Kalms Consulting Newsletter 2018/01

Out-patient reimbursement code received

Successful support for allergan

Kalms Consulting is happy to announce the successful support and execution of our client Allergan’s reimbursement strategy to receive an outpatient reimbursement code for the physicians treating the over-active bladder with BOTOX® injections. Starting on 1st January 2018, physicians get an extrabudgetary add-on payment for the treatment on top of the insufficient codes that could be used until 2017.

BOTOX® is FDA approved to treat overactive bladder symptoms such as a strong need to urinate with leakage, urgency and frequency in adults when another type of medication (anticholinergic) does not work well enough or cannot be taken. The transurethral injections can be done in an inpatient as well as in an outpatient setting for suitable

Over three years, Kalms Consulting was involved in Allergan’s efforts to initiate a dialogue with relevant stakeholders of the decision-making process –
convincing them of the benefit for patients and of potential cost-cutting for health funds by shifting a part of the cases from the hospital to the outpatient setting. Furthermore we have supported selective contracts between single public health funds and regional physicians associations – to put pressure on the process on the federal level and bridge reimbursement until a nationwide solution.

Receiving an outpatient reimbursement code is a long-term project in the German public health system. Contrary to the formalized procedures in hospital reimbursement, the process in the outpatient sector is based on open negotiations between the federal association of health funds and the federal physicians association. In most cases – contrary to the Botox case – a prior formalized benefit assessment is obligatory.

Kalms consultants are happy to inform you about the details of the rules and the necessary steps to take.

Market access strategy with selective contracts

An alternative approach in accessing the german healthcare system

The German healthcare system has two comprehensive Reimbursement systems, one being the DRG-Catalogue in Hospitals, the other being the EBM-Catalogue for the outpatient sector. These catalogues value diagnostics and therapeutical interventions for reimbursement. In the private
sector, there is a further catalogue, the honorary table for physicians (GOÄ).

These catalogues are final. There are several approaches for new methods to be included in one of the catalogue and thereby obtain a reimbursement value. Due to the strong
regulation of the German healthcare system and in particular due to the strict separation of hospital and outpatient care, lawmakers in Germany created an additional instrument to give patients access to integrated care or special outpatient care. This instrument is called selective contracts and creates opportunities for additional reimbursement or use of methods not approved for the regular outpatient care. In a selective contract, one or more
medical provider (physicians, doctors’ offices or hospitals) negotiate with one or more health funds on a special care pathway with the respective payment of a specific treatment or diagnostics.

This care is accessible for all patients insured with this health fund. Selective contracts are a relatively „fast“ track into the German healthcare system, especially if the method is positioned at the boundary between hospital and outpatient care or if an outpatient method is creating special economic benefits for the health fund. The negotiation of selective contracts is complex. A vigorous and complete preparation is necessary. Economic and medical advantages need to be evaluated and clearly explained for the negotiating partners. Equally important is the selection of the service providers and health funds for the initial negotiations. Moreover, any selective contract should always be seen in context of a broader market access strategy to align on mid-term goals. For example, negotiating an open contract with the possibility to allow other service providers and health funds to enter the contract is enlarging the potential market.

Kalms Consulting has been part of negotiations and execution of selective contracts and possesses the right amount of experience to embed the element of a selective contract into a market access strategy. This ensures that this vital instrument is used at the right time.


Author's Photo

Marco Kalms offers profound expertise in operational management, strategic approach, market access and reimbursement. In 2012, he founded Kalms Consulting, focusing on European market access for international medical device, diagnostic and bioscience companies.

Marco Kalms

CEO Kalms Consulting

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