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.
Featured Content
Key Considerations for Medicare Advantage Plans Evaluating New Part B Step Therapy Flexibility
Following its recent announcement to grant Medicare Advantage (MA) plans the flexibility to use step therapy techniques for Part B drugs beginning in January 2019, the Centers for Medicare & Medicaid Services (CMS) released an FAQ with additional guidance on its implementation.
CMS Announces New Flexibilities in Medicare Part D
Under an indication-based formulary design approach, Part D plans will be able to tailor the drugs that are on their formulary by indication.
Eliminating Drug Rebates Requires Complex Solutions
Reforms to “eliminate rebates” could have varying impacts based on features of their design.
CMS Grants Medicare Advantage Plans Flexibility to Use Step Therapy for Part B Drugs
Beginning in January 2019, Medicare Advantage (MA) plans will have the flexibility to use step-therapy techniques for Part B drugs, according to a CMS memo released on August 7.
CMS Proposal Would Alter Office Visit Payments
In its proposed changes to the Medicare Physician Fee Schedule (MPFS) for Calendar Year 2019 (CY2019), the Centers for Medicare & Medicaid Services (CMS) proposes a potentially sweeping change to the way it values physician office and outpatient visits, also known as Evaluation & Management (E/M) codes.
CMS Proposal Encourages Advanced Alternative Payment Model Participation
Early adoption and participation in an AAPM can provide a higher incentive payment to Medicare clinicians than MIPS.
FDA Seeks Stakeholder Input on How to Enhance Biosimilars and Interchangeable Biologics Market
Earlier this week, the Food & Drug Administration (FDA) released a Part 15 public hearing announcement and request for comment on how the FDA can facilitate greater availability while balancing competition and innovation for all biologics.
Dialogue Proceedings / Advancing Patient-Centered Malnutrition Care Transitions
Although malnutrition can lead to greater risk of chronic disease, frailty, and disability, and increases healthcare costs, patients’ nutrition status is rarely evaluated and managed as they transition across care settings.
ICER’s Use of FDA Approval Volume to Calculate Budget Impact Thresholds: A Scenario Analysis
ICER’s reliance on the average number of FDA drug approvals to calculate budget impact thresholds leads to significant variability.
Fewer Seniors Get Vaccinated as Their Out-of-Pocket Costs Increase
New research shows higher cost sharing for vaccines under Part D leads to fewer seniors getting vaccines. Immunization rates are higher for vaccines covered by Part D plans with lower cost sharing.
Strategic Imperatives for Skilled Nursing Facilities Preparing for New Payment System
In August 2018, CMS is expected to finalize a proposed new payment methodology for skilled nursing facilities (SNFs) that would shift the focus from resource use to patients’ clinical needs.
CMS Rejects Massachusetts’ Medicaid Closed Formulary Proposal
On June 27, CMS notified Massachusetts of a partial approval of the MassHealth program’s proposed 1115 waiver request.
Reforming Medicare Vaccine Coverage to Reduce Barriers to Access
On June 14, Avalere experts came together with Cynthia Tudor, former Deputy Center Director of the Center for Medicare and Senior Advisor to Avalere, to discuss vaccine coverage and access challenges under Medicare.
Shifting Drugs from Medicare Part B to Part D: Learnings from Medicare Coverage of Vaccines
A proposed shift of Part B drugs into Part D could affect patient access and increase the burden on providers.
CMS Expands Benefit Flexibilities in Medicare Advantage
Earlier this year, the administration granted Medicare Advantage plans greater flexibility to target benefit designs for individuals with certain high-risk health conditions. These changes are expected to position the program for continued growth.
Developing a Shared Decision-Making Tool in Collaboration with Patients and Clinicians
Avalere used a human-centered design approach structured around patient preferences to help guide advanced breast cancer patients.
Medicare Trustees Report Triggers Program Funding Warning
In its 2018 Report, the Medicare Trustees issued a Medicare funding warning, citing concerns over the program's near-term financial health and spending impact on the federal budget.
HTA Oncology Recommendations Have Grown More Restrictive Over Time
Of the 329 oncology HTAs analyzed from the period 2013–2017, 29% resulted in positive recommendations without restrictions.
Avalere Releases Patient-Perspective Value Framework Scoring Methodology Report
Today, Avalere published a technical appendix to the PPVF Version 1.0 methodology report, outlining a quantitative method for incorporating patient preferences into value assessments and healthcare decision making.
Readmission Rates Are 6 Times Higher for Some Conditions in Medicare’s New Bundled Payment Program
As the deadline approaches for providers to make decisions on their participation in BPCI Advanced, Avalere analysis shows that certain conditions may provide greater opportunity for success.