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.
Advancing Diabetes Care in the Era of CGM: Dialogue Proceedings
As one of the most common chronic conditions in the US—affecting approximately 10.5% of the US population and growing—diabetes (and the optimal management of this condition) remain a persistent healthcare challenge.1
Assessing Changes in Prenatal Care During the COVID-19 Pandemic
COVID-related concerns influenced shifts in utilization and changes to the delivery of major pregnancy-related services. The expanded use of telemedicine in the maternal care continuum increasingly provided expectant patients with access to healthcare services while adhering to social-distancing guidelines.
Accurate COVID-19 Testing to Protect the Military and Support Schools
The US continues to face challenges with managing COVID-19 (SARS-CoV-2) while reopening communities. Accurate COVID-19 diagnostic testing is an effective tool in minimizing the risk of transmission.
Avalere Statement on US Support of TRIPS Waiver for COVID Vaccines
On May 5, the Biden administration announced its support for waiving World Trade Organization (WTO) intellectual property regulations with respect to COVID-19 vaccines, in an effort to increase supply and worldwide access to the vaccines.
President Biden’s Address to Congress Highlights Healthcare Priorities
In his first address to Congress, President Biden signaled that healthcare will continue to be a high priority for his administration, specifically highlighting pandemic response, drug pricing priorities (e.g., Medicare negotiation), and Affordable Care Act (ACA) enhancements.
Removing Low-Risk Cancers Has Variable Impact on OCM Performance
An Avalere analysis found that the impact of removing low-risk/low-intensity episodes from the Oncology Care Model (OCM) reconciliation process would not have a notable impact for most practices. Among practices where performance would change, however, performance would improve for most practices if enrolled in 1-sided risk but worsen for most practices if enrolled in alternative 2-sided risk.
New Data-Sharing and Interoperability Mandates Create New Challenges
Digital health will continue to be a focus under recently confirmed Secretary Becerra‘s leadership at the Department of Health and Human Services. As the Biden administration looks to enforce compliance across a range of data interoperability and price transparency rules, as well as usher in new Food & Drug Administration (FDA) and Centers for Medicare & Medicaid Services (CMS) coverage policies for medical technologies and digital health tools, the industry is responding with a range of innovations.
AI in Healthcare: Raise the Evidence Bar Now or Be Forced to Later
In 2012, experts predicted that artificial Intelligence (AI) would eventually replace as much as 80% of current clinical practice by physicians. While AI has certainly expanded in healthcare—especially during the COVID-19 pandemic—the last few years have included some eventful setbacks in the use of AI across several sectors of the economy, including healthcare.
Pending ASP Changes Impact Payments & May Shape Future FDA Filings
Beginning July 1, 2021, average sales price (ASP) calculations for Part B drugs with an additional non-covered self-administered formulation could alter Medicare reimbursement.
Part D LIS Patients Have Lower Rates of Specialist-Prescribed Drugs
For prescription drug fills across 4 therapeutic areas, Avalere analysis finds that Medicare Part D beneficiaries who receive the Low-Income Subsidy (LIS) have those drugs prescribed by a specialist less frequently than those who do not receive LIS.
Exchange Operational Models for 2021
In 2021, most states are relying on the federal government for some or all exchange operational functions.
Advancements in Cell Therapies Require New Patient Support Solutions
Manufacturers seeking Food & Drug Administration (FDA) approval for cell therapies will need to assess the financial and logistical burden on patients and develop novel solutions to help alleviate these challenges.
The Need for a Centralized Immunization Information System
Immunization Information Systems (IIS), or immunization registries, are used across the US to provide consolidated and complete accounts of patient immunization history in a given city, state, or region.
PACHA Highlights Need to Address HIV PrEP Coverage Disparities
On March 8–9, the Presidential Advisory Council on HIV/AIDS (PACHA) discussed avenues to achieving equitable access to HIV prevention products for at-risk populations as well as next steps in revising the National Strategic Plan to End the HIV Epidemic.
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.