Insights & Analysis
There’s one constant in healthcare: change. Count on us to break down the trends so you can stay up to date. Follow our take on each piece of this deep, intertwined, and often perplexing industry to find opportunities and practical approaches to move healthcare forward.
An updated Avalere analysis examines Medicare Part D plan tier placement of generic prescription drugs, finding that over time their percentage on generic tiers has declined from 65% in 2016 to 43% in 2022.
To fully realize the benefits of home-based care, including improved outcomes, inpatient hospital capacity, and patient experience, state and federal regulators may consider formalizing regulatory flexibilities, removing current barriers to participation in models such as Acute Hospital Care at Home, and testing the impacts of these waivers under the Center for Medicare & Medicaid Innovation (CMMI).
Malnutrition is a complex and burdensome condition that is often connected to social determinants of health—including food insecurity—that can widen disparities in health outcomes.
Updated Avalere analysis shows that routine immunization continued to lag in 2021 below pre-pandemic levels, highlighting the continuing effect of COVID-19 on routine vaccination.
Amid recent policy focus on the accelerated approval pathway and questions regarding the pathway’s evidentiary standards and decision framework, Avalere reviewed the history, process, and use of this pathway to date and the potential future use of accelerated approval for pipeline products.
The percentage of Medicare enrollees with chronic obstructive pulmonary disease (COPD) in Medicare Advantage (MA) plans is growing (3.1% growth projected between 2020 and 2030), but the majority (60%) of enrollees with COPD are in fee-for-service (FFS) Medicare. Compared to the general FFS Medicare population, more beneficiaries with COPD are dual eligible for Medicaid and fewer beneficiaries with COPD have employer sponsored insurance as a source of supplemental coverage.
New analysis finds that just over 40,000 Medicare Fee-for-Service (FFS) patients with end-stage renal disease (ESRD) elected to enroll in Medicare Advantage (MA) during the 2021 open enrollment period—the first time all ESRD patients had access to an MA plan. This enrollment shift increased the proportion of ESRD patients enrolled in MA from 23% to 30%.
A recent Avalere analysis of Medicare Fee-for-Service (FFS) data illustrates that treating major depressive disorder (MDD) in Medicare-eligible beneficiaries results in a 4% reduction in total cost compared to untreated patients, highlighting the importance of incentivizing adequate provider supply and payment in the geriatric psychiatry market.
While some food industry stakeholders have begun to integrate their operations into the healthcare system, opportunities remain for further collaboration to improve outcomes and quality of life for their patients, customers, and members.
An Avalere analysis found differences in the performance of low- and high-intensity prostate cancer episodes in the Oncology Care Model (OCM). High-intensity prostate cancer episode expenditures were consistently below the benchmark price while low-intensity episode expenditures were similar to the benchmark price. This finding is likely driven by the Centers for Medicare & Medicaid Services (CMS) methodology used to calculate benchmark prices but may also indicate participant success in controlling costs for these episodes.
Congress would operationalize Medicare negotiation for Part B drugs as outlined in the Build Back Better Act (BBBA) by cutting drug reimbursement to providers, which raises 4 potential downstream implications
In 2020, the total number of emergency department (ED) visits for Medicare fee-for-service (FFS) beneficiaries declined, but patients presenting with non-emergency care sensitive conditions were more likely to be admitted than in 2019.
An Avalere analysis determined that Medicare Fee-for-Service (FFS) patients who received personal care services experienced a decrease in Medicare expenditures over time when compared to a statistically comparable control group comprising patients who did not receive the same level of personalized care. The reduction in spend was specific to a subset of chronic conditions that were targeted operationally for intervention and case management.
The FY 2022 update of the ICD-10-CM includes 19 new Z codes that relate to social determinants of health (SDOH). Z codes present an opportunity to standardize and improve patient SDOH data collection to assist stakeholders in addressing non-clinical needs that impact health outcomes and healthcare costs.
New Avalere analysis finds that 3 proposals to redesign the Part D benefit would lead to larger increases in mandatory manufacturer discounts on brand drugs within the Part D “6 protected classes” compared to brand Part D drugs overall. Mandatory manufacturer discounts within the protected classes would increase by 661%, 301%, and 409% across the 3 proposals evaluated, compared to 153%, 63%, and 64% for Part D drugs overall.
A new Avalere analysis examines the prevalence of utilization management (UM) in the commercial market from 2014 to 2020, focusing on drugs treating cancer, autoimmune diseases, and a range of other chronic conditions.
New Avalere analysis finds that the latest version of Medicare negotiation in the Build Back Better Act (BBBA) would lead to a 40% cut on average for Medicare providers that furnish the Part B drugs that are likely to be initially targeted for negotiation.
In plan year (PY) 2022, most states continue to rely on the federal government for some or all exchange operational functions. However, 3 states have transitioned to state-based exchanges (SBEs).
While proponents of universal pre-K (UPK) and other early care and education (ECE) programs have long cited its value for promoting children’s cognitive and social emotional development, preliminary evidence shows that these programs have similar direct health benefits.
In September 2021, Avalere conducted an online survey of 51 US-based health plans and pharmacy benefit managers (PBMs), representing roughly 59 million covered lives. The survey indicates that 56% of payers have executed an outcomes-based contract (OBC) as of September 2021.