprises. The platform is also capable of real time sending, editing and sharing of a variety of formatted data between all the participants before, during and after the telemedicine session. The telemedicine platform has a small footprint and is portable, features ideally suited for use in the patient’s home.

The company’s business need was for us to help them determine where to locate their sales representatives in the U.S. based on telemedicine coverage policies, licensing and billing rules and reimbursement amounts.

Our Approach

For our client we developed algorithms to research and query Medicare, Medicaid and U.S. private payer databases so we identify and prioritize these three payer groups based on the most favorable telemedicine policies and rules and reimbursement amounts.

The results from our data analytics determined Medicaid is the beachhead payer and is where we focused our efforts from here on out.  We researched all (50) U.S. states Medicaid telemedicine coverage policies, rules and regulations and reimbursement amounts. The outcome of this analysis was for us to build a database that allowed us to categorize and query the (50) states into three categories relative to the company's telemedicine platform. The categories were, states with Medicaid telemedicine polices with restrictions, states with negative coverage policies and states with inconclusive telemedicine coverage policies.

The U.S. states with inconclusive results where moved to the next research phase. This phase required us to conduct primary research to categorize the state's Medicaid telemedicine policies, rules and reimbursement amounts.

States that do not cover and reimburse for telemedicine services where eliminated because healthcare provider reimbursement is not possible.

States with Medicaid coverage and reimbursement for telemedicine services where further stratified based on the degree of restrictive coverage policies, licensing and credentialing, the breath of services reimbursed, and the amount reimbursed to the healthcare providers for preforming telemedicine session.

The Results

Based on our stratification of the states with telemedicine policies, we recommended to our client to consider placing sales representatives in five Midwest states based on the following rationale. 

1) Broad spectrum of covered telemedicine services is available.

2) Least number of restrictions for the available telemedicine services.

3) Physician reimbursement amounts, including other providers, were average to above average and had little historical fluctuations.

4) Good sized metropolitan areas serviced by major airports and highways. Automobile driving terrain is flat and time zone differences minimal.  This case study is intended to be an introduction to the use of Payer and reimbursement data to help solve business operational questions and strategically consider selling medical technologies based on how they are covered and reimbursed by the Payers and focus less on how the products are sold.






Mid-Tier Company

The Client’s Business Need

This case study illustrates the use of payer, hospital utilization and other reimbursement data to assist with investment decision making.

An institutional investor contacted us regarding a potential investment in a Seattle, Washington based company. The company was developing a product line of non-invasive systems to diagnosis and to monitor the regression or progression of the Traumatic Brian Injury (TBI) following testing and treatments. Diagnosis and monitoring is possible because the company's system can be used over the entire TBI spectrum and in a variety of care settings. There is a portable system designed for use in memory centers and sporting events. For moderate care intensive sites of service, such as the skilled nursing facility, the development of a mid-range system was underway. For the most care intensive site of service, the hospital neurology ward and the neurocritical care unit, a high-end system was also under development.

The client’s business need was for us to help them with their investment due diligence. To do this they asked us to provide them with 1) the most current procedure volume data for mild, moderate and severe TBI for several different diagnostic tests and, 2) the TBI patient discharge volume from U.S. based hospitals and emergency departments.

Our Approach

To determine the TBI diagnostic procedure data and the TBI patient discharge volume, we first had to identify from a vast array of U.S. commercial and public payer databases and selected confidential third-party reports. Once identified we prioritized the most relevant payer databases from which to query, extract and consolidate the payer data.  We often use payer databases for our market intelligence work because we consider this data to be of high quality for the following reasons,

1) The data is actual and is not forecasted.

2) The data is current and the availability of historical data for trending purposes.

3) The data is available for multiple sites of care like the emergency department and the hospital.

4) The data is derived from reputable sources such as United Healthcare and Medicare.

The Results

Our customized market analysis using actual data determined the TBI diagnostic procedure volume data was larger than the institutional investor had forecasted. In addition the hospital vs. the emergency department discharge data was materially different than the investors were expecting.

A primary reason for the disparity between our findings and the client's expectations is a result of the data specificity we can achieve in our analysis using payer and reimbursement data when compared to third party, boilerplate-marketing reports, which the client was using.

