July 18, 2024
Medical Devices Reimbursement

Ensuring Access: The Economics of Medical Device Reimbursement

The healthcare sector has seen monumental advancements in medical technology over the past few decades. From diagnostic imaging machines to intricate surgical tools and implants, medical devices have transformed patient care and outcomes. However, for innovators in this field, one enduring challenge has been navigating the complex reimbursement processes to get these lifesaving innovations into the hands of those who need them. In this article, we analyze the current landscape around medical device reimbursement in key s and propose strategies to help streamline access to cutting-edge care worldwide.

The United States Model

The US healthcare system remains highly influential as the largest medical devices globally. Under Medicare, the national health insurance program for seniors and disabled individuals, the Centers for Medicare and Medicaid Services (CMS) determines coverage and sets reimbursement rates for medical devices and procedures. For hospital inpatient payments, CMS utilizes the Medicare Severity-Diagnosis Related Groups (MS-DRGs) case-mix system which classifies treatments into diagnosis related groups based on clinical characteristics and expected resource use. Hospitals are then paid a predetermined fixed amount for each MS-DRG, providing limited flexibility around newer, high-cost devices and technologies.

For outpatient care, CMS commonly relies on Ambulatory Payment Classifications (APCs) to bundle related services into ambulatory visit groups. Device-specific Level II Healthcare Common Procedure Coding System (HCPCS) codes are also assigned by CMS to track utilization and reimburse eligible devices under various payment systems like the Hospital Outpatient Prospective Payment System (OPPS). However, navigating the HCPCS code application process can often be lengthy, creating reimbursement uncertainty early in a device’s access. Private insurers also often follow CMS coverage policies and payment levels, impacting uptake.

Europe’s Mixed Models

Across Europe, Medical Devices Reimbursement frameworks vary significantly by country with mixed public and private systems. Nations like Germany, France, and the UK have universal health coverage through social health insurance, where statutory sickness funds determine funding based on clinical value assessments. Regional governments also play a role in capital budgeting and technology adoption decisions.

Some European countries employ Diagnosis-Related Groups (DRG) like the German G-DRG system for inpatient care. Others rely more on fee-for-service reimbursement negotiated between suppliers, providers, and third-party payers. However, rising healthcare budgets have increased pressure on Member State governments to contain costs through health technology assessments (HTA) and value-based pricing strategies. The European network for Health Technology Assessment (EUnetHTA) aims to pool HTA resources and foster collaboration, though implementation challenges persist across borders.

Asia’s Rapid Growth

Healthcare s in Asia have shown some of the strongest growth globally in medical device spending in recent years. Major economies like China, Japan, India, and South Korea now represent sizeable commercial opportunities. However, they also face their own reimbursement hurdles as systems modernize.

China is transitioning to a basic medical insurance scheme covering over 90% of its population by 2020. But coverage decisions and price negotiations currently happen regionally through provincial authorities, resulting in unpredictable access timelines. Japan’s universal health insurance is increasingly scrutinizing cost-effectiveness through the Central Social Insurance Medical Council, driving adoption of international HTA practices.

Meanwhile, some Association of Southeast Asian Nations (ASEAN) countries are advancing public insurance expansions through schemes like Thailand’s Universal Coverage Scheme. However, limited funding per capita constraints widespread coverage and use of high-cost innovations. Regional harmonization of HTA frameworks remains a work in progress. Overall, reimbursement pathways across diverse Asian systems require creative, region-specific engagement strategies from industry.

More Collaboration Needed
As medical technology progresses at an unprecedented pace, international collaboration on reimbursement policies has never been more urgent. Sustainable healthcare systems demand a balance between promoting innovation through appropriate funding while ensuring affordable access for patients worldwide. A few proposals could help streamline this process:

– Development of global HTA guidance and best practices under the auspices of the World Health Organization to foster consistent, scientifically rigorous evaluations.

– Exploring mutually-recognized HTA outcomes or conditional coverage with evidence development across major s like the US, EU, and Asia to accelerate patient access.

– Increased manufacturer participation in real-world evidence generation to continuously demonstrate clinical and economic value post-.

– Regional Centers of Excellence for Health Technology Assessment and joint scientific advice from regulators/payers could advise multiple jurisdictions simultaneously.

– Public-private partnerships to support reimbursement dossier preparation and health economic modeling capability transfers to emerging s.

With industry, governments, and multilateral stakeholders working together using harmonized frameworks and data sharing, the challenges around ensuring viable medical device s globally can be overcome. Our shared goal must be delivering life-enhancing innovation to all those in need of advanced care.

1. Source: Coherent Market Insights, Public sources, Desk research
2. We have leveraged AI tools to mine information and compile it