Professional Documents
Culture Documents
December, 2016
Goals
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Project questions
1. For each indication (for example, Percutaneous Angioplasty), what products are utilized? Why do surgeons
utilize product A and not product B? If applicable, why don’t they utilize premium brands?*
a) Possible responses to be explored: Does not know product? Does not have access? Cheaper?
Culture? The hospital only purchases Product A, and not B? (supplier does not offer). Responses will
not be quantified and will be based on qualitative interviews;
2. Which are the hospital ‘entrance doors’ for Bard, and what messages must be conveyed to hospitals?
3. Mapping of applicable private and public reimbursement/funding pathways and, when applicable, specific
tariffs;
4. Overview of local (country-level) public and private reimbursement mechanisms and their relevance for Bard
business;
6. Local clinical and non-clinical stakeholders’ map, including their influence in the selection and purchasing
processes;
3
Project timeline
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Products
Products categories Products (summarized) Indications
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SWOT Analysis – Market Access Perspective
MEXICO
Strengths Weaknesses
•HTA gov bodies with high level laws • The main HTA gov. body (CENETEC) that attends
regulations device needs, nowadays hasn´t decision power
•DI with strong clinical evidence into the inclusion process
•Increased National Devices Manufacturing • Even when the device has been included yet at
process formulary, purchases happen more through 3rd
•Strong relationship with “Integrators” (3rd channels than directly sales. In this sense, even
channels in order to get purchases even without inclusion is not mandatory
healthcare code)
Opportunities Threats
• Value payments more than fee for services • Cost containment issues (expected
purchasing based on unit cost) unprecedented cutting costs at healthcare
• Increase awareness on clinicians around national budget 2017)
clinical/economic benefits from technologies
(devices)
• Oncology innovation treatments will decrease
its usage due to unethical price/effectiveness
ratio
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Traditional approach
Bard
Distributor/Integrator MoH/subsystems/hospitals
Stakeholders
Payer Hospital KDM
& integrators
Focus on Facilitated
reducing cost relationship
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Approaching Mexican Private Payers
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Opportunities – Early adopters of Technologies
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Helping Payers and Providers
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Opportunities: create new channels with
integrators / states
Engage with distributors • Primary focus on price negotiation and thereafter include value
(integrators) payment discussion
Engage with states • Primary focus to get include it into a portfolio service, which in turn will
be provided by Bard or integrator
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Priority to approach
How to generate value?
Order of priority Their goals Approach
Show clinical and economic benefits
Achieve and expand access of Bard
Public healthcare aligned with business models. Begin
Portfolio based on value payment
system with real world data to generate
methods and patient access schemes
Value based evidence
payments Early engagement with Audit
Insurance
aligned Minimize financial risk, manage costs Committees to demonstrate value
companies
w/business (benefits vs cost)
models. Bard In the very begininng Bard must go
will move with discounts or aggressive
gradually to new Get joint ventures to offer the vast proposal versus competitors to be
commercial Integrators majority of the pipeline and mature considered into the Integrator
schemes devices of Bard. portfolio. After this, Bard must
redesign approach w/integrator to
push a “win-win” strategy
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Short-term opportunities
Direct engagement with Integrators and
Private insurance companies
• Bard is effectively promoting its premium technologies to the market
• However, the integrator still have almost total control into the devices
selection without transparency to open and balanced market share between
competitors.
• Bard must directly push innovative strategies with government sector in order
to align and help integrator and distributors to engage and increase
purchases, to configure out better scenarios that balanced the market
• Manufacturers and/or DI is not aligned with insurers needs neither patients
perspective
• Partnering with hospitals and indirectly with patients to approach package payments based on
value and avoid those practices like fee for service
• Most of the insurances companies are not aware of the clinical neither
economic benefits of Bard products and will decline payment based on price
only
Direct engagement with healthcare gov.