We use actual, not forecasted, data and from multiple sites of care; not one site of care. This type of data specificity is not possible with the third party, boilerplate-market reports because these reports use forecasted data, often from one site of care, to calculate their "aggregate forecasts". To further enhance our data specificity, we will conduct longitudinal analysis, which allows us to follow patients as they move between sites of care.

Our high-level of specificity and customized approach to market sizing is cost competitive and uses different research methodologies than the third party, boilerplate- market reports. There is no reason for any company, start up to large multinational to settle for anything less.

 




Emerging Company

The Client’s Business Need

This case study shows how we identified multiple monetization pathways for a smartphone and tablet-based test. This study is also intended to demonstrate the company's reimbursement planning should had begun three years, not one year, prior to product launch.

A German medical software company began preparation for the U.S. launch one year prior to the forecasted FDA 510K class II smartphone/table-based tests. The company’s software can transform the medical professional's smart phone or tablet into a full suite of clinically accepted, gold-standard orthopedic rehabilitation assessment and monitoring tests which are performed following knee and hip replacement and ACL reconstruction. The initial focus is the U.S. orthopedic surgeon office market. The providers of interest are the surgeon and the physical therapist.

The company’s mobile digital test platform offers benefits to the surgeon and physical therapist relative to the (current) subjective and the office-based rehab equipment testing methods, they are;

1. Real time comparative and systematic normative data analysis.

2. A mobile platform which facilitates conducting the tests in different sites of care.

3. Electronic integration of the test results with the patient’s electronic medical record.

4. Faster test times without compromising specificity and sensitivity.

5. Lower test price.

The client’s business need was for us to define and implement the U.S. monetization plan for their smart phone/ tablet based orthopedic rehab assessment and monitoring tests. In addition, the company wanted us to integrate the tests' monetization plan into the ongoing product launch planning efforts. The company contacted us one year from U.S. launch date.

Our Approach

While the mobile test incorporated the gold standard rehab tests accepted by providers and payers, we were more concerned about coding and reimbursement amounts than coverage at this point.We decided to conduct a comprehensive payer prioritization based on reimbursement amounts and the availability of alternative monetization pathways outside of traditional reimbursement.

We believed alternative pathways were going to be important since launch was less than one year away. Alternative monetization pathways would had been less of a concern for us if the company reached out at least three years prior to launch.

The Results

The screening criteria and stratification noted above determined Medicare was a payer of interest. Medicare had in place traditional reimbursement mechanisms and an alternative monetization pathway. While the Medicare reimbursement amount was lower relative to other payers, the value of Medicare's alternative payment pathway was paramount.

Reimbursement for the surgeon and physical therapist (the providers) using the mobile-based test could be possible under the Medicare’s current reimbursement mechanisms and policies. However, we believed Medicare would soon eventually deny the providers' claims for a variety of reasons such as costs.

This was not to be the case for the alternative monetization pathway we identified because its mechanisms are different from traditional reimbursement.

As a result, the alternative monetization pathway became more important than traditional reimbursement in supporting the company's mid-term U.S. commercialization efforts. It would be the company’s primary provider payment mechanism used while concurrent efforts to secure new coding and revised reimbursement amounts were underway by the company and us.

The key takeaway from this case study is the work described above should have started at least three-four years prior to launch. Doing so gives a company the time to establish relationships with the payers, to apply for codes and to collect the evidence needed to help justify to the payers the basis for the mobile test's reimbursement amount.

 


 


 






Start-Up Company

The Client’s Business Need

This case study demonstrates the importance of reimbursement planning commencing in the R&D phase. This study is intended to demonstrate why payers’ coverage policy decisions, not coding, is a major reason for payers to deny reimbursement of new medical technologies.

A privately held startup company based in Boston and with 45 employees was preparing to raise its Series C round. The company is developing substantial procedural improvements to an accepted catheter-based cardiac therapeutic procedure. Collectively the improvements will translate into expanding the number of physicians and centers who can perform the company’s catheter-based procedure. The U.S. launch of the company’s catheter-based therapy is at least three years away.

