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Evolution from fee-for-service to pay for value
A leading agent of change in healthcare.

Reimbursement is only part of the story

Strategic consulting around reimbursement, accelerating time to revenue, and idea generation has always been to those of us at HillCo HEALTH as much about art and creativity, as it is about hard facts – fee schedules, codes, clinical utility and evidence.

Many in our industry provide clients with the “best approach” based on facts alone. We provide a contrarian viewpoint. We believe there is no one right answer and are relentless to ensure we do the right thing for the right reasons for our clients. We all have walked in the shoes of those we seek to influence, and we speak with and through authority as a result. We cut our teeth as the team to engage when knotty problems arise that others fail to address. We are are now leveraging those same skills proactively to help our clients map out the optimal strategy from the onset. This has become increasingly important to our clients as the health care world evolves from a cost plus to pay for value orientation.

We appreciate the faith, trust and friendship shown to us by our clients and colleagues these past 13 years and promise the best is yet to come.

Marc Samuels

HillCo HEALTH is a boutique health care advisory services firm. Our business is making companies more valuable.

At HillCo HEALTH, we:

  • Convert knowledge of the US and International healthcare markets to identify risks and opportunities
  • Translate the business implications of health policy and regulation
  • Create or accelerate market access for new products and services

Diagnostics

Devices

Drugs

Services

“Reimbursement risks are probably as important these days as regulatory [risks]. Reimbursement is part of the economic equation as investors ask whether payers will pay and what authorized reimbursement codes are available for the product.”

Source: The Pink Sheet

Case Study

Coding

Sometimes Working With Specialty Societies Demands A Change in Strategy

  • Problem

    CPT codes for application of a novel skin substitute were improperly valued. The valuation was due to use of an improper vignette by the AMA/Specialty Society RVS Update Committee (RUC), a mistake made by many organizations without proper counsel. The conflict with this valuation caused serious reimbursement problems for physicians and, as a result, for the product manufacturer, our client.

  • Solution

    HillCo HEALTH proposed new CPT codes to separate the application of the client product from the predicate products in the existing code set. The CPT Editorial Panel believed that both the novel product and predicates were too similar and appointed a workgroup. As a result of the delay and length of the workgroup deliberations, the reimbursement problems persisted. Recognizing this issue, we revised our strategy and worked with CMS to create temporary HCPCS G codes while the CPT Workgroup sought resolution.

  • Results

    CMS created new G codes for the 2010 Medicare Physician Fee Schedule and developed fees for the codes. The G codes eased the reimbursement problems. They were in effect until a year later when new CPT codes for skin substitutes were implemented.

“HillCo is by far the most capable firm I have worked with in my 17 years in Washington, DC. What stands out the most is their ability to achieve positive resolution on complex issues – they don’t just provide advice, they get things done. HillCo is simply the best company when it comes to achieving results.”

Work Done: Reimbursement Strategy. Public Policy. Advocacy.

Case Study

Reimbursement Strategy

  • Problem

    Proton Beam Therapy is a new and highly effective treatment for radiation of solid tumors. While there are only a handful of active Proton Beam Therapy Centers in the country, both Medicare and commercial payers have instituted strict coverage and payment policies and many do not cover the technology beyond prostate, head and neck, and for children.

  • Solution

    HillCo HEALTH singled out one of the largest payers in the U.S., Health Care Service Corporation (HCSC), which at the time had non-coverage for Proton Beam Therapy for solid tumors. We suggested working with two of the Proton Beam Therapy Centers in the HCSC’s region to change the coverage and payment policy. Our strategy was to work with the clinicians at these institutions to amass and collect all available evidence. We also opened a dialogue with the Chief Medical Officer of HCSC in a proactive and candid attempt to discuss levels of evidence and even “coverage with evidence” approaches. Finally, we focused on the effectiveness of the technology in children to leverage the strong body of evidence for children in getting immediate coverage.

  • Results

    HCSC agreed to cover and pay for head and neck, brain and prostate cancers within three months. It also agreed to cover children within six months. After one year, HCSC agreed to conditional coverage of lung and implemented a process to fast-track additional tumor-type coverage. Lastly, they also solidified payment at a premium above fair market value.

“Not only does HillCo have broad respect from CMS staff – both political and career staff, they also have a wide network of contacts within the patient and physician community. Few consultants have the ability to match well developed tactics with broader company goals.”

Work Done: Coding. Product Launch. Market Access. Payer Impact.

Private Equity

Commercial Payers

Due Diligence

Due diligence on healthcare services and products reimbursed by major insurers.

Surveys

We can survey active medical directors at major health insurers throughout the U.S.

Advisory Boards

We can arrange meetings with medical directors currently at major health insurers, providing our clients with access to their current thinking about healthcare in a roundtable discussion.

Private Equity

Government / Political

Due Diligence

Due diligence and predictive analysis on legislation and regulation and its impact to particular healthcare services or products.