sector and interinstitutional KDM
Goal
• Achieve positive coverage decision (i.e. approvals) from interinstitutional formularies (IMSS, ISSSTE)
and more important get the first per patient purchase to leverage central decisions to increase
affordability coverage – increase reimbursement
Tasks
• Establish contacts and schedule meetings with KDM to leverage value payment methods (trainings
around these innovative strategies)
• Present products and economic benefits considering institutional perspectives
• Ideally, estimates must be calculated based on real world data or at least w/local inputs
• Possibly, in the near future get negotiations through prices negotiation commission
• Get alliances with integrators to maintain purchases targets . Bard must keep in mind that integrator
approach won’t be untenable
Requirements
• Offer trainings, round tables and top discussions with KDM around market entry agreements
Timeline – intermediate
• Expected 12 – 24 months
Strengthen relationship with healthcare
secretariats at states
Goal
• Increase or create new commercial agreements with states or municipalities through identification of
those states with decentralized public institutions with local budget and historical purchases destined
to get innovations (e.g. through Seguro Popular reimbursement-CAUSES-Appendix I based on ICD
classifications that includes devices into the description)
Tasks
• Create or strength relationship with key stakeholder at each state or municipality
• Use traditional commercial channels to get purchases at each state
• Train sales forces around the pathways to get purchases from Seguro Popular reimbursement
• Get aid or contract 3rd key player to offer same trainings, but offered to clinicians to avoid conflict of
interests
Requirements
• High level knowledge from our sales forces and strong confidence on those 3rd key players
Timeline – intermediate
• Expected 12 to 36 months for approvals
Mapping and engaging
with payers
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1. Mapping payers
2. If possible, list KDM with highest number of negative decisions for Bard
Healthcare subsystems are more prone to adopting high-quality products through subrogate services contracts
1. Medical area (AECAT area) and finance division (Coordination Unit of finance planning) at IMSS.
2. Infrastructure division (which oversight drug and equipment areas) and medical management at ISSSTE
1. In order to include some International Classification of Disease to indirecty get coverage of Bard products, Bard must be aware of inclusion dates
every year to submit on time.
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2. Engaging with Payers
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3. Demonstrating Value for KDM
• Biggest concerns:
Lack of cost & outcomes data from hospitals (i.e. “I do not know exactly
how much this procedure costs”)
Hospitals may extend use of high-cost materials to a niche patients pop
• Time-horizon
Due to Budget control and professional evaluations, KDM focus on
benefits generated within 12 – 24 months
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4. Opportunities at healthcare subsystems
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Recommendations by
product
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Product ‘preference’ map*
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PICC
Benefits
Recommendations
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Port
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Stent and Stent graft
Benefits
Recommendations
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Balloon
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Meshes
• Extensive portfolio
Benefits
• Premium products may be in contact with viscera
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Matrices
Benefits
Recommendations
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Sealants and Hemostats
Benefits
Recommendations
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Purchasing
Case Examples
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Stakeholders mapping
MEXICO
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Interview considerations
• The scope of the interviews was to collect qualitative information and should
not be understood as a significant representation of the overall market
• Bard’s identity was not disclosed in connection with the project to any third
party preceding or during the project
• Stakeholders are identified only when there was an authorization for such,
otherwise they are referred to in generic terms
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Hospital that serves Public System (The case of IMSS)
Economic Every year, Economic Analysis Unit alongside MoH and the main healthcare subsystems
convene to the pharma industries to negotiate prices, specifically price from those high
Analysis Unit cost drugs for (e.g. target therapies). In this sense, devices are not discussed into the price
alongside Secretary of health negotiation yet.
and the main healthcare • Probably next year will begin to convene device industry to reach out the first
subsystem agreements around high cost devices (agenda 2017)
Nowadays a key player has been working between healthcare institution and the
Intermediary manufacturer/device industry:
INTEGRATOR. The integrator (e.g. VitalMex, Medicus, Selecciones Médicas) offer
Pricing key player a service that cover a disease through medical and/or surgical approach.
The coverage include pharmacotherapy, surgical procedures including
(between healthcare institution
and the manufacturer/device
devices
industry) Even when the device hasn´t been accepted at the national formulary, the
integrator could push the purchase made by the IMSS.
ISSSTE, Army, Navy, PEMEX Oil Company performed alongside IMSS a market
Budget limit, research to identify needs in order to project quantities required of healthcare
supplies, drugs, devices, services (integrated)
Buying
set by local • But, even when they follow IMSS rules, the vast majority of the times they
government could purchase device without following consolidated process.
Economic Analysis Unit alongside Secretary of health and the main subsystems (ISSSTE,
Economic Army, Navy, PEMEX Oil )Company
Analysis Unit • Convene to the pharma industries to negotiate prices, specifically price from those
high cost drugs for (e.g. target therapies). In this sense, devices are not discussed into
alongside Secretary of health
the price negotiation yet.
and the main healthcare
subsystem • high cost devices negotiation is on next year agenda. (2017)
Intermediary
INTEGRATOR: The figure of integrator does not have much impact as it has into
Pricing key player the IMSS. In this sense, manufacturer could made commercial agreements
(between healthcare institution directly with these institutions
and the manufacturer/device
industry)
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Hospital that serves Public System (The case of ISSSTE, Army, Navy, PEMEX Oil Company)
Specific Medical Devices overview
The institution that follow a tender process, do not have a special basket
destined (for example) to cardiovascular surgery or gastrointestinal procedures.
Every and each supplies will be covered, purchased and finally reimbursed
through the consolidated purchase
These institutions could purchase these devices even when it does not have
healthcare code.
In-depth interview – Local Stake Holders and regulatory experts
Hospital that covers Public System- Civil hospitals state healthcare institutions
(Special case - ISSEMyM, ISSSTECH, ISSTECALI)
Budget limit,
Buying
set by local
government To Purchase healthcare supplies directly to
distributors, manufacturers or integrators
Economic without involve into the tender process
Analysis Unit
alongside Secretary of health
and the main heallhcare
subsystem
Intermediary Economic Analysis Unit alongside Secretary of health and the main subsystems
(ISSSTE, Army, Navy, PEMEX Oil )Company
Pricing key player • Convene to the pharma industries to negotiate prices, specifically price from
those high cost drugs for (e.g. Target therapies). In this sense, devices are not
(between healthcare institution discussed into the price negotiation yet.
and the manufacturer/device
industry) • high cost devices negotiation is on next year agenda. (2017)
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National Institutes and Hospitals of the Secretary of Health
The case of National Institutes of Health and High Specialty Hospitals
Innovations
Coverage
•HIC. approves after negotiate prices with hospital and MDT/distributor (usually all have previously
Health listing procedures or products list)
•The negotiation will be individually and is based around each device
Pricing Insurance •HIC has its own physician networking
• Probably in the next years we are going to move from fee for service to a new kind of payment based on a package of
Companies services covered through capita. (private sector has been recognized the utility of Innovative price models or market entry
agreements)
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Healthcare System at México
Complexity due to its
subsystems
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Country profile
Total population (2015) 127,017,000
Mexico
Gross national income per
capita (PPP international $, 16
2013)
Life expectancy at birth m/f
74/80
(years, 2015)
Probability of dying under five not available
(per 1 000 live births, 0)
Probability of dying between
15 and 60 years m/f (per 1 000 174/93
population, 2013)
Total expenditure on health
1,122
per capita (Intl $, 2014)
Total expenditure on health as
6.3
% of GDP (2014)
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Mexico Health System Organization
Sector Public
Private
Social Security Secretary of Health, SESA
Federal State
Funds Government Employers' workers'
government
contribution contribution government Individuals Employers
contribution contribution contribution
Seguro
Popular
(Universal Health Care)
Buyers
IMSS ISSSTE
Government workers security
Insurance Companies
Modified from The health system of Mexico. Salud Publica Mex 2011;53 suppl 2:S220-S232.
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Healthcare System Mexico
PBI
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Healthcare System in Mexico
Sources: Constitution Article 196; ANS September 2016 (latest available data)
MX payers mapping
Coverage & reimbursement
MX Pop 122
million
Federal Commission for the Protection against Sanitary
Risk (COFEPRIS)
influences Public and Private healthcare
• The Federal Commission for the Protection against Sanitary Risk (COFEPRIS) is currently experiencing a
significant backlog of registrations and the review timelines for registrations and administrative changes
remain unclear.
• Premarket controls include a three-tier, risk-based classification system. Devices are also classified according
to usage category.
• The rules for classification are based on EU rules with some modifications. The classification system drives
the premarket review process.
• Statutory review times are short, with review periods of 30, 35 and 60 days specified for Class I, II and III
devices, respectively.
• Actual review periods are considerably longer and currently range from two to 12 months.
• No local GMP standards exist but a quality management system certificate from the country of origin is
required for imported devices.
• COFEPRIS maintains information regarding manufacturers, market representatives, importers and
distributors.
• Post market controls currently include adverse event reporting, tracking and recalls.
• COFEPRIS is authorized to take samples marketed products and conduct testing for compliance purposes.1
http://www.gob.mx/cofepris/
Diario Oficial de la Federación, 17 de Abril del 2009. Ley General De Salud, Titulo Decimo Septimo,
Vigilancia Sanitaria, Capitulo Unico, Artículo 401 Bis.
Licensing process of medical devices in Mexico(Summary)
Level of evidence required for approval Not required. Clinical trials for Class II
Publication of regulatory decision and The list of approved items is public, not the process or the
transparency reasons to approve or not approve
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4 types of Medical Private Payers in
Mexico
• Managed by insurance companies (e.g. VitaMedica, MetLife,
Insurance Zurich), 5% pop (it has been increased exponentially)
• 8 million people
• 5% pop
Out-of-pocket • Private hospitals
• Not-for-profit institutions
Philanthropy • e.g. Red cross hospitals
Current expenditure to 2004-2020 in drugs, devices and medical supplies from the main public entities for healthcare (MXN
pesos)
Year IMSS ISSSTE MoH Seguro Popular TOTAL
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Overview of regulatory processes
© 2013 Emergo Group – You are welcome to publish this chart on your website, or copy it for use in presentations or other materials 55
Time lines
* COFEPRIS has authorized certain “third party” companies to conduct registration reviews for Class I, II and III devices. These time frames apply only if you have elected to use a third party to review
your submission.
** Companies which cannot claim “equivalency” and will not be using a third party reviewer are subject to COFEPRIS’s standard review process.
© 2013 Emergo Group – You are welcome to publish this chart on your website, or copy it for use in presentations or other materials 56
Overview of reimbursement processes:
since regulatory approval to reimbursement
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Timelines: reimbursement
Access timelines for Health care (Focus on medical devices) to be included and reimbursed into the Public sector
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Strategic analysis of reimbursement
• Mexico (1)
• COFEPRIS (Federal Commission for Protection Against Sanitary
Risks) review and approve new device technologies to deliver a
Regulatory Certificate (which implies not only the device itself,
besides its supplies)
• Registry has a term of 5 years, and the device must meet safety,
quality, and efficacy standards
• Providers, manufacturers establish the market price, however
healthcare public sector acquire devices through tender fixing prices
http://www.cofepris.gob.mx/AS/Documents/RegistroSanitarioMedicamentos/req_dm.pdf
http://www.pwc.com/mx/es/retos-dispositivos-medicos/accesocomercializacion.jhtml
http://www.xcenda.com/Insights-Library/HTA-Quarterly-Archive-Insights-to-Bridge-Science-and-Policy/HTA-Quarterly-Spring-2015/Mexico-Navigatingthe-
Regulatory-Landscape-for-New-Product-Approvals-and-Pricing/.
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Strategic analysis of reimbursement
• Mexico (2)
• Specific interagency catalog for devices (Cuadro Basico) that
determines which devices can be purchased by the public
subsystem (e.g. IMSS, ISSSTE, PEMEX, etc…)
• Some cases social security institutions could purchase devices not
included yet into the formulary, either directly or through bundled
services at their discretion
• General Health Council regulates “Cuadro Basico”
• Manufacturers, Medical Societies and public institutions could
request inclusions. GHC through its members (each one from the
main healthcare public institutions) decides which include or reject.
http://www.csg.gob.mx/descargas/pdfs/cuadro_basico/Reglamento_CI_CByCISS_05092011.pdf.
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Strategic analysis of reimbursement
• Mexico (3)
• Every subsystem request an additional submission to robust its own
formulary (most of the times implies re-submit the same package
previously submitted to GHC, but with some prices assumptions
[discounts, IPMs])
• Otherwise, manufacturers could get some purchases through
integrators (e.g. VitalMex offer integral services with a diversity of
devices from the main devices manufacturers into the country)
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Strategic analysis of reimbursement
• Mexico (4)
• Most of the subsystems get the vast majority of devices through
consolidate annual tender (in the previous year Healthcare gov.
sector made a market research to identify medical needs, supplies,
quantity and prices)
• Tender is leaded by IMSS
• At the middle/end of the FY, IMSS and other institutions could
configure out some extraordinary purchases (e.g. implantable pulse
generators are needed more than the initial estimates, in this sense
extraordinary purchases must happened to cover these needs)
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Key stakeholders for introduction of
medical technologies in Mexico
HTA users Applications
National Commission Pricing (Economic Analysis Price regulation (for drugs only and potentially for
Unit) devices into the next 3-5 years)
State Health Secretariats; Decentralized Public (nowadays Federation Treasury has been audit
Institutions expenses for those states with incremental debts,
the vast majority of states all across the country)
Hospitals
National agency responsible for the definition or recommendation Comisión Interinstitucional del Cuadro Básico y Catálogo de
of coverage Insumos del Sector Salud – Seguro popular
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