The company’s business need was for us to help them with the preparation for their Series C fund raising efforts. We did this by identifying the most favorable physician and hospital reimbursement pathways and to outline the plan to secure the payer approvals in the absence of reimbursement mechanisms.

Our Approach

We made three strategic decisions early in our work, they were,

1) Use comparative, not an absolute, analysis methodologies.

2) Include competitive therapies and multiple provider types.

3) Identify the Beachhead Payer.

As noted above the company initially requested us to focus our work solely on their procedure, that is to conduct an absolute analysis. We strongly believed it was to the company’s best interests to understand how competitive and gold standard procedures such as drug therapy, surgery and other catheter-based approaches are reimbursed. The company agreed.

In addition, the company initially asked us to concentrate our work on identifying physician reimbursement pathways. We concluded it was to the company’s advantage to understand the reimbursement pathways for the hospital provider and to not focus solely on the physician. We made this recommendation after reviewing hospital admission data and recent payer policy changes. These new policies placed more financial responsibly for patient care on the hospital providers. As a result, the hospital would have more authority in the purchasing decision.

Finally, we introduced the planning concept of identifying the Beachhead Payer for the company's procedure. The determination of the Beachhead Payer is one of several key strategic decisions made by companies in their reimbursement planning. To identify the Beachhead Payer, required us to write algorithms in order to extract multiple consecutive years of anonymized patient data from U.S. private and public payers. Following the data extraction phase, we conducted a longitudinal analysis to determine the Beachhead Payer. 

The Results

Based on our payer data analytics, we recommended Palmetto as a Beachhead Payer for the following reasons;

1) Established reimbursement pathways and a lower claims denial rate relative to the U.S. commercial payers.

2) Reimbursement was possible for multiple facility providers.

3) Aggregate reimbursement amounts were less but not materially so relative to U.S. commercial payers.

4) A patient population who could benefit from our company’s improved procedure.

Just as invaluable to our client was a definitive understanding of the Palmetto reimbursement pathways for competitive and gold standard procedures such as medical therapy, surgery and other catheter-based procedures.

Our work identified hospital and physician reimbursement from Palmetto was adequate. We also concluded the competitive catheter-based procedures could be vulnerable to possible coverage policy changes due to overuse. If these changes were ever to be enacted, the result would most likely be a reduction in physician and facility provider reimbursement.

This potential policy change demonstrates an often-overlooked fact; payers’ coverage policy decisions do affect reimbursement for new technologies. Based on the potential for the policy changes we put into place an ongoing monitoring program designed to alert the company when public and (selected) commercial payers are considering changes to relevant coverage polices.

Regarding the company's more immediate need, preparing for the Series C round, our work and findings were included in the documents and presentations shared with investors. On behalf of the company we were able to speak with investors to explain the reimbursement pathways for the company's procedure and to put into context the risks and opportunities that lie ahead

 







Incubator-based Company

The Client’s Business Need

This case study demonstrates two points. First in the absence of traditional reimbursement other monetization pathways maybe available. The other point is to show how reimbursement can be used to define their Indications for Use (IFU), and the claims and labeling language prior to formal discussions with the FDA.

A company, under the guidance of a Minnesota-based incubator, was developing a Point of Care (POC) diagnostic test to detect the presence or absence of Urinary Tract Infection (UTI). The test’s market was acute stay hospitals. The company’s third-party market intelligence concluded the incidence and prevalence of UTI is higher than normal in older patients and particularly those who are admitted to the hospital.

Based on this intelligence the company believed the test’s FDA regulatory and clinical trial efforts should focus on the test’s use during the admission period. This period is defined as the time from patient hospital admission to discharge. The proposed regulatory strategy which included the test's claims, Indications for Use (IFU), labeling and FDA clinical trial design were all geared to secure 510K clearance for test use during the admission period.

The client’s business need was for us to determine if and how the POC-UTI test based on the regulatory strategy described above would affect hospital reimbursement.

Our Approach

Our first step in our work was to re-confirm, unequivocally, the company's conclusion that UTI incidence and prevalence rates are higher in older patients who are admitted to the hospital. We also had to identify the Beachhead Payer for the test. Doing so would help focus our reimbursement and monetization planning efforts for the POC-UTI test.

