Federal Policy
As the largest, single US healthcare payer, the government plays a dominant role in shaping the healthcare marketplace. Our experts track, interpret, and model federal policies that affect insurance coverage, access, and consumer choice so you can see around the bend.
Featured Content
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.
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.
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.
Podcast: Healthcare Price Transparency
Tune into another episode of Avalere Health Essential Voice in our Start Your Day with Avalere series. In this segment, our policy experts discuss the topic of healthcare price transparency in terms of policy, compliance, and the potential impact of making previously confidential pricing information public.
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.
Webinar: Navigating Drug Pricing Proposals and the Role of Value
Join Avalere’s panel of data analytics, market access, and policy experts for a discussion on the potential for federal drug pricing reform in Congress or via administrative action.
Ruth Liu and Myra Simon Join Avalere Health
They bring nearly 40 years combined healthcare experience to the firm, with expertise in the health insurance sector.
Impacts of Part D Redesign Vary by Therapeutic Area
New Avalere analysis finds that 3 proposals to redesign the Part D benefit—H.R.19/S.3129, Prescription Drug Price Reduction Act (PDPRA), and Elijah Cummings Lower Drug Costs Now Act (H.R.3)—would increase 2023 mandatory manufacturer discounts by 80%, 81%, and 283%, respectively, with significant variation across therapeutic areas.
MA Enrollment in Plans with Extra Benefits for Chronically Ill Tripled in 2021
Over 3 million Medicare Advantage (MA) beneficiaries are enrolled in plans providing additional supplemental benefits to individuals with chronic illnesses, compared to just over 1 million in 2020.
What to Watch for in MA and Part D Contracting for the 2022 Plan Year
Recent regulatory action released in the final days of the Trump administration related to Medicare Advantage (MA) and Part D could significantly impact plan and manufacturer calendar year (CY) 2022 contracting strategies and stakeholder advocacy priorities.
Medicare Covers More Part B Therapies for Breast Cancer than NHS England
Avalere analysis found that in 2017 and 2018, more than half (56%) of Medicare patients with breast cancer taking a medicine covered by Medicare Part B received a therapy that was not routinely covered by England’s National Health Service (NHS) or its Cancer Drug Fund (CDF).
COVID-19 Pandemic May Reduce MA Risk Scores and Payments
The COVID-19 pandemic has created significant challenges for all Americans, particularly for its most vulnerable populations, including the elderly and people with disabilities in Medicare. The Centers for Medicare & Medicaid Services (CMS) recently reported that 21% of fee-for-service (FFS) Medicare enrollees have stated they are forgoing non-COVID-19 related care due to the pandemic. Avalere conducted analyses to determine if a similar decrease in utilization is occurring in Medicare Advantage (MA) and assess the potential impact of deferred care on MA enrollees and plans.
Fewer Highly Rated MA Plans in 2021 than in 2020
On October 8, the Centers for Medicare & Medicaid Services (CMS) published their 2021 Star Ratings for Medicare Advantage (MA-PDs) and standalone Prescription Drug Plans (PDPs) on Medicare Plan Finder.
SCOTUS Overturn of the ACA May Invalidate Biosimilar Pathway
The 351(k) biosimilars pathway was legally established under the Biologics Price Competition and Innovation Act (BPCIA) provision of the Patient Protection and Affordable Care Act (ACA) of 2010. Since the passage of the ACA, 28 biosimilars have been approved by the Food & Drug Administration (FDA) along with the promulgation of policy that also applies to all biologics, including the creation of a suffix within the nonproprietary name of these products. Additionally, substantial case law has been made with respect to intellectual property pertaining to biologics. With the legality of the ACA currently under scrutiny, the future of BPCIA and biosimilars is uncertain.
Part D Senior Savings Model Participation and Premiums Vary
New Avalere analysis finds higher premiums for the enhanced standalone drug plans participating in the model.
Step Therapy Can Lead to Higher OOP Costs for Crohn’s Disease Patients
Avalere analysis finds that patients with Crohn’s disease who experience a negative outcome when required to step through a plan’s preferred product may face higher upfront out-of-pocket (OOP) costs and could increase costs to payers.
SCOTUS Ruling on ACA Could Impact Coverage and Policy Outlook
With the US Supreme Court set to hear arguments starting November 10 on California v. Texas, and Judge Amy Coney Barrett’s nomination under consideration in the Senate, questions remain regarding the future of the law.
ESRD Patient Spending Differences Between Puerto Rico and the 50 States
Avalere analysis finds End Stage Renal Disease (ESRD) spending in Puerto Rico varies substantially, and most spending is related to outpatient dialysis and inpatient services.
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.
