Reimbursement

Question 1

What is a hospital?

Answer 1

HC institution providing patient treatment with specialised staff and equipment

Question 2

How has uncertainty affected HC investments?

Answer 2

It is a rapidly changing environment with a lot of uncertainty
Investment is the primary driver in HC startup world
There is an unclear reimbursement landscape in the future
Unclear is the new normal, so we have to invest

Question 3

What is redefining the reimbursement environment?

Answer 3

Blending between digital and medical.

Crossover between medical outcomes, economics, and increasingly informed population

Question 4

What are recent hospitals changes in various countries’=

Answer 4

Holland - strongly community based, moving away from hospitals
Korea - validate hospitals, build very large new ones
UK - strongly GP based

Question 5

How are healthcare providers paid?

Answer 5

They are paid by insurance / government payers through reimbursement of medical services and goods
This means they first provide the medical services, then they file for reimbursement

Question 6

Common misunderstandings about reimbursement

Answer 6

Regulatory approval does not mean you will get reimbursed

If medical devices are not classed as such, you cannot apply for reimbursement

Question 7

Changes in the healthcare environment - Drivers

Answer 7

Impact of austerity
Older population
Different clinical condition types and their impact

Question 8

Response to drivers of change in HC environment

Answer 8

Move to LOWEST COST MODEL

This involves managing patients in the community

Question 9

What is the technology response to these drivers?

Answer 9

Move to HC apps and AI (this especially is fundamental for the future)

Question 10

What is AI’s place in reimbursement?

Answer 10

AI was not included when they created/redesigned the system to approach these drivers.
AI is not included in reimbursement systems, so there is no way for those who create it to be reimbursed
- no funds have been set aside for AI > these resources are therefore not commonly employed and are cut out the market e.g. app to manage diabetes

Question 11

Healthcare system types

Answer 11

Free market (insurance based) - US
Bismark (competing social funds) - France, Germany
Hybrid (private insurance for high earners, social for all others)- Japan, Holland
Beveridge (free at point of care, social based) - UK, It, Port, Spain, Scandinavia
Ex- Semashko restructured beveridge/bismark) - Russia

Question 12

Who came up with Value Based Healthcare Reimbursement?

Answer 12

Michael Porter

Question 13

What is Value Based Healthcare Reimbursement?

Answer 13

The future of reimbursement will be based on the value created by the product and the ability to demonstrate that value

Question 14

How are reimbursement systems changing?

Answer 14

Slow to change

Now beginning to embrace new technology

Question 15

What is basic structure of UK health system

Answer 15

Gov DoH
NHS England
CCG
NHS trusts, Ambulance Services, Mental Health, GP

Question 16

How do codes in the healthcare system work?

Answer 16

Each intervention or procedure is covered by a code

This code informs the CCG what the intervention is and what the billing tariff id

Question 17

What are Healthcare Related Groups?

Answer 17

Grouping of all the codes of everything used (both interventional and diagnostic)
This forms the basis of hospital reimbursement

Question 18

What are the 2 types of codes used?

Answer 18

Operation: OPCD
Diagnosic: ICD10

Question 19

How can hospitals save money?

Answer 19

They are allocated income to complete each operation/procedure
If they are able to reduce costs or redefine services to do the procedure for less, they save money

Question 20

What is an example of redefining services?

Answer 20

Moving patients around the bed to avoid bed sore formation

Question 21

How does the coding system differ in the US

Answer 21

They have three different types of coding

Categories I - III

Question 22

What is the main difference with healthcare service provision in the US?

Answer 22

The doctors have a fee for service, so they receive payment for delivering the service

Question 23

What are the three biggest healthcare markets in the world?

Answer 23

US
Japan
EU

Question 24

Give an example of value based reimbursement

Answer 24

A wound dressing for DFU can be more expensive than one for VU, as VU has higher cost to society

Question 25

What is value in value proposition?

Answer 25

Health outcomes that matter to patients
/
costs of delivering that outcome

Essentially considers what the best outcome for the patient is, and how much that will cost

Question 26

What is the central goal in healthcare for value based healthcare?

Answer 26

Value for the patient is the central goal

Not volume, cost containment of meeting medical parameters

Question 27

What does Value Based Health Care act as?

Answer 27

Fundamental driving force between:

• adoption of services,
• fees for services
• design for medical products

Question 28

Explain QALY

Answer 28

Quality Adjusted Life Years
1 QALY = 1 year in perfect health 
0.5 = bedridden 
0= death 
Negative = worse than death

Question 29

How could you reduce costs in medical care?

Answer 29

• Reduce stay in hospital
• Manufacture cheaper products
• Change clinical pathway

Question 30

What was Eykonia

Answer 30

Takes 3D images of wounds to document their progress
Received a lot of angel investment as it was starting off
It failed because nurses have low prescribing power, and it is unnecessarily expensive for something you can do with a ruler
Now re-adapted for gaming and 3D imaging.

Question 31

To achieve reimbursement you must demonstrate:

Answer 31

• Clinical Trial Design
• Regulatory Path
• Health economics