The Results

Because we have access to current and actual (not forecasted) payer data for UTI incidence and prevalence rates before, during and after the hospital admission period we were able to unequivocally re-confirm our client’s conclusion; UTI incidence/prevalence rates are high for admitted older patients. Our analysis also identified the test's Beachhead Payer.

Based on these two key conclusions the reimbursement and alternative monetization pathways analysis we conducted determined the following;

1) Hospital reimbursement for the POC-UTI test is not possible due to structural reasons.

2) An alternative monetization pathway for the hospital is possible.

The alternative pathway to traditional hospital reimbursement we identified does financially penalize any hospital in the event a patient acquires UTI during the hospital admission period. However, if UTI is detected at the point of hospital admission the Beachhead Payer will not financially penalize the hospital. Another words there is a financial incentive for the hospital to purchase the POC-UTI test in the absence of reimbursement for the hospital.

Based on our identification of an alternative pathway to monetize the UTI test the company changed the test's FDA regulatory and clinical strategy. The revised regulatory and clinical strategy re-positioned the test for use at the point of hospital admission vs. the original positioning of during the admission period. The change was done to ensure there is a hospital monetization pathway after the test's FDA clearance and market launch.

 

 






University-based Company

The Client’s Business Need

This case study illustrates the use of one-on-one interviews with Medical Directors from U.S. private insurance carriers. The interviews were conducted in order to assist a major U.S. based university with de-risking its corporate licensing efforts.

The faculty of a major university was developing a molecular Point of Care (POC) test to detect selected autoimmune diseases. The test’s objectives were first to reduce the unnecessary use of an expensive hospital-based test. The hospital test is considered the diagnostic gold standard. The second objective was for the university’s test to be used in a relatively less expensive site of care than the hospital, that site of care was the physician office setting. Collectively these two objectives could assist physicians with more control in triaging their patients with these

The university was referred to us to help them better position the POC test to corporate licensing partners. The university believed a better understanding the POC test's reimbursement pathways would be one way to improve the test’s marketability to corporate licensing partners.

Our Approach

Because of the test’s disruptive factor is high, we suggested a combination of secondary (data analysis) and primary research methods be used. The primary research included one-on-one interview with Medicare Directors from U.S. private payers. The university preferred we interview those Medical Directors whom Rowinski Group had established professional relationships in place. As a result of our work with interviewing Medical Directors, we know first-hand the importance interviewee selection and vetting.

Medical directors have the authority to 1) manage the use of new technologies outside their traditional sites of care, 2) define evidentiary requirements for coverage and reimbursement for new and unproven tests, 3) can speak of the concerns related to changing workflow and usage outside traditional settings, and 4) provide input into the POC test pricing strategy.

We identified, recruited and confirmed five Medical Directors to participate in a private interview. The Medical Directors were from different private insurance payers based around the U.S. All had experience with new medical technologies and were comfortable with technologies that have the potential to change traditional workflow, referral patterns and cost structures.

To prepare each Medical Director for their interview we created an interview packet and provided other pre-interview support mechanisms such as a one-hour teleconference prior to their interview. Comprehensive preparation of interviewees is often overlooked by companies, but from our perspective is just as crucial as the selection and vetting process.

We conducted the interview with each Medical Director over a three- and half-week period. We consolidated all interviews into a single summary. This summary allowed the university to easily compare responses from each interviewee. Reference documents included a transcript and video recording for each interview. This information was used by us to discuss with the university the interview conclusions, key points and next steps.

The Results

The feedback from the interviews helped the university clarify how to improve the POC test’s positioning with potential corporate licensing partners. The Medical Directors realigned our client’s expectations in terms of the overall potential market size, the proposed pricing strategy, concerns of the overuse and the type of evidence needed to code and reimburse this novel and disruptive autoimmune POC test. The Medical Directors also outlined action items and road maps to improve the test’s appeal to payers.

Following the interviews work began at the university to consolidate the action items and road maps outlined by the five Medical Directors. The next step is to stratify and prioritize selected action items including budgets and other resource allocation needs and to continue the effort of de-risking the test for corporate licensing partners

 


 


 




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