In healthcare, the biggest question isn’t always whether treatment works but who pays for it. Pic: Getty Images
Securing government or insurer support can help unlock predictable, scalable revenue stream for healthcare companies
Emyria has a reimbursement deal with Medibank Private to cover eligible members accessing PTSD and TRD programs at Empax clinics
EBR’s WiSE CRT device was approved by the US FDA in April 2025 and locked in Medicare reimbursement by October
Gaining government and medical insurer support can be a key catalyst for an ASX healthcare company.
The funding model not only unlocks a predictable revenue stream but also removes one of the biggest barriers to scaling a medical service – the question of who pays.
Morgans’ healthcare analyst Iain Wilkie told Stockhead that for small-cap ASX health companies, solving the payer problem could be the difference between a promising idea and a long-term viable and growing business.
“Out of pocket expenses and what people have to pay matters,” he said.
“Having treatment subsidised by the government or funded by insurance, particularly for expensive treatments, can make a big difference to patients and companies,” he said.
Emyria – the insurer is paying
Emyria (ASX:EMD) operates regulated mental health programs through its Empax clinics for eligible patients under specialist clinical care, including programs relating to post-traumatic stress disorder (PTSD) and treatment-resistant depression.
Emyria has a Brisbane Empax clinic in partnership with Avive Health, alongside two Perth-based clinics, including a site within a private mental health hospital and a community centre.
The company recently established its first Victorian-based Empax clinic within Avive Health’s Mornington Peninsula Private Hospital.
It has also entered an agreement with Matilda Healthcare to establish a clinic at Matilda Nepean Private Hospital in Kingswood, NSW, earmarked to open in Q3 2026, subject to regulatory approvals.
Emyria has secured a reimbursement agreement with Medibank Private (ASX:MPL), Australia’s largest private health insurer, to cover eligible members accessing its PTSD and TRD programs across its national Empax network.
The Australian government’s Department of Veterans’ Affairs (DVA) is also funding eligible veteran card holders to access Emyria’s programs for PTSD and TRD.
Emyria managing director Dr Michael Winlo noted the cost of serious mental health conditions had been climbing for payers, with Medibank spending more $2 billion on mental health hospitalisations alone in just the past decade.
“Payers are taking a genuine interest in new approaches to care for PTSD and TRD,” he told Stockhead.
“However, they aren’t just funding activity, they want to track real-world outcomes like clinical and cost effectiveness too.
“It’s great to see payers leading this kind of innovation and helping to improve new models of care within regulated clinical settings.”
Wilkie said the coverage announcement with Medibank and DVA was more than a revenue unlock.
“The reimbursement agreement provides additional funding pathways for eligible patients,” he said.
The Therapeutic Goods Administration (TGA) recently announced changes to its recommendations for the Authorised Prescriber (AP) scheme for psychedelic-assisted psychotherapy.
The changes expand the range of clinicians required as one of two therapists in the psychedelic-assisted psychotherapy dyad, which to date has mandated a clinical psychologist or medical practitioner be present during dosing.
Pacific Edge working to reinstate coverage
If Emyria illustrates what unlocking government funding can do for a healthcare company, Wilkie said dual-listed Pacific Edge (ASX/NZX:PEB) demonstrated what happened when it was removed.
The New Zealand-based cancer diagnostics company has developed its Cxbladder suite of non-invasive urine-based genomic tests for bladder cancer detection and surveillance.
Wilkie said its primary market was the US, where securing Medicare reimbursement was critical to driving laboratory test volumes and revenue.
For a period, Pacific Edge had that coverage but then in 2025, major Medicare Administrative Contractor (MAC) for the Centers for Medicare & Medicaid Services (CMS) Novitas issued a non-coverage determination for Cxbladder.
“Operating revenue fell from $10.9 million to $5.9m in the following half, and the company’s net loss after tax widened to $19.1m as it chose to maintain its market presence rather than retreat,” Wilkie said.
To keep the reimbursement fight alive, the company launched a NZ$25.4m institutional placement in May 2026, which was upsized from an initial NZ$18m target after strong investor demand, priced at NZ17 cents per share.
A NZ$6m retail offer to eligible existing shareholders followed at the same price, and by the time the retail offer closed had attracted applications of NZ$14m.
Funds are being used in a campaign to regain Medicare coverage with the company recently announcing a key development in its bid.
Novitas has issued a draft Local Coverage Determination establishing haematuria evaluation as a Medicare benefit for the first time, with both Cxbladder Triage and Triage Plus indicated for coverage for intermediate risk haematuria patients.
Pacific Edge has already been advised that products covered in the draft are eligible for claim-by-claim reimbursement for the defined patient population, meaning revenue can start flowing before the LCD is finalised.
“Over the last year we have completed the foundations necessary to grow our haematuria business, establishing a Medicare price of US$1328 for Triage Plus and obtaining draft coverage,” CEO Peter Meintjes said.
While a draft LCD is not a final determination, it represents concrete progress toward enduring Medicare coverage.
“Supported by the equity raised in May our team, now stronger after several years of adversity, are focused on achieving the company’s long-standing potential.”
“The inclusion of Triage Plus in the LCD gives us the opportunity to progressively phase our haematuria volume to the higher performing and higher margin test based on demand.”
Reimbursement at heart of EBR’s WiSE System
EBR Systems (ASX:EBR) is also set to benefit from US Medicare support for its WiSE system, a wireless cardiac pacing technology designed to deliver left ventricular stimulation without the need for leads.
Traditional cardiac resynchronisation therapy (CRT) requires leads to be threaded through veins to the heart, a procedure that is not possible for a significant portion of patients.
WiSE was approved by the US Food and Drug Administration (FDA) in April 2025 with the company locking in Medicare reimbursement by October 2025, clearing the two biggest commercial hurdles for any medical device entering the US market.
The CMS approved a New Technology Add-On Payment (NTAP) for inpatients, which is a temporary top-up above standard Medicare hospital payment rates encouraging adoption of devices where costs are not yet fully captured in standard pricing.
For WiSE, the NTAP provides up to US$41,145 per eligible case, which is paid on top of the standard diagnosis-related group (DRG) payment, the fixed rate Medicare pays hospitals based on a patient’s diagnosis and procedure.
For outpatient procedures, CMS separately granted Transitional Pass-Through payment status, covering 100% of the device cost.
EBR is now in the limited market release phase for WiSE in the US and recently announced implant volumes had more than doubled during Q1 2026.
The company completed 41 commercial WiSE implants during the quarter, more than doubling total commercial implants to 71 as Q1 revenue reached US$2.4m (A$3.4 million).
This article does not constitute financial product advice. You should consider obtaining independent financial advice before making any financial decisions.
At Stockhead, we tell it like it is. While Emyria and EBR Systems are Stockhead advertisers, the companies did not sponsor this article.