The curious case of the costly complication. A medical device company cleared a major hurdle with FDA approval for their new product, but they hit a snag when commercial payers refused to provide a medical coverage policy for the device. When this happens it can be difficult and costly for patients to access treatment even if its the best available. In order to be covered, the device company needed to prove their device was more cost effective than the current standard of care. But how? Enter Optum®, a leading health services and innovation company with years of proven experience helping clients find solutions to difficult problems. Optum had the keys to unlock the answers with a massive amount of de-identified, real-world patient data from claims and electronic health records and the technology and expertise to integrate, sort, and analyze that data.
Like all surgical procedures, the current standard of care comes with possible complications. After hearing the device company’s story, Optum began to dig deeper into the data and quantify the costs of those complications. If the newly approved device could avoid or minimize complications and associated costs, the device company would have the proof they needed to differentiate their solution. The first step was to compile a list of “complication codes”. This required close collaboration between the Optum Medical Director and the device company’s Medical Director, a practicing physician familiar with both the current standard of care and his company’s solution. Optum data identified patients who had undergone the surgical procedure during a seven-year period, and included the associated diagnosis and procedure codes.
The Medical Directors were able to cross-reference the codes and determine which ones pointed to complications post-procedure. Armed with that knowledge, Optum zeroed in on the medical and pharmacy costs associated with the complications, looking at key variables, at 90 days, one year, and three years post-procedure. The Optum data provided other clues around; condition diagnosis, prescriptions for medications, and condition-related health care utilization. The company soon discovered exactly what they needed. Optum’s cost analysis gave them actionable data to drive discussions and impact decisions. Another case closed. Now on to the next one.