mhealth israel_payers, providers & reimbursement_amir inbar_mediclever
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1 / 26 Copyright © 2016 Mediclever Ltd.
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2 / 26 Copyright © 2016 Mediclever Ltd.
Dec. 21st, 2016 - Amir Inbar, CEO - Mediclever Reimbursement Consultants Ltd.© Copyright 2016 Mediclever Ltd. All rights reserved. Proprietary and confidential. Neither this presentation nor any information it contains may be viewed, disclosed, published, reproduced or used for any purpose without prior written approval from Mediclever.
Payers, Providers & the
Business of Healthcare
About Services Resources
Navigate your reimbursement pathway smarter.
3 / 26 Copyright © 2016 Mediclever Ltd.
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
4 / 26 Copyright © 2016 Mediclever Ltd.
How I Ended up Here?
North America
Europe
Other
Amir Inbar
Founder and CEO
Arie Shen
US Business
Development and Sales
Gerald N. Rogan, MD
Senior Reimbursement
Consultant, USA
Peter Buschmann
Senior Reimbursement
Consultant, EU
Prof. Dr. iur. Gerhard Igl
Senior Reimbursement
Consultant, EU
Richard K. Baer, M.D.
Senior Reimbursement
Consultant, USA
Neil Grubert
Pharmaceutical Market
Access Specialist
Anat Elhai
Director of Operations
Carlos Del Giudice
Market Access
Specialist, Spain
Malca Chen-Zion, Ph.D.
Clinical and Regulatory
Consultant
Dr. med. Ferdinand
Hundt
FFPM (RCP UK)
Ernesto Gallone Arnaboldi
Market Access Specialist,
Italy
Majed Elhewaihi, PhD
Market Access
Specialist, EU
Yehuda Zicherman D.Sc.
Market Access Specialist
Gianluca Furneri
Market Access, Pricing &
Health Economics
David Furst
Advisor
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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JohnDr. Zhivago
1848
Charlottesville
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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= ~$1,200
Physicians practicing in Charlottesville, Medical Charges, June 9th, 1848 (http://blog.hsl.virginia.edu/feebill/)
Charlottesville
1848
JohnDr. Zhivago
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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$40 (Amputation
rate)
JohnDr. Zhivago
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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Employees
$40 (Amputation
rate)
$35 (Amputation
allowable rate)
JohnDr. Zhivago
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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Employees
$35 (Amputation
allowable rate)
Dr. Zhivago
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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Charlottesville
# in group:
Probability of amputation, per person, per year:
Cost per amputee:
Expected monetary value for group:
100
2%
$35
$70
~$30 (Administration
and Profit)
$1
(Premiums)
~$70
(Payment)
Employees
$35 (Amputation
allowable rate)
Employees & Employers
Dr. Zhivago
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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# in group:
Probability of amputation, per person, per year:
Cost per amputee:
Expected monetary value for group:
100
2%
$35
$70
Dr. Zhivago
Employees & Employers
$1
(Premiums)Premiums
~$70
(Payment)
~$30(Administration
and Profit)
~30%
Healthcare Providers
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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Premiums
~30% (Administration
and Profit)
Health Insurer
Employees & Employers
Healthcare Providers
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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Young invincibles
Pre-existing conditions
Unemployed
Uninsured
(Administration and Profit)
~30%Max: 15%
Premiums
Health Insurer
Employees & Employers
Healthcare Providers
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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Young invincibles
Pre-existing conditions
Unemployed
Uninsured
(Administration and Profit)
Max: 15%
Premiums
Health Insurer
Employees & Employers
Healthcare Providers
Healthcare Providers
Employees & Employers
Citizens
PremiumsTaxes
NHS(National Health
Service)
Health Insurer
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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NHS(National Health
Service)
Health Insurer
Healthcare Providers
Employees & Employers
Premiums
Healthcare Providers
Citizens
Taxes
Beneficiaries
Payers
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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Healthcare Providers
Beneficiaries
Payers
Treatment
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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Healthcare Providers
Beneficiaries
Payers
Treatment
Out of Pocket
39%
32%
12%
17%
USA
Reimbursement (71%)
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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Healthcare Providers
Beneficiaries
Payers
Treatment
Out of Pocket
39%
32%
12%
17%
USA
Reimbursement (71%)
Healthcare Providers (HcP) Beneficiaries
Treatment
Payers
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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Healthcare Providers (HcP) Beneficiaries
Treatment
Payers
What is Reimbursement
• When Payers pay Healthcare Providers the agreed upon allowable rate,
• for treating their beneficiaries
• according to their coveragecriteria.
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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Healthcare Providers (HcP) Beneficiaries
Treatment
Payers
Without reimbursement very difficult to reach mass volumes.
Why Reimbursement
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
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Healthcare Providers (HcP) Beneficiaries
Treatment
Payers
a. The problem Diagnosis Code/s
b. The service Procedure Code/s
c. Add. details Age, gender, etc.
2. The Payer checks if the above combination has COVERAGE
1. On his claim, the HcP uses CODES to tell the Payer:
10101101
3. If positive, the Payer pays the healthcare provider according to the allowable rates
$
Reimbursement =101110
$10101101 $+ +
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
How does it work
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Reimbursement =101110
$10101101 $+ +
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
Healthcare Providers (HcP) Beneficiaries
Treatment
Payers
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Reimbursement =101110
$10101101 $+ +
1. Reimbursement is comprised of Codes, Coverage and Payment.
3. Different settings Different reimbursement mechanisms.
2. To obtain reimbursement, different stakeholders should be convinced to allocate codes, grant coverage and assign payment rates.
2. Healthcare Markets1. Introduction
2.2. Operation2.1. Formation
25 / 26 Copyright © 2016 Mediclever Ltd.
About Services Resources
Take a minute to learn about medical technology reimbursement.
26 / 26 Copyright © 2016 Mediclever Ltd.
About Services Resources
Navigate your reimbursement pathway smarter.
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