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
Anticipated Impact of COVID-19 Treatments on State Medicaid Budgets
Compared to other drivers of state budget pressures during the COVID-19 pandemic—including higher Medicaid program enrollment due to increased unemployment and lower state tax revenues as a result of economic shutdowns—the relative financial impact of COVID-19 therapeutics on state Medicaid budgets will likely be minimal.
“Most Favored Nation” EO Creates New Questions on International Prices
On September 13, the Trump Administration released the much-anticipated “Most Favored Nation” (MFN) Executive Order (EO), calling for models that would cap the price Medicare pays for select Part B and D drugs. The President’s EO underscores the administration’s continued focus on reducing prescription drug price disparities between the US and other developed countries.
Using Diagnostics to Mitigate the COVID-19 Public Health Emergency
Mitigating the public health emergency (PHE) caused by SARS-CoV-2 requires a multifaceted approach.
Dan Mendelson Commentary on Health Equity Featured in Forbes
The COVID-19 pandemic and a summer of focus on racial justice has finally begun to intensify government interest in reducing racial disparities in healthcare. Understanding that healthcare providers and systems tend to respond to the economic incentives that are presented to them, current government decisions on payment options around renal dialysis present an important test case for the Trump Administration.
Avalere Statement on “Most Favored Nation” Executive Order
Yesterday, the Administration released the awaited “Most Favored Nation” Executive Order (EO), which calls for a model that would cap the price Medicare pays for select Part B and D drugs.
Fall Medicaid Outlook: Key Events to Watch
Medicaid will continue to experience considerable changes at the state and federal levels, both in terms of beneficiary demographics and the payer landscape. Stakeholders should consider how upcoming elections, policy proposals, and COVID-19 will impact benefits and payer dynamics.
CMS Finalizes New Reimbursement Method for CAR-T Treatments
Policy changes to Medicare’s CAR-T inpatient reimbursement set a precedent for high-cost durable treatments. Looking ahead, questions and concerns remain for pipeline cell and gene therapies that have high up-front costs.
Declining WIC Participation May Lead to Poorer Health Outcomes
With fewer eligible Americans participating in WIC, increased risk of food insecurity and decreased access to quality healthcare may place a greater burden on our healthcare system. The COVID-19 pandemic further exacerbates the challenges of vulnerable populations in access to food resources and routine and acute care.
CMMI Model Would Increase Gap Discounts for Non-Insulin Products
Avalere analysis finds that 51% of all drug spending for non-LIS beneficiaries using insulins and enrolled in enhanced plans in 2018 was for products not participating in the model.
Who Will Approve a COVID Vaccine in the US?
As life sciences companies sprint toward COVID-19 vaccines and therapies, the discussion below considers who has the authority to make the call on their availability at the Food and Drug Administration (FDA) and the US Department of Health and Human Services (HHS).
COVID-19 Therapies Could Benefit from NTAP Reimbursement Opportunity
Therapies currently being developed to treat COVID-19 in the inpatient setting have opportunity for additional Medicare reimbursement.
New ESRD Analytics Featured in Kidney 360
On August 25, “Calcimimetic Use in Dialysis-Dependent Medicare Fee-for-Service Beneficiaries and Implications for Bundled Payment” was published in Kidney 360. The article featured research and analytics conducted by Avalere experts.
5 Activities to Make the Most of the HEDIS® Off-Season
While the HEDIS® collection season lasts for a limited time, the focus on initiatives that impact HEDIS results is a year-round priority. The period between submission and HEDIS season ramp-up, known as the “off-season,” offers an opportunity for health plans to elevate the member experience, amplify quality improvement activities, and improve HEDIS submission effectiveness.
COVID-19 Guide for Patients and Providers
As our healthcare industry rapidly evolves to address the COVID-19 pandemic, keep track of new resources and policies affecting patients and providers with the COVID-19 guide below.
CMS Proposal Would Increase Provider Payment for Vaccine Administration
The proposed CY 2020 MPFS rule includes provisions that, if finalized, would increase provider reimbursement for vaccine administration. However, the proposed crosswalk of the codes to a separate, nonvaccine related code could subject the code to future unrelated payment fluctuations.
MedPAC Proposes Replacement for MA Star Ratings Program
Under the Medicare Advantage (MA) Star Ratings Program, plans with 4-stars or more receive the greatest benefit from the Quality Bonus Program (QBP) in the form of higher benchmarks and bonus payments.
Charitable Assistance Covers a Small Share of Part D Non-LIS OOP Costs
As policymakers discuss ways to curb program expenditures and improve patient affordability in Medicare Part D, the role of charitable assistance in helping beneficiaries with out-of-pocket (OOP) costs has garnered interest. To understand the relationship between charitable assistance and various Part D metrics, Avalere examined Part D prescription drug claims for beneficiaries without the Low Income Subsidy (LIS) for 2014 and 2018.
Overview: Balance Billing or Surprise Medical Bill Reform
Surprise and balance billing reform efforts have been a subject of ongoing debate at the federal level.
EO on Rebate Reform Raises Key Considerations for Pharmacies
As currently written, a proposed rule on rebate reform from January 2019 may impose financial and operational challenges for pharmacies related to cash flow and new technology requirements.
Bringing COVID-19 Vaccines and Therapeutics to Market
On July 22, Avalere experts discussed the marketplace for COVID-19 vaccines and therapeutics in the “Cutting Through the Noise: Market Evolution and Pathways to Access for COVID-19 Vaccines and Therapeutics” webinar. They examined FDA regulatory considerations, coverage and access challenges, and key pricing and distribution scenarios for optimal US market access.
