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Reimbursement strategy

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Reimbursement summary for angioplasty of arteries of lower extremities

This post presents an extract from our reimbursement analysis for angioplasty of arteries lower extremities using plain and drug-coated balloons (DCBs) for peripheral artery disease in England, France and Germany. Plain balloon angioplasty is reimbursement via DRG solely and DCBs are reimbursement via combination of DRG and add-on reimbursement.
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Open consultation on changes to the NHS Payment Scheme from April 2024 in England

In December 2023, NHS England launched a consultation regarding proposed changes in the 2023/25 NHS Payment Scheme (NHSPS). The 2023/25 NHSPS came into effect in April 2023 and applies for two financial years – 2023/24 and 2024/25 (financial year starts in April). However, NHS England is proposing amendments to the NHSPS starting on April 1, 2024. The deadline for submitting comments is January 26, 2024.

The following proposed changes concerned the High Cost Device List (HCDL):

  • Nine devices are proposed for inclusion in HCDL;
  • Seven of these nine are proposed for inclusion via a new process being developed by NHS England’s SSDP (Specialised Services Devices Programme) in partnership with NICE. It will apply to devices recommended by NICE IPG (Interventional Procedure Guidance) to be used with ‘Special arrangements’ if the following conditions are met: 1) the device is either part of a specialised pathway or would be covered by an existing excluded category which is the commissioning responsibility of NHS England; 2) the device is high-cost, and a barrier to providers using without reimbursement; 3) the device has a relatively recent published NICE IPG; 4) the device has been submitted to the Device Steering Group and been supported. The process will include further analysis of cost-effectiveness for the NHS and will involve a prioritization process. Reimbursement will be limited to providers, agreed with the supplier, who are able to support the evaluation. Reimbursement will only be made if providers follow the relevant NICE guidance and confirm the data submission to NHS England and/or the device supplier;
  • The examples of devices proposed for inclusion via the new NICE Special Arrangements Process are Percutaneous Left Ventricular-Assist Devices (IPG633), Hypoglossal nerve stimulation or Upper Airway Stimulation (IPG598), Sonata system for diagnostic imaging and treatment of symptomatic uterine fibroids (IPG689);
  • Two devices are suggested for inclusion within regular HCDL arrangements, for example, an implantable pulmonary artery pressure sensor.

The key changes to support the delegation of specialised services include the following:

  • Each provider of specialised services is guaranteed a minimum level of elective top-up funding, irrespective of the amount of top-up-eligible activity delivered;
  • Unit prices (specific reimbursement category codes and tariffs) will be introduced for four types of specialist radiotherapy: Stereotactic radiosurgery/radiotherapy (SRS/T), stereotactic ablative therapy (SABR), selective internal radiation therapy (SIRT), and brachytherapy. So, it will be paid for as part of the variable (activity-based) component of the aligned payment and incentive (API) model.

Other amendments comprise adding one item to the MedTech Funding Mandate, a pause of the nationally mandated CQUIN (Commissioning for Quality and Innovation) incentive scheme, and payment for certain procedures covered by the Evidence-Based Interventions program.

The HRG prices are not the subject of this consultation. They will be calculated using the approach set out in Annex D of the 2023/25 NHSPS. A prices workbook (Annex A) for 2024/25 will be issued separately, and no consultation is planned.

No changes are proposed to the general payment approach used to support elective recovery.

See the full details here and here.

This news is just one of about 300 market access news collected by our team in the premium subscription service Market Access Monitor every week from more than 80 organizations. Access our paid service to stay on top of all developments specifically for your products in Europe (reimbursement news) and globally (HTA news). Access is organized as an online Database and email alert formats. Contact us to get a free, three-month, no-obligation trial.