Success in Medical Devices May Be Easier Than You Think – Part 2: The Payer’s Perspective

This is the second part of a 3-part series on strategic considerations for patient engagement, market access and promotion for medical devices and procedures. In this blog, we’ll discuss the important factors from the payer’s perspective that many times are overlooked and not given their full due by well-meaning corporate teams. As an early disclaimer, the following thoughts and opinions are mine and from my experience. Any similarity to another person’s real or semi-real experiences are purely coincidental.

The end first – “Not everything that can be counted counts, and not everything that counts can be counted.” Albert Einstein. So let’s first define the three basic interests of a decision-maker: 1) what matters to them, 2) where do you fit into their agenda, and 3) how do you make it easy for them to say “YES”. Let’s take a closer look at how you can clarify and manage expectations for fun and profit…please read on.

A peek behind the curtain – Let’s pull the curtain aside and crack the door of a closed meeting open a bit. Now you can listen in on the hushed conversations that transpire from the long and secluded hallway. The information you hear will surprise you, if only because it’s not all that different from what you would do. The names may be different, the numbers have a few extra zeros in them and more people might be involved, but human behavior is hard-wired into all of us.

When I was a Medicaid Pharmacy Director, my decision-maker responsibility was for more than 900,000 beneficiaries with a Fee-for-Service (FFS) drug spend of more than $1.5 billion at the time. This was in addition to oversight and quality audits for five Managed Medicaid providers, carved-out drug reimbursements, Durable Medical Equipment (DME), ancillary medical billing (J-codes) and other medical devices/procedures. Throw in the hierarchical organizational structure of the Department of Health and Human Services, State government involvement and a hiring freeze and you can begin to understand what a typical day might feel like – maybe just a little. Let’s build on that and please read on…

First – What matters to them? It’s simple, what matters is what is on their agenda that day! From my experience, healthcare decision-makers care about the people they serve (beneficiaries) and the budgets they have to accomplish that. They need to gets things done and are not looking to add more things on their plate unless they provide added value.

Ask directly and be genuine. The response will be illuminating and lead to the next step.

Second – Where do you and your device or procedure fit into their program or plan? Your real goal is to make the decision-maker comfortable to know how your device or procedure will impact (or upset) his current apple cart.

It’s critical to know who the competitive therapies are, what the market basket for the therapeutic area looks like and who is advocating for your product or service. If your device is new, then it’s not standard of care (SOC) and other options are being utilized. You’ll also need to define and communicate your therapeutic and business model, the impact to market utilization, the judicious use of rebates and proactively address the lack of utilization history.

Third – Make it easy to say ‘Yes”. Decision-makers, as the name implies, are responsible for, and make many decisions. Some we want to make, and most we have to make. Much of the time, these decisions will impact tens and hundreds of thousands people, as well as millions of dollars.

For consideration and experience, here is a quick check list of necessary items that are important: 1) what is the 30-second explanation of the added-value so I can pass it along when asked, 2) what is the impact on my patients and plan in terms of outcomes and economics, and 3) do you have this information on a one-page paper (two sides are okay) with hyper-links for drilling deeper if and when necessary?

In summary – The decision-maker focuses on covering lives, their plan satisfaction and operational integrity. You’ll need to provide some type of treatment validation and health outcomes in addition to your 510(k) clearance or FDA approval. If you can’t directly document and validate the important numbers, use a meta-analysis-type of comparison. Another option would be to focus on the people aspect and then build the necessary and strategic documentation and advocacy to support your value message.

So there you have it in a nutshell from the payer/decision-maker perspective. Your device or therapy needs to show adequate results. Efficacy and safety are implied with clearance and approval. You should validate your outcomes or outcomes modeling and you need to create awareness and advocacy of the payer team, including the contracting team, the medical and pharmacy teams. With some simple and strategic planning, you can avoid the circus experience and enjoy the ride…

Coming up on our next Blog Tuesday, Part-3 The Company Perspective and a Realistic Game Plan for Success. Stay tuned…