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
2021 State Drug Pricing Legislation: The Evolution Beyond Transparency
The majority of state legislatures are currently in session, and many states are taking steps to address prescription drug spending and prices through a range of legislative proposals. While states have historically focused on price transparency, state policymakers are now moving beyond those measures to more directly control prescription drug prices through reference pricing, affordability review boards setting upper payment limits, and other price control mechanisms.
Majority of Part D Spending Is on Brand Drugs in Classes with Generics
With Congress likely to consider a second reconciliation bill in the near future that may include various drug-pricing and Medicare Part D reform policies as spending offsets, an updated Avalere analysis examines spending across classes with various availability of brand and generic drugs.
OPPS 340B Policy Reversal Lowers Hospital Payment and Increases Copays
A new analysis from Avalere estimates the impact of reverting back to the Calendar Year (CY) 2017 Medicare Outpatient Prospective Payment System (OPPS) payment policy that reimbursed all separately payable drugs at average sales price (ASP) plus 6%. Key findings suggest beneficiary cost sharing for separately payable drugs at 340B OPPS hospitals would increase by $472.8 million. Also, 82% of all OPPS hospitals—specifically 89% of rural, 80% of urban, and 49% of 340B hospitals—would see net total payment decreases.
Medicaid Expansion Map
Since passage of the Affordable Care Act (ACA), 36 states and DC have expanded Medicaid. Some of the remaining states may reconsider expansion given new federal funding incentives.
OCM, OCF, and the Future of Cancer Care: 5 Things to Look Out For
As the Oncology Care Model (OCM) approaches its conclusion, stakeholders are anxiously awaiting the details of the Center for Medicare & Medicaid Innovation's (CMMI’s) next oncology episodic payment model, Oncology Care First (OCF).
Three Considerations for 2021 Drug Pricing Reform Outlook
A second reconciliation package could include significant drug pricing reforms as a means to pay for permanent coverage expansion and other top priorities.
How the Transitional Drug Add-On Payment Adjustment (TDAPA) Works
The TDAPA supports payment and patient access to new therapies introduced to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS). While no major TDAPA revisions were finalized in the Calendar Year (CY) 2021 ESRD PPS Final Rule, stakeholders should continue to monitor this payment adjustment policy, as it has evolved since its introduction and may continue to change in future rulemaking cycles.
Assessing the Reach of Oncology Clinical Pathways
Avalere analysis finds that approximately 1 in 5 Medicare beneficiaries with advanced urothelial carcinoma (UC) or renal cell carcinoma (RCC) see a physician that has access to McKesson Value Pathways or Elsevier ClinicalPath vendor clinical pathways programs
Differences in Spending and Demographic Profiles in Medicare KCC Model
The Kidney Care Choices (KCC) model, a new alternative payment model launched by the Center for Medicare and Medicaid Innovation (CMMI), is scheduled to begin on January 1, 2022. This model will provide population-based payments for beneficiaries with both advanced-stage chronic kidney disease (CKD) and end-stage renal disease (ESRD) to improve patient health outcomes and lower Medicare fee-for-service (FFS) spending.
RWE Strategy Leads to Support for Avalere-Developed Composite Measure
Avalere was pleased to partner with the nutrition community to develop and test the Global Malnutrition Composite Score, which has now received conditional support from the Measure Applications Partnership (MAP)—pending endorsement by the National Quality Forum (NQF)—for inclusion in the Hospital Inpatient Quality Reporting (IQR) Program.
Measuring Scope of COVID-19 Relief Coverage Expansion Provisions
Avalere analysis finds that Congress's healthcare reforms under the COVID-19 relief bill could expand exchange coverage subsidies for up to 18.3 million individuals.
Generic Drug Placement on Part D Generic Tiers Declines Again in 2021
A new analysis from Avalere finds that in 2021, Medicare Part D plans place generic prescription drugs on generic tiers 45% of the time, a decrease from 64% in 2016.
Incorporating Clinical Factors Could Improve OCM Cost Prediction
An Avalere analysis found that among high-risk breast cancer episodes, those in later stages of the disease had higher episode expenditures relative to their benchmarks compared to those in earlier stages.
Copay Accumulator and Maximizers: Evolving Policy Landscape
Implementation of copay accumulator and maximizer programs continues to increase; recent policy provisions finalized through federal rulemaking and state-level legislation have created new uncertainty for the future of these programs and the stakeholders they affect.
Strengthening Our Public Health Infrastructure: COVID-19 Lessons
Amid the continuing pandemic and calls for healthcare reform, the new administration seeks to confront the myriad public health issues facing our country today.
Kidney Care Policy, Market Shifts in Light of New and Old Challenges
The COVID-19 public health emergency, new policy changes, and existing unmet patient needs will pressure the evolving payer, provider, and reimbursement landscape for kidney care in 2021.
Lengthening Episode Duration Would Not Improve OCM Performance
An Avalere analysis found that lengthening episode duration from 6 months to a year would not have a large impact on the relationship between episode expenditures and benchmark costs, meaning that performance on longer episodes would not improve relative to shorter episodes.
mAb Utilization for COVID-19 Remains Low, Despite Availability
Since the beginning of the Public Health Emergency (PHE), manufacturers have been developing monoclonal antibodies (mAbs) and other treatment modalities to prevent and treat COVID-19.
Medicare FFS Utilization Decreased During the COVID-19 Pandemic
Avalere analysis finds healthcare utilization among Medicare Fee-for-Service (FFS) beneficiaries decreased in the spring of 2020 compared to the spring of 2019.
Senior Preferences for COVID-19 Vaccination Released with Tivity Health
The COVID-19 pandemic has disproportionately impacted seniors nationwide, with this population at an increased risk of hospitalization or death following a COVID-19 diagnosis.