Quantifying Value for Niche Medtech in a Payer Conversation
Nicole Coustier has over 20 years of experience in U.S. Reimbursement and Market Access and has helped early-stage MedTech achieve widespread reimbursement coverage in the U.S.
When your technology isn’t aimed at one of the high-prevalence, high-cost conditions like heart failure, cancer, or diabetes, convincing payers to cover it can feel like an uphill climb. You don’t have the advantage of massive patient volumes, so you have to make every data point work harder. That starts with knowing exactly how to quantify your value in terms that a payer cares about.
Anchor the Conversation in the Right Denominator
For large-condition technologies, payers think in terms of population-wide impact: “If we improve outcomes by just 2%, that’s thousands of members and millions of dollars.” In a niche space, that framing won’t land. You need to make the denominator smaller and more relevant.
That might mean focusing on only the high-risk subgroup where your device is indicated, or zeroing in on the subset of facilities or clinicians who perform the relevant procedure. By showing impact within a tightly defined population, you can shift the conversation from “This is rare” to “This is high impact where it matters.”
Translate Clinical Impact Into Claims Impact
Payers live in the world of claims data, so it’s critical to connect your clinical outcomes to the events and costs that appear on their ledgers.
Instead of simply saying, “Our device reduces post-op complications by 40%,” translate that into something like, “In a population of 1,000 covered members receiving this procedure annually, this could mean 120 fewer readmissions, avoiding approximately $1.2M in inpatient costs.”
Even if your total dollar impact is smaller than a blockbuster drug or device, showing that the per-case savings are significant can make the economics compelling.
Don’t Forget Avoided Costs Beyond the Obvious
Many technologies have ripple effects that aren’t immediately obvious in claims but still influence payer costs. For example, preventing a complication may also avoid additional imaging, specialist visits, or durable medical equipment. It may reduce the length of disability leave in working-age members, which matters to employer-sponsored commercial plans. Bringing those secondary cost impacts into the discussion strengthens your ROI story.
Put Quality Measures in the Mix
Especially in Medicare Advantage and Medicaid managed care, plans are graded and paid based on performance against quality metrics. If your technology influences a measure, such as reduced readmissions, improved patient-reported outcomes, or better chronic condition management, it can be a tipping point for coverage. Sometimes the value to the payer in improving a quality measure outweighs the direct cost savings.
Make It Local
National averages are fine for context, but payers are far more interested in how your technology will perform for their members. Whenever possible, use local market data or partner with a provider in the plan’s network to generate real-world results. Even a small case series in their own market can be more persuasive than a large national dataset.
Coverage Policy vs. Claims Reality
It’s easy to assume that the ultimate win with a payer is securing a formal, published coverage policy. But for some niche technologies, that’s not always necessary and chasing it can even be counterproductive.
If your customers are already getting claims paid consistently and without denials, you may already have the functional equivalent of coverage, even if the payer has never issued a policy in writing. In these cases, trying to force the development of a formal policy can invite unnecessary scrutiny, or result in overly narrow coverage criteria that limit rather than expand access.
For certain products, the real “end game” isn’t a line in a coverage manual, it’s making sure that providers are using the right codes, submitting clean claims, and getting paid reliably over time. If that’s happening, clamoring to get the payer’s attention for a policy development process may be a moot point.
From Niche to Necessary
For niche MedTech, the goal is to make your device feel essential to a specific problem the payer cares about, not just “nice to have” in a rare scenario. That means narrowing the focus, quantifying the per-member-per-month and per-case impact, connecting outcomes to claims events, and weaving in quality and equity arguments where they fit.
When you do this well, even a small clinical footprint can translate into a strong payer business case. And once one plan sees the numbers, it becomes much easier to replicate that win across others.
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