A Checklist for Getting Paid in Healthcare

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
By Annie Case
Photo credit: @michaelsprague

We hosted our second Rock Health Summer School workshop, organized in partnership with Skillshare, on Wednesday night, featuring two health startup veterans—Aaron Ginn and Shannon Bergstedt. The class,  “Getting Paid in Healthcare: Business Models and Money Flows,” aimed to guide potential health entrepreneurs to the right path towards establishing and monetizing a sustainable business. This session’s topic was particularly timely, as the Supreme Court’s decision on the Affordable Care Act was announced less than 12 hours later.

Aaron and Shannon used two examples, CardioDX and WellnessFX, as case studies for their course topic and discussed  what new and emerging startups can learn from their experiences. Their message was simple: if you want to get paid in healthcare, you need to plan ahead and think about the pathway to payment early and often. Here is their checklist of things to consider and questions to think about before jumping into the health care space:

1. Disruptive vs Incremental – Is this a new, game-changing technology or a modest improvement upon existing technologies?
2. Place of Service – Will this technology be delivered online, in a clinic, in a hospital, or someplace else? Entrepreneurs should think about how this will influence the payment pathway.
3. Provider Types – Who will be providing the technology or service, and what are their needs and interests?
4. Payer Mix – Who will you be selling this product to, and who are the primary payers for those people?
5. Primary Stakeholders – You need patients to want it, doctors to order it, and payers to pay for it. Be sure to have a compelling value proposition for each.
6. Incremental Cost & Who Pays It – Is this technology cost-additive? If so, can it still be justified?
7. Added Value – You need to prove to the payers that the product is worth it, in quality and/or efficiency terms.
8. Coding – Does this technology require a code for payment? If so, can it fit under an existing code or does it require a new one? You may want to consult a coding specialist.
9. Competition – Who else is in this space? What can you learn from them?
10. Coverage Landscape – Are similar technologies covered? If so, what are the rates and options?
11. Regulatory Approval – 510k or PMA? This will affect how long it takes to develop your business.