ARTICLE SUMMARY:
Reimbursement strategies are key to succeeding in the growing, underserved market for women’s health technologies. Excerpted from our recent feature, The Business Case for Investing in Women’s Health.
The women’s health market represents a $41 billion opportunity, yet obtaining financing has been a significant challenge for women’s health start-ups. Obtaining reimbursement is another hurdle.
For healthcare services companies like New York-based Paloma Health, which focuses on thyroid care for women, reimbursement is straightforward and revolves around contracting with payors, said Marina Tarasova, the co-founder and chief operating officer. More alarming are the disparities in reimbursement for men’s versus women’s procedures and devices and a virtual-first multistate clinic, she added.
First-time founders often neglect to convince payors that their solution can solve a payor problem and address why their innovation matters to payors right now, stated Melissa Reilly, an angel investor and behavioral health executive, who previously worked as chief growth officer for Evernorth Behavioral Health and before that was a VP at Optum Ventures. Founders need to address whether their solution will help payors with cost challenges and also know who is driving payor decisions—is the employer or will payors act on their own because the problem is urgent? Also important is identifying whether the payor has a dedicated women’s health specialist or team. “If you don’t know that exists inside a payor, you [need] to find out who is making those decisions, Reilly continued.
Jodi Neuhauser, founder and CEO of In Women’s Health, a career platform for women’s health, and co-founder of the Women’s Health PAC, which supports political candidates who focus on women’s health, said that women’s health in addition to being underfunded is undervalued. “Consumers do not understand why their ob-gyn spends only 15 minutes with them, and most people do not understand how reimbursement works or what a RUC committee is, or the role CMS plays in reimbursement,” she stated, noting that less than 5% of the roughly 10,000 CPT codes used in the US to obtain reimbursement are related to women’s health.
CMS rates are benchmarks used by commercial payors, and so need to be fixed. The RUC committee currently does not have an ob-gyn member, and there are no surgical women’s health reps on the RUC. The HHS Secretary has power to change that.
“It is not always easy to demonstrate value to a payor within their one-year budget cycle,” Tarasova admitted. One influence on payor decisions is the employer-customer, because payors have to compete for their business. The Women’s Health Collaboration Collective is a group of companies that approach payors and brokers and large employers as part of a one-stop shop, she continued. Companies need to work with payors 18 to 24 months prior to going to market, and they should have a strategy for covering those two years, said Neuhauser.