The Client’s Business Need

This case study illustrates the use of one-on-one interviews with Medical Directors from U.S. private insurance carriers. The interviews were conducted in order to assist a major US university with de-risking its corporate licensing efforts.

Teaching faculty at the university was developing a molecular Point of Care (POC) test to detect selected autoimmune diseases. The test’s objectives were first to reduce the unnecessary use of an expensive hospital-based test. The hospital -based test is considered the diagnostic gold standard. The second objective was for the university’s test to be used in a relatively less expensive site of care than the hospital, that site of care was the physician office setting. Collectively these two objectives could assist physicians with more control in managing and triaging their patients. The university’s POC test is considered a disruptive because it changes the site of care where this auto immune test is conducted from the hospital using expensive equipment and staff to the physician office using a simple POC test.

The university was referred to us o help them better position the POC test to corporate licensing partners. The university believed a better understanding the POC test’s reimbursement pathways would be one way to improve the test’s marketability to corporate licensing partners.

Our Approach

Because of the test’s disruptive factor is high, we suggested a combination of secondary (data analysis) and primary research methods be used. The primary research included one-on-one interview with Medicare Directors from U.S. private payers. To assist with interviewee selection and vetting, the university preferred we interview those Medical Directors whom Rowinski Group had already an established professional relationship.

Medical directors have the authority to 1) manage the use of new technologies outside their traditional sites of care, 2) define evidentiary requirements for coverage and reimbursement for new and unproven tests, 3) can speak of the concerns related to changing workflow and usage outside traditional settings, and 4) provide input into the POC test pricing strategy.

We identified, vetted, recruited and confirmed five Medical Directors to participate in a private interview. The Medical Directors were from different private insurance payers based around the U.S. All had experience with new medical technologies and were comfortable with technologies that have the potential to change traditional workflow, referral patterns and cost structures.

To prepare each Medical Director for their interview we created an interview packet and provided other pre-interview support mechanisms such as a one-hour virtual meeting prior to their interview. Comprehensive preparation of interviewees is often overlooked by companies, but from our perspective is just as crucial as interviewee selection and vetting.

We conducted the interview with each Medical Director over a three-and half-week period. We consolidated all interviews into a single summary. This summary allowed the university to easily compare responses from each interviewee. Reference documents included a transcript and video recording of each interview. We used the summary and reference documents to discuss with the university the five interviews conclusions, key points and next steps.

The Results

The feedback from the interviews helped the university clarify how to improve the POC test’s positioning with potential corporate licensing partners. The Medical Directors realigned our university client expectations of the overall potential market size, the proposed pricing strategy, concerns of the overuse and the type of evidence needed to code and reimburse this novel and disruptive autoimmune POC test. The Medical Directors also outlined action items and road maps to improve the test’s appeal to health insurance payers.

Following the interviews work began at the university to consolidate the action items and road maps outlined by the five Medical Directors. The next step is to stratify and prioritize selected action items including budgets and other resource allocation needs and to continue the effort of de-risking the test for corporate licensing partners