How MedTech Innovators Can Win Payer Coverage Outside Heart Failure, Cancer, and Diabetes
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.
If You’re Not Solving for Heart Failure or Cancer, Can You Still Win Big With U.S. Payers?
It’s no secret that when U.S. payers talk about their priorities, certain conditions rise to the top again and again: heart failure, cancer, and diabetes. These are high-prevalence, high-cost diseases that dominate the healthcare spend. If your technology addresses one of them, the path to a payer’s attention can feel more direct.
But what if your innovation doesn’t live in those spaces?
What if your device is for a rare disease, a low-incidence complication, or a highly specialized procedure?
Can you still win big with payers?
Can you even get their attention?
The short answer is yes, but the pathway looks different.
Why the Big Conditions Dominate Payer Thinking
Payers are in the business of managing population health and total cost of care. From their perspective, targeting the conditions that drive the largest slices of the spending pie offers the highest potential return. A single improvement in heart failure management can save millions in avoidable hospitalizations; an advance in cancer care can shift survival curves and reduce end-of-life costs.
It’s not that they don’t care about smaller categories, it’s that the math for investment and coverage decisions is driven by population-level impact. That means innovations outside the “big three” have to work harder to show their relevance.
Finding Your Way Into the Payer Conversation
If your technology isn’t tackling a blockbuster condition, you can still capture payer interest by reframing your story in terms they care about. That might mean connecting your device to a measurable improvement in a quality metric, showing a reduction in expensive downstream events, or aligning it with a targeted population where the per-member-per-month impact is meaningful.
For example, a device that reduces surgical complications for a niche procedure might not move the needle for every member on a plan. But if those complications carry a high per-case cost and your device reliably prevents them, it can make a compelling case for coverage in that defined group.
The Value of Precision in the Pitch
This is where precision matters. Broad claims about “improving outcomes” aren’t enough when you’re working in a lower-volume category. Payers need specifics: how much will this reduce readmissions in this subgroup? How many ER visits will be avoided? How does it influence total cost of care in a clearly defined cohort?
Pairing those specifics with real-world data, especially from settings or geographies similar to the payer’s own population, can make the story concrete and credible.
Leverage Non-Cost Priorities
Not every payer decision is purely financial. Medicaid programs may prioritize technologies that improve access equity. Medicare Advantage plans may focus on innovations that support their quality ratings. Commercial plans may respond to patient satisfaction gains in competitive markets. Understanding those non-cost levers and aligning your message to them can open doors that pure ROI arguments can’t.
Winning Outside the Big Three
You don’t have to be in heart failure, cancer, or diabetes to be valuable to a payer. But you do have to make the connection between your innovation and the plan’s priorities unmistakable. That means narrowing your target, proving your impact in that space, and telling the story in terms that resonate with their goals, whether that’s savings, quality, equity, or competitive differentiation.
When you do that well, even a small slice of the healthcare spend can add up to a big win.
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