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Necessity Fosters Innovation as COVID-19 Changes the Scope of the Patient Access Industry

PRIA clients are provided a high-touch, white-glove service to support their patient access services.

Necessity Fosters Innovation as COVID-19 Changes the Scope of the Patient Access Industry

As the saying goes, necessity is the mother of invention. For PRIA Healthcare, necessity became the mother of innovation as the COVID-19 pandemic swept the globe in early 2020, unfavorably impacting their business focused on securing patient access to new, innovative medical technologies.

“Going into COVID, our business was trending upward at a consistent pace,” said PRIA Healthcare CEO Michael Simon, “That trend changed.”

As rates of elective surgical procedures plummeted—a direct result of the Centers for Medicare and Medicaid Services guidance to limit non-essential medical, surgical, and dental procedures as COVID-19 cases surged—PRIA clients, which are representative of medical device companies, began to feel the impact, which Simon described as “massive.”

“The monetary impact on our client’s businesses was greatly impacted,” he added. “The uncertainty of timing caused a dramatic shift in spending.”

But rather than allow the pandemic to negatively impact a thriving business, Simon, decided to pivot his business in a new direction and expand the offerings of PRIA.  Simon expanded his team to include Kelli Hallas, an accomplished thought-leader in the reimbursement and health economics space with over 25 years of medical device industry experience. With Hallas on board, Simon was prepared to provide additional value-added services to PRIAs clients.

PRIA clients are provided a high-touch, white-glove service to support their patient access services. Historically, Simon said, the company “would not support any patient access services that were considered arms reach.” As Simon and Hallas began to reevaluate PRIA’s trajectory and the new service needs of the medical device industry impacted by COVID-19, the arms reach services grew into an attractive value-add option that could benefit the device industry and the patients they serve.

“This was an opportunity to capitalize on where we were missing opportunity,” he said. “We looked at where we could help our clients find different solutions that we previously hadn’t thought through. We were very focused on patient access. And although we did well with that, there were times where our clients would look elsewhere for different pieces of the puzzle. In a lot of ways, the pandemic helped us capture more of what our clients were searching for.”

When healthcare providers asked for an in-demand medical device a decade ago, they received it. Today, things have changed: payers have the upper hand and control healthcare utilization and spending, often limiting patient access to new technologies. As PRIA sees it, the success of a medtech device company depends on establishing market access and advocating for a long-term coverage policy.

These objectives sound simple, but the reality is much more complex: the payer reimbursement system is broken, and communication has failed between payers, providers, and patients.

In the United States, healthcare costs exceed 17% of the gross domestic product; spending has also increased, rising from $2,900 per person to $11,200 per person between 1980 and 2018—representing a 290% increase. And according to the Harvard Business Review, these costs are continuing to trend upward. An aging population and the accelerated development of new devices and treatments, combined with a fee-for-service care model, have all contributed to the current payer reimbursement model. This so-called cost crisis has had devastating outcomes on all aspects of healthcare—including serious limitations placed on what devices and treatments providers and patients can or cannot access.

Solving these cost and access problems is still PRIA’s core competency; but now, their solutions have taken on additional forms.

“We hang our hat on our intellectual properties and our network,” Hallas said. “In the past, our network has been used to collect finite information on the preauthorization process. We’ve looked at other ways to build out our network and capture utilization, for example, to support our clients with Category III codes. Now, we’re able to help them track these data and meet requirements from the AMA to secure Category I codes.”

“We’re thinking outside the box on other ways to position the data that we have collected for our customers and work on unique ways to help them forecast, target commercial payers, and secure coverage policies,” she added.

To expand the slate of PRIA offerings, Simon and Hallas turned their gaze inwards, stepping back and focusing on the internal PRIA team.

“Our team has exceptional talent,” said Hallas. “This was an opportunity to develop these talents.”

The first priority was to build out the current teams, providing internal talent with the tools and opportunities to support current PRIA clients. According to Simon, training and education were key, as client needs—and the way PRIA met them—shifted during the pandemic. As a group, the team began asking questions to formulate new opportunities to service their clients. For Simon, this development paid off in a big way.

“I feel like we have a different level of engagement with our clients than we ever did before,” he said. “We’re in much deeper with our clients, with their products and their needs. We now have the ability to assess those needs, develop solutions to address them resulting in a positive win for everyone: including the patient.”

“Historically PRIA has always offered individual one-off solutions to address clients’ needs.” said Hallas, “however, we were never asked to provide a comprehensive ‘360 degree’ solution. Once we invested in our internal capabilities, we were able to use all of these different elements and facets of the business to develop new programs and support our clients in the ways they’ve asked us to.”

Today, PRIA is doing more for its clients than ever before. They remain focused on patient access but are now supporting that access in different ways through their proprietary network with programs that collect real-world, real-time utilization data to support patient access. The company has also become more involved in providing support to facilities, including hospitals and surgery centers on behalf of their clients.  They are continuing to evolve and evaluate clients’ needs and new program offerings.

“It’s been a challenging year for us,” said Simon. “We really had to look at how we could work with our clients to meet their unique needs. It’s not that we didn’t have the ability to do so in the past; it’s that we never took the time to understand that there even was a need.”

Despite the challenging year, PRIA has come out on top. In August 2020, Simon announced the company’s acquisition of Lindstrom Healthcare Advocacy and founding owners Walter and Kelley Lindstrom. Since 1996, the Lindstrom’s have dominated the patient advocacy space, representing thousands of patients through their journeys to access life-changing and medically necessary treatments. The acquisition represents the opportunity to “combine similar visions that patients—not profit—be a payer’s first priority.”

As PRIA looks to the future, both Simon and Hallas are optimistic. Very little about the future is certain—except for the likelihood that the current healthcare system may one day, once again, change.

When it does, Simon and Hallas are ready. “At the end of the day,” said Hallas, “this is all about increasing patient access to emerging, life-changing technologies.”

In the end, the patient has to win.

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