Value and Coverage: How reimbursement decisions impact innovations needed to improve health

In this report, FasterCures notes that when it comes to the issue of value and coverage for medical innovations, the medical research community is in search of a better understanding of the evidentiary standards that payers consider when reimbursing treatment and care. Top of mind throughout the workshop, held in the summer of 2013, was this concept that who determines value and what informs that determination are vastly unclear but have large implications for both the cure and care ecosystems. More than 50 leaders from across all sectors in healthcare and medical research participated in the workshop, convened in partnership with the Cystic Fibrosis Foundation.

FasterCures presents a number of recommendations for patient organizations and for other stakeholders engaging with patient organizations to consider. Recommendations fall under three major categories:

  1. COLLABORATE. Engage with CMS and other payers regularly to increase their understanding of your condition - from the nature of the disease, the impact of existing therapies on quality of life, and even coverage and pricing issues your constituents face. Regular engagement helps inform the decision process and prevent decisions made in a vacuum.
  2. LEVERAGE DATA. Anecdotes are important, but data matter most. Articulate in clear and concise terms what patients consider meaningful to enhance the assessment of clinical benefit.
  3. DEPLOY BETTER, SMARTER CARE. To ensure coverage for life-saving innovations, you must be vigilant about removing waste from the system and not allowing new forms of waste into it, including misuse of products and services. Challenge behavior that contributes to wasteful spending and lack of accountability.


FasterCures Value and Coverage Issue Briefs: