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
Details Matter: Healthcare Coverage Landscape Varies in Super Tuesday States
Ahead of the Super Tuesday primaries on March 3, healthcare remains a top issue among voters. According to January 2020 polling from Bipartisan Policy Center, 56% of individuals ranked healthcare as one of their top 3 issues when determining how to vote in the upcoming election, above the economy (44%), immigration (33%), taxes (31%), gun control (30%), and environmental policy (23%).
Recent Federal Rule Could Undermine Some Patient Support Programs
The Center for Medicare & Medicaid Services (CMS) recently issued its proposed Notice of Benefit and Payment Parameters (NBPP) for the 2021 plan year. The proposed rule would significantly expand commercial payer flexibility to not count manufacturer copay support toward deductibles or out-of-pocket (OOP) maximums.
OOP Costs for MS Drugs Are Substantially Higher for Non-Employer-Based Part D Plans
Employer Group Waiver Plans (EGWPs) have lower out-of-pocket (OOP) costs for multiple sclerosis (MS) drugs than beneficiaries enrolled in other types of Part D plans.
CMS Proposal May Increase Obstacles for State-Mandated Benefits
In the Notice of Benefit and Payment Parameters (NBPP) for the 2021 plan year, CMS questioned whether states were appropriately deciding if the state was required to defray the premium impacts of new benefit mandates added since 2011. CMS proposes requiring states to report on and justify defrayal decisions for all state benefit mandates.
With an Influx of Cell and Gene Therapies on the Horizon, New Access, Coverage, and Financing Models Are Needed
With new cell and gene therapies poised to revolutionize treatment for a growing number of disease states, stakeholders are working to reimagine existing value and reimbursement models to meet the special challenges these breakthrough services present.
Patient Costs Among Medicare Part D Users of Mental Health Drugs
According to a new analysis from Avalere, Medicare Part D beneficiaries who are taking mental health drugs and do not receive low-income cost-sharing support are responsible for a higher share of the cost of mental health drugs (46%) than for non-mental health drugs (23%).
The State of COVID-19 Vaccine Candidate Development
The novel coronavirus (COVID-19) was first reported in Wuhan, China, on December 31, 2019, and within a month was declared a public health emergency of international concern (PHEIC) by the World Health Organization (WHO).
Medicare Advantage and Medicaid Managed Care Growth Present Risks and Opportunities for Post-Acute Care Providers
The payer landscape continues to evolve for post-acute care (PAC) providers. Fueled by lower annual costs and expanded benefit options relative to the Medicare fee-for- service (FFS) program, Medicare Advantage (MA) is growing rapidly, now encompassing more than one-third of all Medicare beneficiaries. At the same time, nearly half the states have implemented managed care plans to provide Medicaid long-term care benefits.
Medication Adherence Rates Low Among Patients with Serious Mental Illness
Avalere research recently published in ClinicoEconomics and Outcomes Research compared patient characteristics and real-world outcomes in 2 distinct high-risk cohorts of patients with serious mental illness (SMI), including patients with a hospitalization related to SMI (recently discharged) and patients newly diagnosed with SMI (early episode). The research included 51,705 patients with bipolar disorder, major depressive disorder, and schizophrenia.
5 High Impact Areas in the MA Advance Notice & Proposed Rule
This month, the Centers for Medicare & Medicaid Services (CMS) proposed changes to Medicare Advantage (MA) through the annual Advance Rate Notice and Proposed Rule. These proposals impact MA in many ways, including changes to quality bonus payments, network adequacy requirements, coverage of End Stage Renal Disease (ESRD), plans targeting dual eligibles, and supplemental benefit offerings. Stakeholders should examine each of these areas closely as they respond to CMS.
Live Discharge Rates for Hospice Patients Vary by Diagnosis
Avalere’s analysis found that hospice patients diagnosed with cardiovascular and dementia conditions represent the largest proportion of “live discharges” compared to patients with other conditions.
CMS Proposes Allowing Part D Plans to Implement a New Preferred Specialty Tier
Implementation of a preferred specialty tier could have various impacts on Part D plans’ formulary and benefit designs and could affect manufacturer contracting strategies.
For the First Time, a Majority of Generic Drugs Are on Non-Generic Tiers in Part D
According to a new analysis from Avalere, Medicare Part D plans place generic prescription drugs on non-generic tiers 53% of the time in 2020.
Preventive Care Commentary Featured in Health Affairs Blog
On January 29, Richard Hughes published a piece on the Health Affairs blog discussing the presidential candidates’ opportunities to incorporate preventative services into their healthcare policy platforms.
Details Matter: Healthcare Coverage Landscape Varies in Early Primary States
As the early presidential primaries unfold, healthcare remains a top issue among voters. As recently as the November Democratic primary debate, polls showed that 24% of Democrats or Democratic-leaning independents said healthcare was the number one issue they wanted to hear discussed, ahead of the environment (12%), immigration (6%), jobs and the economy (5%), education (4%), and gun control (4%).
What to Watch for in this Week’s Call Letter and Proposed MA-PD Rule
CMS is set to release its annual proposed changes to Medicare Advantage (MA) this week. Some of the topics that may be addressed include End-Stage Renal Disease (ESRD), network adequacy requirements, payment to MA plans that offer the hospice benefit, and the MA quality bonus program.
CMS’s Healthy Adult Opportunity Program Includes Significant Changes to Medicaid Drug Benefit
The Centers for Medicare & Medicaid Services (CMS) announced the Healthy Adult Opportunity, a new Section 1115 demonstration initiative allowing states to shift toward capped Medicaid financing models with an opportunity for shared savings. If the option is chosen by states, it could be the largest change to Medicaid since the ACA.
Nutrition Support Therapy Could Potentially Save the Medicare Program $580 Million
Avalere’s findings were featured in the Journal of Parenteral and Enteral Nutrition.
Avalere Statement on CMS’s Healthy Adult Opportunity Program
CMS’s Healthy Adult Opportunity program, a new Section 1115 demonstration initiative, will allow state Medicaid programs to move toward capped financing models for some non-disabled adult beneficiaries with an opportunity for shared savings and additional flexibilities.
Addressing Social Determinants of Health Requires a Strategic Approach in an Evolving Healthcare Environment
Increasing pressure on providers to assume accountability for meeting the goals of the Triple Aim has inspired a new focus on the social determinants of health.