Surveys

Macro analysis of shifts in healthcare.

Advisory Boards

We can initiate surveys and work to help identify future policy changes in States.

“HillCo offered tremendous insight into the [commercial] policy, coverage and reimbursement of our products. Their dedication and devotion to our coverage situation continues throughout the life cycle of the product supporting both local and national level issues.”

Work Done: Medicare Coverage, Local and National. Commercial Payer Coverage. Quality Measure Development and Guideline Development.

Case Study

Payer Impact and Access

  • Problem

    Many of our clients encounter knotty problems with market access and reimbursement in commercial payer settings, despite best efforts or solid PBM contractual relationships. We often find that the source of their struggle comes from inaccurately or inadequately translating the value proposition of their product or service into the language and currency of payers.

  • Solution

    HillCo HEALTH works to showcase the significant impacts that our clients’ products and services have on system costs, clinical outcomes, and the patient experience. We assist in the development and execution of their payer and purchaser strategies, accelerating coverage and reimbursement, and driving more rapid market adoption. We work with clients to help integrate their offerings into the payers’ care management and customer service processes, and can serve as their in-house reimbursement, national accounts or medical staff.

  • Results

    We have had success in making coverage or reimbursement changes in over thirty key commercial payers and across all MAC and Durable Medical Equipment Medicare Contractor (DMAC) regions. In keeping with our efforts to always provide multiple approaches, we also create direct-to-employer strategies to showcase how utilization or integration can lead to lower employee costs and increased days at work.

“We would recommend HillCo highly to you if you want an insider’s perspective of [federal and state] agencies, an encyclopedic knowledge of Medicare and Medicaid, and a group that knows how to get things done.”

Work Done: Due Diligence. Public Policy. Reimbursement Strategy. Health Economics Analysis.

Case Study

Quality and Guideline Development

  • Problem

    An innovator biopharmaceutical company launched a product in head & neck and colon cancers. After a successful product launch, it was found that a diagnostic test could predict whether use of the product would benefit the patient. Payers began linking the test to the product and instituted prior authorizations. Because physicians were not familiar with the test, use of the product slowed considerably and sales were negatively impacted.

  • Solution

    Once payers linked the test to the product, our team surmised that we needed to create strategies that would pull through use of the product to the drug. Our strategy would also raise the profile of the test, the drug, and the positive ROI to payers from promoting both. We suggested the American Society of Clinical Oncology (ASCO) Quality Oncology Practice Initiative (QOPI) measures as a good place to begin. Many oncologists use these measures because reporting counts toward their internal medicine boards.

  • Results

    Three QOPI measures were created and accepted by ASCO. Uptake and use of the test was also helped by educating physicians through an ASCO plenary session at the well-attended June meeting. Payers dropped their prior authorizations. Use of the test — and consequently the drug — is now above ninety percent. HillCo and physician KOLs have developed and passed two other oncology quality measures and two cardiology measure sets across relevant specialty societies. We also have co-developed provisional clinical opinions (PCOs) in advance of specialty society guidelines and worked with KOLs on guideline development for specialty societies.

“Marc Samuels is one of the best kept secrets for those seeking to work with CMS. He is the insiders’ insider, who is often brought into issues during a crisis or after others has failed. While many consultants impress with titles, fancy PowerPoints, and process, HillCo impresses based on the wisdom of their advice and counsel, and their ability to achieve results. ”

Work Done: Audit. Coverage. Procurement and Partnerships. Advocacy. Due Diligence.

Case Study

Procurement & Partnering Opportunities

Our team has been engaged in all of the below scenarios, forging partnerships and providing guidance to procurement opportunities with government and commercial plans.

  • Issues

    A large care management company in several disease states; a software manufacturer partnered with a leading digital health provider; a rural Medicare partnership – each entity seeking a win on a solicited or unsolicited request to the Centers for Medicare and Medicaid Services (CMS)/HHS.

    A large multi-national insurer; a regional Blue; a digital health and a diagnostic start-up – looking for senior executives to add or build their management team.

    A drug company and a provider of DME; a coalition of service providers; a care management company and a handful of disease centers of excellence; a collaboration of physicians – all interested in joint sales and/or marketing projects or in harnessing groupthink to mete success.

  • Solution

    HillCo HEALTH worked with these companies to find upcoming opportunities in government and the private sector. Generate Ideas. Capture new business or forge business to business partnerships.

  • Results

    HillCo HEALTH worked with these companies to find upcoming opportunities in government and the private sector. Generate Ideas. Capture new business or forge business to business partnerships.

Agents of Change

Our team members bring experience from the Centers for Medicare and Medicaid Services (CMS), Food and Drug Administration (FDA), Medicare Administrative Contractors (MACs/DMACs), State Medicaid, the White House and private healthcare industry.