May 18, 2017
Per Capita Caps Could Reduce Funding for Children Covered by Medicaid
All 50 states and DC would receive fewer Medicaid dollars for non-disabled children.
All 50 states and DC would receive fewer Medicaid dollars for non-disabled children.
The elimination of cost sharing reductions could lead to low income individuals facing higher deductibles and maximum out-of-pockets.
Today, Avalere and FasterCures published Version 1.0 of the Patient-Perspective Value Framework (PPVF).
New analysis from Avalere finds that Medicare Advantage (MA) patients use fewer post-acute care services after being discharged from the hospital compared to traditional Medicare fee-for-service (FFS) patients.
Funding earmarked for high risk pools in the American Health Care Act will cover five percent of the total number of enrollees with pre-existing chronic conditions in the individual market today.
At the Asembia Specialty Pharmacy Summit 2017, an Avalere-led panel identified three focus areas for specialty pharmacies looking to achieve market leadership in an increasingly value-based care environment.
Capping Medicaid funding could also shift costs to Medicare
Citing alarming statistics that show that nearly 1 of every 2 older Americans is at risk of malnutrition and that disease-associated malnutrition in older adults is estimated to cost $51.3 billion annually, a broad group of advocates laid out a roadmap for a new national effort to help millions of Americans…
New research from Avalere finds that under the American Health Care Act (AHCA), large states as well as those states with fewer insurers offering plans in the individual and small group markets could receive the most money from the federal government to help stabilize their markets.
Low-income and older individuals would incur higher penalties for failing to purchase health insurance, compared to current individual mandate.
Analysis shows Medicaid block grants and per capita caps could result in state budget gaps.
Avalere analyzed data from eight Medicare Advantage Organizations (MAOs) representing 1.1 million beneficiaries in more than 30 unique plans operating across the country to understand the impact of shifting the determination of plan risk scores from the Risk Adjustment Processing System (RAPS) to the…
Plans sold in exchange markets in 2017 feature higher premiums, growing consumer out-of-pocket costs, and more restricted access to providers and hospitals than in previous years, according to a new analysis from Avalere.
As 2017 exchange open enrollment begins, Avalere examined marketplace changes in plan choice and premiums at the county level.
New analysis from Avalere finds that 1.2 million individuals from non-expansion states could gain Medicaid coverage in 2017 should a newly elected governor decide to expand the program.
2017 exchanges struggle to address challenges with enrollment, risk management, and consumer choice.
A new analysis from Avalere finds that consumers with a range of common health conditions could reduce their spending between $8,800 and $90,020 by purchasing insurance through the Affordable Care Act (ACA).
Proposed Requirements in 21st Century Cures Act Would Increase Transparency Requirements
A new analysis from Avalere finds that individuals who enroll in exchange coverage during special enrollment periods (SEP) have higher costs and lower risk scores than open enrollment period (OEP) consumers.
New quality measures to address malnutrition among hospitalized older adults are now being evaluated by the National Quality Forum (NQF) for endorsement, and by the Centers for Medicare & Medicaid Services (CMS) for inclusion in their Hospital Inpatient Quality Reporting Program.
Avalere experts predict that one-third of the country will have no exchange plan competition in 2017, leaving consumers with few options for coverage.
In June 2016, in collaboration with FasterCures, Avalere launched the Patient-Perspective Value Framework (PPVF) Initiative to develop a value framework that appropriately incorporates the patient’s perspective on value.
Since 1992, the Food and Drug Administration (FDA) has collected $7.67 billion in user fees from pharmaceutical manufacturers to fund drug reviews based on an Avalere analysis of FDA data.
Avalere experts say that the impact for most hospitals will be modest.
Prescription drugs are not outsized contributors to rate increases.
Rates vary widely by state; popular low cost options see smaller increases.
Earlier today, the Centers for Medicare and Medicaid Services (CMS) released participation information for its new Oncology Care Model (OCM) slated to begin July 1.
