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.
Earlier today, the Trump Administration released long-anticipated drug pricing reforms, including rules related to a Most Favored Nation (MFN) approach for drugs administered by providers in Medicare and rebate reform for the Medicare Part D program. Both rules represent fundamental shifts in our current system and have significant implications for manufacturers, health plans, pharmacies, providers, and patients.
Liquid biopsies test blood samples for circulating tumor DNA (tumor derived cell-free DNA), circulating tumor cells, cell-free tumor DNA, proteins, metabolites, exosomes, messenger RNA, and microRNAs. The promise of liquid biopsies is a new modality that screens for cancer in ways that complement and, in some cases, improve existing tests, and allow testing for early detection, cancer diagnosis, and monitoring of minimum residual disease and recurrence, without the need for invasive biopsies.
With a number of cell and gene therapies (CGTs) expected to obtain Food & Drug Administration (FDA) approval in the next 3 years, stakeholders must consider the unique patient access and affordability barriers that may limit patient ability to receive these novel treatments. Stakeholders should explore affordability solutions that can optimize access, or they risk excluding patients from obtaining potentially life-saving treatments.
The Centers for Medicare & Medicaid Services (CMS) released coding and payment instructions associated with the first physician-administered outpatient COVID-19 therapeutic. The release specifies that during the public health emergency (PHE), Medicare will cover and pay for these infusions in the same way it does for COVID-19 vaccines.
State Medicaid programs are likely to face significant budget impacts from emerging cell and gene therapies and may seek to implement a variety of strategies to manage utilization and address provider reimbursement and financing challenges.
On November 3, the Journal of the Academy of Nutrition and Dietetics published an article entitled “Implementation Science in Evidence-Based Nutrition Practice: Considerations for the Registered Dietitian Nutritionist,” co-authored by Christina Badaracco.
New Avalere research featuring payer views of COVID-19 finds a heightened concern about the clinical effectiveness of related future vaccines and therapeutics, a substantial reduction in preventive services due to the COVID-19 public health emergency, and a significant uptick in telehealth adoption.
The COVID-19 pandemic has created significant challenges for all Americans, particularly for its most vulnerable populations, including the elderly and people with disabilities in Medicare. The Centers for Medicare & Medicaid Services (CMS) recently reported that 21% of fee-for-service (FFS) Medicare enrollees have stated they are forgoing non-COVID-19 related care due to the pandemic. Avalere conducted analyses to determine if a similar decrease in utilization is occurring in Medicare Advantage (MA) and assess the potential impact of deferred care on MA enrollees and plans.
On October 8, the Centers for Medicare & Medicaid Services (CMS) published their 2021 Star Ratings for Medicare Advantage (MA-PDs) and standalone Prescription Drug Plans (PDPs) on Medicare Plan Finder.
The 351(k) biosimilars pathway was legally established under the Biologics Price Competition and Innovation Act (BPCIA) provision of the Patient Protection and Affordable Care Act (ACA) of 2010. Since the passage of the ACA, 28 biosimilars have been approved by the Food & Drug Administration (FDA) along with the promulgation of policy that also applies to all biologics, including the creation of a suffix within the nonproprietary name of these products. Additionally, substantial case law has been made with respect to intellectual property pertaining to biologics. With the legality of the ACA currently under scrutiny, the future of BPCIA and biosimilars is uncertain.
On November 4, Avalere experts presented “Development of a Claims-Based Algorithm to Identify Patients with Agitation in Alzheimer’s Dementia” at the Gerontological Society of America Annual Scientific Meeting.
The 2020 presidential election will have significant implications for the US healthcare system and Americans’ healthcare options.
With the US Supreme Court (SCOTUS) set to hear arguments starting November 10 in California v. Texas and the swearing in of Justice Amy Coney Barrett on October 26, questions remain regarding the future of the Affordable Care Act (ACA) and its impact on laws passed in at least 18 states creating coverage protections for essential health benefits (EHB) and coverage of pre-existing conditions.
Avalere analysis finds that success in the first 4 performance periods of the Oncology Care Model (OCM) was correlated with reductions to inpatient expenditure and spend reductions within certain high-cost tumor types. Further, smaller community-based practices and those that had lower per-episode expenditure in the baseline period tended to be more successful.
The convergence of the seasonal influenza and the current COVID-19 vaccines will merge several distribution considerations for a diverse group of stakeholders.
New analysis from Avalere finds that Medicare beneficiaries are more likely to receive Part D autoimmune drugs and less likely to receive Part B autoimmune drugs from providers who are part of Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) compared to non-ACO providers.
Avalere research was published online in the Journal of Clinical Oncology Clinical Cancer Informatics, showing a considerable drop in cancer screening, diagnosis, and treatment for Medicare beneficiaries as a result of the ongoing COVID-19 pandemic.
Medicare Advantage (MA) plans continue expanding coverage of supplemental benefits, including services related to the pandemic.
Avalere analysis finds that patients with Crohn’s disease who experience a negative outcome when required to step through a plan’s preferred product may face higher upfront out-of-pocket (OOP) costs and could increase costs to payers.
The outcomes of the 2020 elections will hold implications for state policymaking on key healthcare issues that could impact patients’ health insurance coverage status and how they access care.