PHASE 6: PAYER
In Ontario, a decision to fund an innovative health product is determined by the payer (the health care system). Before a product is adopted into the health care system, decision makers (i.e., payers) require a solid foundation of evidence to assess the value of a new product before making significant changes to existing practices. A payer must ascertain that the social, economic, organizational and ethical factors benefit both patient health and the health care system.
The health care system demands compelling evidence to invest in an innovative health product. A product may lack the evidence to support adoption into the health system. To generate the required evidence, a product may need to undergo further testing and/or product redevelopment. This is a timely and costly endeavour. Refer to Phase 4: Evidence Generation and Phase 5: Health Technology Assessment to determine whether your product has sufficient evidence and a strong business case needed by payers in the Ontario health care system in order to invest.
Decisions to reimburse or purchase an innovative health product in Canada are highly de-centralized. Canadian provinces are responsible for managing their own health services. Purchasing decisions are highly dependent on a constrained health care budget, single payer system, and priorities of the public health care system in Ontario. The vast majority of purchasing decisions for market-approved products are made by procurement agencies at the hospital or LHIN level. A product may be reimbursed by the Ontario government, procured by an individual hospital or group of hospitals, or purchased by alternative payers (e.g., direct to consumer; private clinics or insurance companies).
Confirm who will pay for the product (i.e., government, hospital, alternative payer).
Confirm that the product meets the evidence requirements requested by the payer.
Understand the pricing and reimbursement models of the payer.
Produce a strong business case for the product that aligns its value in the health care system and with the payer.
Last update: 2018-Nov-26
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