A medical device company was concerned with the challenges that providers face in securing appropriate reimbursement through Medicare and private payers for a procedure involving one of their newest technologies. The company retained Quorum Consulting to evaluate reimbursement opportunities and barriers associated with the widespread adoption of their technology.
Business Challenge
Quorum’s client was entering a market segment with established treatment practices that involved widely accepted surgical procedures and a narrow patient demographic.
Our Approach
Quorum conducted an analysis of the market and profitability of current procedures using the 2005 MEDPAR file, representing 100 percent of all Medicare inpatient acute care hospital claims discharge data available. That analysis included the review of the subject demographic, procedure volume, charges, estimated costs, and Medicare reimbursement for those surgeries. While the conditions and related surgeries were focused on the Medicare population, Quorum reviewed a nationally representative survey of hospital discharges conducted by the Federal Government (the HCUP). This survey review further established current market size, and confirmed procedure and discharge frequency as well as payer mix across all hospitals and payers.
Additionally, Quorum conducted a data intensive analysis of current procedures focusing on adverse events and complications related to those treatments. By analyzing MEDPAR discharge data, Quorum established the cost and complications directly related to the current surgical procedures conducted in an inpatient setting. To develop a more comprehensive picture, Quorum used the CMS Standard Analytical Files (SAF) claims data, representing 100 percent of all Medicare claims for a randomly selected 5 percent of the Medicare population. Quorum captured and reported complications and co-morbidities for procedures performed outside the inpatient hospital setting, and analyzed those adverse events that took place within the same quarter as the procedure, regardless of setting. This analysis involved the review of patient characteristics, the expected complications or co-morbidities, and those adverse events possibly and probably related to the procedures.
Our Solution
Quorum provided the client with an in-depth review of the market size, frequency, and profitability of the current technology and procedures. Quorum documented the adverse events associated with the current procedures, giving the client empirical evidence to support their position that current procedures and technology can be improved in both cost benefit and health outcomes. Quorum was then in a position to propose a clinical study with related financial data gathering.
Results Delivered
Quorum delivered a comprehensive review of market size based on patient demographics and claim history. Quorum also established the costs, charges, and relative profitability of current technology. To address potential obstructions and resistance to the new technology, Quorum thoroughly analyzed the clinical issues, document complications, and adverse events associated with the historical technology. Finally, Quorum proposed a systematic approach to ensure future payment for the new technology based on clinical trial and the gathering of economic data to document the feasibility and cost-benefit of adopting that technology on a wide spread basis.
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