Hepatitis C and Oncology Are Top Therapeutic Area Targets
Cost-sharing changes could increase costs for many beneficiaries.
Popular low cost options see smaller increases.
Avalere and Inovalon recently entered into an agreement with Bristol-Meyers Squibb (BMS) to support the manufacturer’s innovative initiatives using real-world outcomes data to design and test value-based contracting models. The agreement brings together Avalere’s deep expertise on manufacturer and…
A new Avalere analysis finds that nearly 13 million Americans age 50 or over who are currently uninsured or have individual coverage purchased through the private market—inside and outside the exchange— could be eligible to buy-in to the Medicare program under a plan proposed by Democratic presidential…
An analysis from Avalere shows that more health insurance plans offered through the Affordable Care Act exchanges are making some drugs used to treat complex diseases—such as HIV, cancer, and multiple sclerosis (MS)—more accessible to patients in 2016 than in the previous years. Specifically, plans…
Two Potential Policy Changes Would Reduce Out-of-Pocket Costs for Consumers
Rule Would Decrease Medicare Reimbursement for Drugs That Cost More than $480 per Day; Seven of the 10 Most Affected Drugs Treat Cancer
One third of those who enrolled in a health insurance plan on Healthcare.gov this year picked the same plan as last year, according to a new analysis from Avalere. In total, 3.2 million of the 9.6 million exchange shoppers in 2016 kept their previous plan.
Hospitals should focus on care after discharge, which drives more than 39 percent of spending.
New Avalere report identifies opportunities to refine the risk-adjustment model that could improve the way Affordable Care Act plans are paid
Percentage of Medicare Advantage enrollees in plans with at least four stars continues to grow.
Percentage of drugs in Part D plans that require coinsurance increased significantly since 2014. Medicare Advantage plans require coinsurance far less often than Part D plans.
A new analysis by Avalere finds that, despite efforts by policymakers to encourage broader vaccination rates, Medicare enrollees have limited access to a set of 10 recommended vaccines without having to pay out-of-pocket (e.g., co-payments).
President Obama released his budget for the 2017 fiscal year today. Avalere offers the following observations on the healthcare proposals:
Today, the Department of Health and Human Services (HHS) announced that 9.6 million individuals selected a health insurance plan on HealthCare.gov during the recent open enrollment season. Avalere estimates that 2016 year-end enrollment will slightly exceed the Obama administration’s goal of enrolling…
A new analysis from Avalere Health finds that hospitals and health systems are increasingly taking risk for the cost of Medicare patients and the quality of the care they receive.
A new analysis by Avalere finds that the Centers for Medicare and Medicaid Services (CMS) underpay Medicare Advantage (MA) plans for the costs of treating individuals with multiple chronic conditions.
As the government considers rules for 2017 insurance plans offered through exchanges, a new analysis by Avalere finds that proposed 2017 benefit designs could increase coverage of certain services and drugs, while lowering out-of-pocket costs for many consumers.
A new Avalere analysis finds that participation in the Centers for Medicare & Medicaid Services’ (CMS) voluntary Bundled Payment for Care Improvement (BPCI) program remains strong even after the introduction of downside risk.
A new analysis by Avalere Health finds that proposed modifications to Medicare Advantage (MA) by the Centers for Medicare and Medicaid Services (CMS) could result in large changes in payments in certain geographic areas.
