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.
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How Can Patients and Caregivers Participate in Negotiation?
Recently released guidance and a second draft Negotiation Data Elements ICR introduce several opportunities for patients and caregivers to shape negotiation.
Avalere Experts Respond to Revised CMS Negotiation Guidance
The revised guidance contains significant changes to the initial guidance released in March, but important outstanding questions remain.
Wastage Update: New JZ Claims Modifier Applies to NOC Billing
Starting July 1, providers must report the JZ modifier on all claims for single-use Part B drugs when applicable, including for products billed with an NOC code.
Implementation Science Integrates Evidence into Care
Despite proven benefits, evidence-based interventions are rarely adopted. Implementation science can support the integration of such interventions in routine healthcare.
How Do IRA Policies and Part D Risk Adjustment Interact?
The IRA will increase health plans’ financial risk, elevating the importance of Medicare Part D risk adjustment.
ACIP Contends with Cost, Accessibility, and Equity
At its June meeting, ACIP reviewed data on several currently marketed and novel immunizations, highlighting the committee's focus on cost, accessibility, and equity.
MA Spending Lower than FFS for Those with Chronic Conditions
Updated Avalere analysis finds MA beneficiaries with chronic conditions had fewer inpatient stays and ED visits than FFS Medicare beneficiaries.
340B Stakeholders Consider Impacts of Duplicate Discounts
Drug manufacturers, covered entities, and other 340B stakeholders have shown increased interest in 340B duplicate discounts.
How Does the IRA Affect Providers’ and Pharmacies’ Strategies?
Providers and pharmacies are two critical stakeholders that should prepare their own IRA strategies to adequately react to a changing landscape.
State Copay Accumulator Bans Will Affect 19% of US Commercial Lives
19% of people enrolled in the US commercial insurance market will belong to a health plan that must count copay assistance toward patient cost sharing by 2024.
Oxygen a Large and Growing Share of Medicare DME Spending
Oxygen expenditures as a share of total Medicare DME expenditures grew from 8.5% in 2018 to 9.8% in 2021, with significant variation across states.
First 2023 HCPCS Meeting Focuses on Non-Drug Products
CMS recently convened stakeholders for a public HCPCS meeting to discuss billing, coding, and reimbursement of non-drugs and non-biological products.
Plan Finder Will Play a Key Role in Part D Redesign
Beneficiary interviews show the importance of Medicare Plan Finder as a resource and generated ideas to incorporate IRA reforms and improve user experience.
Key Stakeholders of the 340B Drug Discount Program
Key 340B stakeholders include the federal government, patients, pharmacies, drug manufacturers, PBMs, plans, and the 340B prime vendor.
How Will the IRA’s Part D Changes Affect Plan Strategies?
Plans preparing MA-PD and PDP bids for Plan Year 2025 should consider how Part D redesign will affect enrollee costs, plan payment, and market dynamics.
ICER Opens Brief Comment Period on Proposed Framework Updates
ICER announced proposed changes to its Value Assessment Framework. Stakeholders have limited time to review and comment by June 30.
US Makes Majority of API by Dollar Value in US-Consumed Medicines
Data analysis finds that 53% of the API, in dollars, used in domestically consumed medicines came from the US in 2021, and 85% came from the US or Europe.
Alternative Funding Programs Present Stakeholder Challenges
Increased use of alternative funding programs has introduced new access challenges for patients, plans, and manufacturers for specialty therapies.
What Is the 340B Prescription Drug Discount Program?
Section 340B of the Public Health Service Act requires significant discounts on outpatient drugs for “covered entities"—safety-net providers and programs.
Which Therapeutic Areas Are Likely to Be Affected by IRA Negotiation?
Sponsors with portfolio or pipeline assets within certain therapeutic areas can prepare for the downstream effects of price negotiation on the market.