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.
How Did Public Comments Shape Revised Negotiation Guidance?
Comments on initial negotiation guidance significantly shaped the revised guidance, underscoring the importance of stakeholder engagement in IRA implementation.
Opportunity for Stakeholder Input on SAD List in MPFS Proposed Rule
CMS requests stakeholder comments on the process for defining drugs that are usually self-administered by the patient.
Proposed Operational Updates to the Discarded Drug Refund Policy
In CY 2024 rulemaking, CMS proposes operational clarification to the discarded drug refund policy finalized last year.
How Do IRA Policies and the Enhancing Oncology Model Interact?
Manufacturers should adjust commercial and evidence generation strategies in response to the shifted incentives under the IRA and Enhancing Oncology Model.
CMS Best Price Discount Stacking Proposal May Trigger AMP Cap
Requiring manufacturers to stack all discounts provided through the supply chain could increase Medicaid rebate liability and complicate rebate dynamics.
Use of Patient-Centered Outcomes in ICER Assessments
Avalere assessed the current use of patient-centered outcomes in ICER evidence reports and determined the patient voice minimally influences modeling results.
CMMI Releases EOM Participation and Lessons Learned from OCM
The CMMI’s EOM began on July 1 with 44 participants. A recent OCM evaluation report described net losses to CMS and lessons that can be applied to EOM.
How Can Patients and Caregivers Participate in Negotiation?
Recently released guidance and a second draft Negotiation Data Elements ICR introduce several opportunities for patients and caregivers to shape negotiation.
Avalere Experts Respond to Revised CMS Negotiation Guidance
The revised guidance contains significant changes to the initial guidance released in March, but important outstanding questions remain.
Wastage Update: New JZ Claims Modifier Applies to NOC Billing
Starting July 1, providers must report the JZ modifier on all claims for single-use Part B drugs when applicable, including for products billed with an NOC code.
Implementation Science Integrates Evidence into Care
Despite proven benefits, evidence-based interventions are rarely adopted. Implementation science can support the integration of such interventions in routine healthcare.
How Do IRA Policies and Part D Risk Adjustment Interact?
The IRA will increase health plans’ financial risk, elevating the importance of Medicare Part D risk adjustment.
ACIP Contends with Cost, Accessibility, and Equity
At its June meeting, ACIP reviewed data on several currently marketed and novel immunizations, highlighting the committee's focus on cost, accessibility, and equity.
MA Spending Lower than FFS for Those with Chronic Conditions
Updated Avalere analysis finds MA beneficiaries with chronic conditions had fewer inpatient stays and ED visits than FFS Medicare beneficiaries.
340B Stakeholders Consider Impacts of Duplicate Discounts
Drug manufacturers, covered entities, and other 340B stakeholders have shown increased interest in 340B duplicate discounts.
How Does the IRA Affect Providers’ and Pharmacies’ Strategies?
Providers and pharmacies are two critical stakeholders that should prepare their own IRA strategies to adequately react to a changing landscape.
State Copay Accumulator Bans Will Affect 19% of US Commercial Lives
19% of people enrolled in the US commercial insurance market will belong to a health plan that must count copay assistance toward patient cost sharing by 2024.
Oxygen a Large and Growing Share of Medicare DME Spending
Oxygen expenditures as a share of total Medicare DME expenditures grew from 8.5% in 2018 to 9.8% in 2021, with significant variation across states.
First 2023 HCPCS Meeting Focuses on Non-Drug Products
CMS recently convened stakeholders for a public HCPCS meeting to discuss billing, coding, and reimbursement of non-drugs and non-biological products.
Plan Finder Will Play a Key Role in Part D Redesign
Beneficiary interviews show the importance of Medicare Plan Finder as a resource and generated ideas to incorporate IRA reforms and improve user experience.