A new analysis by Avalere finds that causes of health insurance premium increases in 2016 generally mirror the distribution of healthcare spending in the individual and small group market. Specifically, inpatient and outpatient hospital services are modestly driving premium increases, while physician…
In recent years, several new U.S. Food and Drug Administration-approved, direct-acting antiviral medications to treat the chronic hepatitis C virus (HCV) have entered the market. Because of the potential impact on health plan and pharmacy budgets, researchers have conducted economic analyses, including…
New analysis from Avalere finds that only 16 percent of silver exchange plans in 2015 cover all top HIV drug regimens with cost sharing less than $100 per month per regimen. While almost half of plans include all 10 of the most commonly used HIV regimens on their formularies, many plans charge higher…
A new Avalere analysis finds fewer insurers are offering preferred provider organization (PPO) networks on exchanges in 2016. Specifically, from 2014 to 2016, the percentage of plans offering PPO networks dropped from 39 percent to 27 percent. This represents a 31 percent decline over the three year…
New analysis from Avalere Health examines the 2016 Federal Exchange Premium File. According to HHS, more than 8 in 10 (86 percent) of current enrollees can find a lower premium plan in the same metal level by returning to the exchange and shopping for 2016. As a result, tables and figures below examine…
The third annual open enrollment period for exchanges will kick off on November 1. As patients and the healthcare industry prepare for the 2016 plan year, below are critical questions for the future of exchanges:
According to a new Avalere analysis of data from the Centers for Medicare & Medicaid Services (CMS), premiums for standalone prescription drug plans (PDPs) will increase and the number of PDPs available in 2016 will decrease. Conversely, Medicare Advantage (MA) premiums will decrease in 2016, and the…
The Centers for Medicare & Medicaid Services (CMS) just released annual files containing data on plan participation, beneficiary premiums, and benefit designs for the 2016 Part D and Medicare Advantage (MA) markets. Avalere offers the following observations on key trends in the MA and Part D programs…
A new Avalere analysis finds that 28 organizations who entered the Medicare Advantage market between 2012 and 2015 currently offer plans to beneficiaries. Together, these new players offer 104 plan options, which are available to 13.6 million beneficiaries in 24 states.
Orthopedic, Pulmonary, and Cardiovascular Conditions Most Likely To Be Treated under CMS Bundled Payment Program
A new Avalere analysis finds that more than 2 million exchange enrollees eligible for cost-sharing reductions (CSRs) are not receiving the subsidies because they have selected a non-qualifying plan. In addition to the more publicized tax credits that lower consumers’ monthly premiums, exchange enrollees…
A new white paper from Avalere finds wide variation in how organizations develop and use clinical pathways (CPs)–multidisciplinary plans that provide specific guidance on the sequencing of care steps and the timeline of interventions. While CPs have the potential to improve quality and reduce cost,…
New analysis from Avalere finds that the average provider networks for plans offered on the health insurance exchanges created by the Affordable Care Act (ACA) include 34 percent fewer providers than the average commercial plan offered outside the exchange. The new data quantifies anecdotal reports that…
A new Avalere assessment of the quality measures landscape shows that many important medical conditions are not fully represented in Medicare pay-for-quality programs, which limits Medicare’s ability to pay for value.
Consumers could face average annual premium contribution increases of $3,300 in 2015, if the Supreme Court rules tax credits are illegal in states with a federal exchange, according to new analysis from Avalere.1
A new analysis from Avalere finds wide geographic variation in 2016 premium increases for individual market exchange plans, based on proposed rate filings in eight states where complete data is available.
New research from Avalere finds that despite the innovation of abuse-deterrent properties and labeling for branded opioids, Medicare Part D plan coverage for these products is declining rapidly.
Over the past four years, enrollment in Medicaid managed care has increased by 48 percent, with 46 million beneficiaries now receiving coverage through these plans. The government will soon update regulations that direct the plans providing this coverage.
New research from Avalere Health finds that 86 percent of pharmaceutical companies would invest more in studies to support the development of healthcare economic information if provided additional guidance on their ability to use this evidence with external audiences (Figure 1).
A new analysis from Avalere finds that 17 million women ages 40 to 49 could lose their guarantee of mammogram coverage, if new breast cancer screening guidelines from the United States Preventive Services Task Force (USPSTF) are finalized.
A new analysis from Avalere finds that the penalties associated with the individual mandate, which grow in 2015, might be too low to attract enrollment, particularly among middle-income, healthy individuals.
