If you’ve been studying the contents of the recently passed healthcare reform legislation, and you’ve looked in vain for the elements that emphatically implement systemic cost control and improvements in quality of care, President Barack Obama’s nomination of Dr. Donald Berwick as administrator of the Centers for Medicare and Medicaid Services comes as very good news indeed. With this nomination, the president has demonstrated that he fully understands that insurance reform alone — important as it may be — won’t fix the ills besetting U.S.
Reimbursement
It’s private health insurance, not Medicare, that needs fixing
For the most part, annual changes in Medicare payment rates don’t directly impact medical device manufacturers. With the exception of the very small number of devices that qualify in any year for the Medicare Inpatient New Technology Add-on or Hospital Outpatient Pass-through (PDF) status, or devices used in the home and classified as “durable medical equipment,” demand for devices is influenced more by the overall financial health of hospitals and physician practices than by any particular reimbursement rate decision or trend in payment levels.
Congress is incapable of a positive contribution to health care reimbursement
Three health care reimbursement developments of interest in the last few days:
Healthcare reform is a matter of scale
I’ve recently encountered a number of articles questioning the usefulness of comparative effectiveness research. For example, Keith Winstein, writing in the Wall Street Journal Feb. 10, details the failure of medical practice to adapt to findings from the Courage trial — reported to great acclaim in the New England Journal of Medicine in 2007 — about the relative effectiveness of drug therapy and stenting in relieving chronic chest pain.
Clearing a path to reimbursement, Part II
If “Do you have a code?” is the wrong question to ask when assessing the reimbursement prospects of an innovative device, drug, or diagnostic, is there a right one — a single question that can separate the life science reimbursement gold from the technological base metals that insurers won’t likely pay for? Yes there is, and it’s a question I don’t often hear asked in a clear and concise way:
“Can you demonstrate, with evidence strong enough to withstand rigorous review, predictable clinical benefits to a defined patient population?”
Stated even more simply: “Can you prove your technology’s clinical utility?”
Clearing a path to reimbursement
When pitching to potential life sciences technology investors, entrepreneurs know that they need to demonstrate a clear path to reimbursement. Angels, VCs and strategic partners don’t want to commit resources to develop something that won’t get adequately paid for in a reasonable timeframe. That makes perfectly good sense. Indeed, I’d argue that the need to assess a technology’s likely reimbursement status begins even earlier than the investment pitch.
Competitive effectiveness?
If healthcare reform legislation now before Congress becomes law, it will certainly contain a clearly articulated organization structure and a fairly generous flow of funds to develop and implement a robust comparative effectiveness research program.
Nothing is as constant as change
Nothing is as constant as change, especially at this time of year in the world of coding and reimbursement. For example, are you aware of the following new developments?
- Physician Coding: The American Medical Assn.’s CPT 2010 coding manual was shipped to healthcare providers in October. It contains all the new, revised and deleted Level I codes; Category II (performance measurement) codes and Category III (T codes for emerging technology, services and procedures) that become effective Jan. 1, 2010. Now is the time to become familiar with any changes related to procedures that may involve your products.
Comparative ineffectiveness
Public furor, professional hand-wringing and political posturing over a revised recommendation on mammography screening for breast cancer issued this month by the U.S. Preventive Services Task Force points to a pair of little-discussed but critical impediments to real progress in improving the efficiency and the effectiveness of our healthcare system:
- Our primary media sources of information are increasingly incapable of dealing effectively and informatively with complex or subtle issues.
Where’s the beef in healthcare reform? Maybe not in Congress.
While Harry Reid dithers about the final shape of the Senate’s reform legislation and industry quivers over the prospect of a federal excise tax on medical devices, some key actors – both public and private – are forging ahead with creative initiatives to control health care costs and improve quality and consumer choice.
Healthcare reform without a single payer option is just a Band-aid fix
The likely shape of a healthcare reform bill that the Congress will be debating come Thanksgiving — give or take a week or two — is becoming clearer, and those hoping for something that will significantly “bend the cost curve” right away have reason to be disappointed.