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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.

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.

Joanna Young

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.

Jack Fagan

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.

Emily Gillen

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.

Angel Valladares

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.

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