The Challenge: Navigating the traditional medical device reimbursement landscape is fraught with complexity. Reliance on hospital purchasing decisions, VAC approvals, and opaque insurer negotiations creates significant hurdles for innovative technologies seeking market access.

The Opportunity: A powerful, alternative pathway exists. This report explores a vital strategy gaining traction: securing coverage and reimbursement directly from self-insured health plans. Representing a significant majority (~65%) of the employer-sponsored market, these plans offer unique advantages.

Why Self-Insured Plans Are Different:

• Direct Risk, Direct Incentive: Employers assume the financial risk for employee healthcare costs, driving a keen focus on value, cost management, and customizable solutions.
• ERISA Flexibility: Governed primarily by federal ERISA law, these plans have substantial freedom in benefit design, coverage criteria, and network construction, largely bypassing state-level insurance mandates. This flexibility allows for tailored coverage of specific medical devices.
• Growing Trend: Direct Contracting: Employers are increasingly bypassing traditional intermediaries to contract directly with providers and other entities, seeking greater cost control, transparency, and quality.

Inside the Report: Leverage Plan Design & Direct Contracting

This comprehensive analysis provides a strategic roadmap for medical device manufacturers, market access teams, healthcare strategists, and benefits consultants. Discover how to:

• Navigate the Self-Insured Environment: Understand the dynamics of risk, administration (including the role of TPAs), regulatory landscape (ERISA), and market size.
• Master Direct Contracting: Learn the mechanisms for establishing direct relationships with employers/TPAs and the growing market trends.
• Integrate Devices via Plan Design: Explore strategies for modifying benefit structures, coverage criteria, preferred networks, Centers of Excellence (COEs), and member incentives to ensure device adoption.
• Demonstrate Compelling Value: Understand the crucial evidence requirements—beyond clinical efficacy—focusing on cost-effectiveness, total cost of care impact, and workforce productivity relevant to employers.
• Contrast Models: See a clear comparison between the direct-to-plan approach and traditional hospital-centric sales models, highlighting key differences in decision-makers, reimbursement flow, and commercial strategy.

Takeaway: Success in the self-insured market requires a shift towards a payor-centric, value-driven approach. This report details how to build the business case, engage the right stakeholders, and leverage plan design to secure dedicated reimbursement pathways for your medical technology.

Ready to unlock this market? Read the full article here - https://www.linkedin.com/pulse/leveraging-plan-design-direct-contracting-secure-payor-soqne%2F/?trackingId=l4Q7gewRslFJk9Yt7%2FFyDQ%3D%3D

Or listen to the article - https://open.spotify.com/episode/63zkHP7W2uheJ2s1nPweta?si=8pll4UcmQOKwl24GmNmkPg