The scientific community has a critical role to play in gaining optimal insurance reimbursement for MR-guided focused ultrasound. As Susan Klees, Director of Patient Access for the Focused Ultrasound Surgery Foundation, reports, “Evidence is the key driver for reimbursement, and it all begins with the way studies are designed. Research priorities must be grounded in sound science as well as the realities of the marketplace.” 

Designing studies that address marketplace realities requires an understanding of what is valued by different groups. “We know that physicians are seeking cutting-edge treatment modalities to solve medical challenges, patients want to avoid complex surgery and lengthy recovery times and medical payers expect enhanced outcomes and efficiencies in treatment,” she explains.

Although there has been reimbursement success in countries like Germany, Klees says, private payers in the U.S. are not yet consistently covering focused ultrasound treatments for uterine fibroids. In fact, some have adopted ‘negative’ policies that actively seek to deny coverage. “This is happening even though focused ultrasound has been approved by the Food and Drug Administration and demonstrated important advantages over competing therapies,” she notes. “These advantages include being an outpatient procedure, offering quick recovery and preserving the potential for future fertility.”

Because they view the current body of evidence as unconvincing, many American healthcare insurers are asking for randomized comparative trials and long-term outcomes before reconsidering their stance on MR-guided focused ultrasound therapy.

To avoid such stalemates in the future, the FUS Foundation is encouraging researchers, industry and other stakeholders to collaborate in setting priorities for investigating new focused ultrasound applications. Examples include essential tremor and Parkinson’s disease. “We’re pushing for studies that target the most commercially viable focused ultrasound applications, address safety and efficacy, and generate data that demonstrates the technology’s comparative superiority in long-term benefits, quality of life and cost-effectiveness,” Klees explains.

Written by Ellen C., McKenna

 

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