Crafting a Reimbursement Strategy

An executive explains how a small medical device company created and executes a successful reimbursement strategy. 

Marie Thibault

Reimbursement is a challenge that most medical device manufacturers must contend with, but for many, it remains one of the biggest challenges of the product development process. MD+DI asked Robert Buehler, chief commercial officer at St. Paul, MN-based RespirTech to explain the company's successful efforts to secure reimbursement coverage for its key product, the inCourage System. This product, designed to be a comfortable vest used everyday, clears mucus from the patient's lungs and airway using triangle wave air pulse therapy. This is intended to help patients with a range of diseases, including cystic fibrosis, chronic bronchitis, chronic obstructive pulmonary disease (COPD), and bronchiectasis. 

Buehler details how reimbursement works at RespirTech and the perks of developing reimbursement at a small device company. Buehler will be part of a panel at Minnesota Medtech Week, November 4-5, titled "Planning Ahead for the Changing Reimbursement Landscape: What's YOUR Market Access Strategy?"

Bill Betten, director of business solutions at Devicix, will be moderating the panel and writes that he anticipates the panelists will cover topics like planning for CMS and private payer coverage, differences in reimbursement approaches for big and small companies, and important considerations for U.S. and international reimbursement. "We hope for interesting insights into an important yet often unseen aspect of product development," Betten writes.

MD+DI: How does the reimbursement process start at your company? Please offer details about how early the process starts, who is in charge of the process, any interaction with CMS/private insurers, and what initial steps are taken.

Robert Buehler: At RespirTech, the process typically starts with the sales force explaining reimbursement requirements to healthcare providers. Clinicians must provide specific diagnosis information and a prescription to enable patients to receive our therapy system. RespirTech’s Medical Intake group obtains a patient’s prescription and medical records. The file is then processed by our Customer Care, Clinical Services, Reimbursement, and Insurance teams. Some covered diagnoses have more complicated coverage requirements than others, so each relevant department ensures payer requirements are met.  For certain patients with non-covered diagnoses, our therapy may be deemed medically necessary. In these cases, we may file an insurance claim on the patient’s behalf and if the claim is denied, our experienced Appeals Team can help navigate the appeals process.

MD+DI: What were key hurdles you experienced with the inCourage System? How were these resolved?

RB: One hurdle relates to addressing complicated insurance requirements for covered diagnoses. We train our sales people, prescribing doctors and healthcare teams about payer requirements in order to minimize insurance-related delays for our patients. Another hurdle is securing in-network status from more coverage providers, whether commercial insurers or state Medicaid programs. We work diligently to help insurers understand both the unique benefits and better outcomes associated with the inCourage® System. Some states require an in-state presence for providers in their Medicaid program, and this can also be a hurdle to overcome. In these situations, we may align with another company located in the state, consider opening an office there, or file for an exemption.

MD+DI: Your company has one key medical product at this point. Are there any specific challenges related to securing reimbursement as a one-product company?

RB: We have one therapy system; however, it is used for many covered diagnoses. In some market segments, such as COPD/bronchiectasis, only a fraction of patients with covered diseases actually receive our device—in part, because prescribing clinicians are still learning about how airway clearance vest therapy systems like ours can help various conditions. We are applying significant resources toward educating healthcare teams about the benefits of inCourage® Airway Clearance Therapy. We actively collect patient-reported outcomes data that demonstrate the positive impact our device has on patients’ health and the overall cost of care. We are confident that patients with an even wider range of diagnoses could benefit from our therapy, so we continue to work with payers to expand their coverage accordingly.

MD+DI: I’ve noticed there is a specific page on your company’s Web site dedicated to reimbursement and instructions to allow patients to work closely with your company on the reimbursement/insurance process. Please tell us more about the decision to take this approach.

RB: Patients and their caregivers are motivated to find relief for symptoms and pursue the therapy that has been recommended to them. Also, much of the information required for coverage paperwork comes directly from patients, so it makes sense for us to interact with them. We want to empower patients and help them efficiently navigate complicated coverage scenarios so they can receive their therapy system as quickly and seamlessly as possible.

MD+DI: What is the biggest advantage of developing reimbursement at a small device company? What is the biggest disadvantage?

RB: The biggest advantage in developing reimbursement is in being able to provide our inCourage® System to more patients in an efficient manner. We’re extremely well versed in ensuring patients, caregivers, and payers all have the information they need to move therapy forward. As a result, we’ve established, grown and retained rewarding relationships with all our partners—patients, prescribers and payers. The biggest challenge, particularly for a small company, is allocating the resources necessary to be highly proficient in navigating the ever-changing reimbursement landscape. It’s not a disadvantage, but requires a significant investment in personnel and systems.

Marie Thibault is the associate editor at MD+DI. Reach her at [email protected] and on Twitter @medtechmarie. 

[Image courtesy of BAITONG333/FREEDIGITALPHOTOS.NET]