New analysis from Avalere finds that while exchanges have succeeded in enrolling very low-income individuals, they continue to struggle to attract middle and higher income enrollees.
New analysis from Avalere finds that the proportion of Medicare Advantage (MA) beneficiaries enrolled in plans with 4 or more stars climbed from 38 percent in 2014 to 60 percent in 2015.
Majority of affected enrollees would be exempt from individual mandate
In a new analysis published by the California HealthCare Foundation, Avalere researchers found that Covered California plans provided comprehensive access to the most commonly used drugs.
A new report by Avalere Health published by the California HealthCare Foundation
Determining the cost or co-payment of a specialty drug—high-cost drugs typically used to treat complex diseases like cancer or rheumatoid arthritis—has always been complicated.
A new analysis by Avalere Health estimates that exchange enrollment will total 10.5 million people by the end of 2015, though enrollment could fluctuate up or down by approximately 1 million individuals.
New analysis from Avalere Health finds that 74 percent of Silver plans offered on exchanges have maximum out-of-pocket limits below what is required by law.
New analysis from Avalere Health finds that the most popular exchange plans* in 2014 increased premiums by 10 percent on average in 2015.
New analysis from Avalere Health examines the 2015 Federal Exchange Premium File.
First Time in History of Part D, All PDPs Will Incorporate a Specialty Tier
Avalere Health has identified key issues to monitor during tomorrow’s midterm election.
In at least six states, Medicaid programs could be expanded as a result of the outcome of the 2014 governors’ races.
A new analysis from Avalere Health projects that enrollment of Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries in managed care – i.e., state payment of private companies to provide benefits – will increase by 13.5 million individuals from 2013 to 2016.
A new Avalere Center for Payment & Delivery Innovation(TM) analysis finds that Medicare Shared Savings Program (MSSP) participants that earned shared savings payments, performed no better on quality than their MSSP peers.
A new analysis from Avalere Health, published today in the "Journal of Managed Care & Specialty Pharmacy," examined exchange coverage rates of 11 drugs used to treat rare diseases and found that plans in the exchange cover these drugs 65 percent of the time on average across plans, although coverage…
According to a new Avalere Health analysis of the Centers for Medicare & Medicaid Services’ (CMS) Landscape Files for 2015, the number of Part D standalone prescription drug plans (PDPs) will shrink by about 14 percent, from 1,169 in 2014 to 1,001 in 2015.
A new analysis from Avalere Health finds that in 12 of 15 states where complete data on market share of the health insurance exchanges are available, WellPoint or independent Blue Cross Blue Shield plans captured the greatest percentage of covered lives.
A new report from Avalere Health explores the potential public health consequences of increased clinical trial data transparency.
A new analysis from Avalere Health finds that less than half of all Medicare prescription drug (Part D) enrollees eligible for medication therapy management (MTM) programs receive these services. Under Medicare rules, the Centers for Medicare & Medicaid Services (CMS) requires all Part D plans to provide…
Avalere impressions on the first FDA biosimilar filing.
On July 22, the U.S. Court of Appeals for the D.C. Circuit ruled contrary to lower courts and struck down the IRS’s regulations allowing consumers to receive subsidies for insurance purchased on federally-facilitated exchanges.
The Halbig v. Burwell case before the U.S. District Court of Appeals could negatively impact millions of Americans who are benefiting from the Affordable Care Act (ACA).
The Affordable Care Act (ACA) requires health plans in the individual and small group markets—both inside and outside exchanges—to offer essential health benefits (EHB).
New analysis from Avalere Health finds that many consumers in exchange plans who receive federal assistance to reduce their monthly premiums will face substantial premium increases unless they switch insurance plans in 2015.
New analysis from Avalere Health finds that average proposed premiums for individual market exchange plans will increase modestly in 2015, based on initial rate filings in nine states.
A new analysis from Avalere Health finds that proposed rate increases for 2015 exchange plans in Washington state were lowest among carriers with the smallest share of the 2014 market.
