Baker Tilly helps facilitate discussions between health plans and our client

Our client’s need:

A medical device company wanted to obtain coverage for their percutaneous ventricular assist device (pVAD) from health plans. pVAD is a minimally invasive percutaneous catheter-based device that is powered and controlled by its console and is designed to provide partial circulatory support. The current standards of care are the intra-aortic balloon pump (for high-risk PCI patients) and ECMO/LVAD (for cardiogenic shock patients). Our client’s goal was to inform and educate the health plans regarding the improved outcomes resulting from their technology and the related financial impact.

Baker Tilly solution:

Baker Tilly developed a budget impact model (BIM) to assist our client in its discussions with health plans and was also able to facilitate discussions with key health plans for the client. A BIM is an interactive tool used to demonstrate the impact of new technologies on patient outcomes and the associated financial impact and can help strengthen the value propositions for medical device companies beyond clinical studies. A BIM typically incorporates the following aspects:

  • Transparent, realistic assumptions
  • Real claims data (as opposed to literature-based estimates)
  • Clear standard-of-care comparison
  • Sensitivity to changes in penetration
  • Short time horizons
  • Cost and reimbursement assumptions at the procedure level

The BIM developed for this client allowed for the selection of either one of the two patient diagnoses or a combined scenario, default membership counts, prevalence rates, penetration percentages and reimbursement rates with the ability to enter different values. Based on these inputs the BIM calculated per member, per month (PMPM) and total costs for each scenario.

Results:

The BIM showed that the technology would reduce major adverse events, including death, along with reduced resource consumption (LOS and variable costs per episode). Specifically, the number of repeat lumpectomies and follow-up mastectomies would be reduced, resulting in fewer re-admissions and a better patient experience which helps hospitals align with value-based reimbursement programs. The technology is now covered by most major health plans including Aetna, Cigna, United Healthcare (Medicare Advantage), HealthNet, Humana, Independence Blue Cross, and HCSC. In addition, denial activity was minimized across the country (over 90 percent of claims are now being paid).  

For more information on this topic, or to learn how Baker Tilly healthcare specialists can help, contact our team.