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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.

Zachary Zalewski

SCOTUS Overturn of the ACA May Invalidate Biosimilar Pathway

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.

Nick Diamond

States Mitigate Potential Coverage Losses Ahead of ACA SCOTUS Ruling

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.

Understanding Success Among OCM Participants

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.

Mandatory Kidney Care Model Introduces Financial Incentives and Risks

The ESRD Treatment Choice model demonstrates an increased focus on improving health outcomes for Medicare patients receiving dialysis by realigning incentives to favor the adoption of home dialysis and increasing the rate at which patients receive kidney transplants. This mandatory model could lead to significant disruption for stakeholders in the coming years. Understanding the risk and opportunities associated with this model will be critical for patients, providers, and manufacturers alike.

Emily Belowich

The COVID-19 Impact on US Routine and Seasonal Vaccine Administrations

Avalere conducted a national survey of more than 200 independent primary care providers concerning the impacts of the COVID-19 pandemic on their ability to support continued vaccination programs for patients. Over 90% of respondents indicated the COVID-19 pandemic has increased operating costs and led to revenue loss. Eighty-two percent indicated that an increase in vaccine administration fees would aid sites in overcoming barriers arising from the COVID-19 pandemic, and 75% expressed interest in implementing new care delivery arrangements to facilitate immunizations during the COVID-19 pandemic.

Heather Flynn

Avalere Analysis Shows Home Care Services Reduce Medicare Spending

Avalere analysis determined that Medicare Fee-for-Service (FFS) patients receiving home-based care services experienced a decrease in Medicare spending over time when compared to a statistically balanced, matched control group who do not appear to have received home care services. The spending differential was also found to be higher among Medicare beneficiaries with functional limitations and multiple chronic conditions.

Melissa Morley

COVID-19 Provider Relief Funding and Future Allocation Considerations

The Coronavirus Aid, Relief, and Economic Security (CARES) Act appropriated $100 billion for the Public Health and Social Services Emergency Fund—known as the Provider Relief Fund (PRF)—and subsequent legislation appropriated an additional $75 billion through the Paycheck Protection Program and Health Care Enhancement Act.

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