In a June 2014 analysis, Avalere analyzed 123 silver exchange plan formularies to evaluate tier placement.
A new analysis from Avalere Health finds that consumers in exchanges receiving federal assistance to reduce their out-of-pocket costs may experience inconsistent reductions in spending depending on the plan they choose.
A new analysis from Avalere Health finds that individuals choosing an exchange plan based on premiums are most likely to consider plans from Coventry (acquired by Aetna in 2013), Humana, and WellPoint in regions where they participate.
Over 550K New Medicaid Enrollees Gained Coverage in Non-Expansion States in First Quarter.
Last week, the Department of Health and Human Services (HHS) announced that 8 million people enrolled in exchanges nationwide.
Analysis assumes 85 percent of enrollees pay first month’s premium.
New center will combine data, analytics, advisory services and research for all U.S. healthcare stakeholders to adapt to new payment and delivery models.
700K to 1.3M Additional Medicaid Enrollees through March, If Current Trends Continue.
A new analysis from Avalere Health finds that consumers purchasing insurance through exchanges are twice as likely to face utilization management controls on prescription medications compared to people enrolled in employer-sponsored insurance plans.
New Avalere analysis finds that exchange enrollment is on track to reach 5.4 million by the end of March when open enrollment is set to end. That number falls short of current Congressional Budget Office (CBO) estimates that six million people will enroll in exchanges in 2014.
A new analysis from Avalere Health estimates that from October 2013 through January 2014, between 2.4 million and 3.5 million people have newly enrolled in Medicaid as a result of the Affordable Care Act (ACA).
A new Avalere Health analysis finds that enrollment in Medicare Advantage (MA) plans grew substantially in 2014 versus 2013.
In most exchange plans, consumers will face paying a percentage of the costs—known as coinsurance—rather than fixed-dollar copayments for many specialty medications used to treat rare and complex diseases.
New Avalere analysis finds that while nationwide exchange enrollment has reached 55 percent of projections, state progress varies dramatically.
A Medicare proposed rule change limiting the number of prescription drug plans (PDPs) that insurers may offer in the Part D market could require 39 percent of all enhanced plans to be eliminated in 2016.
Avalere estimates that from October through December 2013, between 1.1M and 1.8M people have newly enrolled in Medicaid as a result of the Affordable Care Act (ACA).
An analysis from Avalere Health finds that Medicaid managed care enrollment will increase by 20 percent from 2013 to 2014 and by 38 percent from 2013 to 2016.
An analysis from Avalere Health finds that most individuals in exchanges will face formularies with four or five cost-sharing tiers that commonly use coinsurance techniques for top-tier medications.
NEWS RELEASE: An analysis by Avalere Health finds that consumers who enroll in exchange plans will, on average, face dramatically different deductibles based on the metallic level plan (i.e., bronze, silver, gold, platinum).
An analysis by Avalere Health addresses key issues faced by various high-need groups that must enroll in exchanges by Dec. 23 to secure coverage by Jan. 1, 2014, including those facing individual market cancellations, individuals in high-risk pools, some Medicaid beneficiaries and uninsured HIV/AIDS…
NEWS RELEASE: An analysis from Avalere Health finds that most individuals in exchanges who reach their maximum out-of-pocket (OOP) cap will be underinsured, despite reduced OOP caps for those below 250 percent of poverty. The Commonwealth Fund defines underinsurance as OOP costs greater than 10…
NEWS RELEASE -- A new Avalere Health analysis shows that, as of November 2, 30 percent of exchange applicants are eligible for federal subsidies to reduce their monthly insurance premiums and out-of-pocket costs for medical care, far below the 84 percent of enrollees who are ultimately expected to qualify…
An analysis from Avalere Health finds that 12 state-based exchanges1 have enrolled about 3 percent of their expected 2014 exchange participants. Together, the 12 states have enrolled 49,100 people in exchanges based on data released by the states, as of Nov. 10. By the end of 2014, Avalere…