D'Souza V, Njue A, Heyes A. DRG-based reimbursement and payment modalities for innovative remote patient monitoring technologies. Poster presented at the Virtual ISPOR Europe 2021; December 1, 2021. [abstract] Value Health. 2021 Dec; 24(12):S2.

OBJECTIVES: Novel technologies offering remote patient monitoring have the potential to ease institutional stresses and promote efficiency. Rapid evolution of healthcare monitoring technologies will create a need for reimbursement for active interventions (e.g., device optimisation, remote follow-up) to ensure optimum follow-up care. This study looked at the challenges of reimbursement for novel technologies within existing funding framework.

METHODS: Secondary research identified reimbursement and funding mechanisms for new medical devices in France, Germany, and the UK. The challenges of reimbursement for innovative devices within existing regulatory framework is summarised.

RESULTS: The billing of services for treating patients using medical devices is mainly based on the Diagnosis Related Group (DRG) payment system; however, each country has its own modification of the system. Although the services and tariff under DRG systems are revised annually, obtaining and updating component procedural codes (CCAM in France, OPCS in England, and OPS in Germany) to support adequate reimbursement for a new treatment are prolonged and expensive processes requiring evidence generation and involving multiple stakeholders. New devices are reimbursed under existing DRG-based codes, making this type of reimbursement insufficient for new higher-cost innovations. Discretionary funding mechanisms are also in place to temporarily reimburse new devices (e.g., New Diagnostic and Treatment Methods Regulation [NUB] reimbursement in Germany). Prices of medical devices reimbursed under DRG systems are typically negotiated between hospitals and manufacturers. The budget allocation is not based on payment by results but by a fixed budget distribution system negotiated between payer and provider.

CONCLUSIONS: The DRG-based payment system in its current form is not compatible with newer technologies looking for fee-per-case type of payment model. A DRG system which has been adapted to suit each healthcare market should adopt a payment modality that encourages efficient use of healthcare resources.

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