Federal and State Policy
As the largest US healthcare payer, the federal government plays a dominant role in shaping the healthcare marketplace, while states take center stage when it comes to developing novel policy approaches. Our experts track, interpret, and model policies that affect insurance coverage, access, and consumer choice so you can see around the bend.
Proposed Medicaid Line Extension Definition Alters Rebate Calculation
The CMS proposes to define line extension under the MDRP to broadly include any product that has at least one ingredient in common with the original drug, even if it is a different dosage form. If finalized, this change would have significant implications on classification and rebate liability for a wide set of current and future products.
Comparison of Dually and Non-Dually Eligible Patients with ESRD
Dually eligible beneficiaries in Pennsylvania with end-stage renal disease (ESRD) are more often people of color and have higher costs compared to non-duals, but their utilization patterns are similar.
Exchanges May Add More than 1 Million New Enrollees due to COVID-19
Affordable Care Act (ACA) exchanges have seen a significant uptick in enrollment, especially from those losing employer-sponsored coverage or who were previously uninsured. However, different approaches to special enrollment periods (SEPs) leave many with limited opportunities to enroll.
Melissa Morley Joins Avalere Health
She deepens the firm’s post-acute and policy analytics capabilities, bringing nearly 15 years' worth of policy analytics experience to Avalere with a specific focus on the provider sector.
COVID-19 Impacts State Policy Priorities
After adjourning or suspending sessions due to the COVID-19 pandemic, state legislatures are reconvening with new priorities, as pandemic-related policy decisions take precedence.
Medicare FFS Risk Scores Vary Based on Eligibility and Entitlement
An analysis of CMS’s Hierarchical Condition Category (HCC) model shows that fully dual-eligible beneficiaries have the highest risk scores.
Medicaid VBP Rule May Facilitate Drug Contracts, But Questions Remain
CMS proposes to alleviate drug price reporting barriers that have hindered the adoption of innovative contracting models for prescription drugs. Stakeholders should contemplate the details and implications of CMS’ proposals—including how the changes would impact current contracting—as well as remaining areas of ambiguity.
Interview: E10, Part 2 – Get the Facts on COVID-19: Healthcare Provider Exemptions and Waivers
Tune into part 2 of our tenth episode of Avalere Health Essential Voice podcast series. In this segment, Avalere experts from the Center for Healthcare Transformation will discuss the impacts of COVID-19 on healthcare provider performance specific to exemptions and waivers.
How COVID-19 Could Reduce MA Risk Scores and Payments in 2021
Deferral of care during the COVID-19 pandemic is resulting in fewer claims and diagnoses among Medicare Advantage (MA) enrollees, which could lead to a 3%–7% reduction in 2021 risk scores and lower plan payments in 2021.
Impact of H.R.3 as Passed by the House on Federal Spending and Drug Manufacturer Revenues
Scenario analysis of varying levels of negotiation under H.R.3 (as passed in the House on December 12, 2019) finds that the bill could reduce federal spending by $850B to $1,060B and decrease manufacturer revenues by $1,275B to $1,655B for CY 2020–2029.
Impact of Protected Class Utilization Management in Medicare Part D
Health plans, including Medicare prescription drug plans, commonly apply utilization management (UM) tools to manage spending on prescription drugs.
Utilization and Spending by Medicare Beneficiaries in Employer Part D
An Avalere analysis finds that, on average, non-LIS Medicare beneficiaries in Employer Group Waiver Plans (EGWPs) have higher utilization but lower out-of-pocket (OOP) costs than non-EGWP enrollees.
Cannabidiol: A Regulatory Snapshot
The US market has seen a recent surge in cannabidiol (CBD) use and sales, despite many of these marketed CBD products being unregulated and untested for most of the claimed indications.
Behavioral Health in Medicaid May Be Unable to Meet Increased Demand
As COVID-19 forces the healthcare system to reprioritize patients and resources, providers delivering behavioral health services may be left with insufficient means to serve the population. Medicaid programs may observe increased demand for behavioral health services but may be ill-equipped to support beneficiaries.
State Medicaid Waivers for SUDs Present Opportunities for Stakeholder Engagement
1115 Waivers approved by CMS allow state Medicaid programs to better address substance use disorders among beneficiaries.
Evolving COVID-19 Impacts on Health Insurance Enrollment
On May 13, Avalere experts discussed key issues and considerations for the healthcare industry as millions of Americans shift in and out of new sources of coverage due to COVID-19.
Manufacturers Must Navigate Evolving State Approaches to Medicaid Drug Benefit Management
As control of the Medicaid drug benefit continues to shift from managed care organizations to states, manufacturers should understand unique benefit dynamics in each state, particularly as Medicaid enrollment is likely to increase amid the COVID-19 pandemic.
Provider Impact of COVID-19 Recession and Coverage Trends
A potential recession due to job losses and business closings as a result of COVID-19 will cause shifts in the payer mix and, ultimately, revenue dynamics for physician practices.
COVID-19 Relief Funding for Healthcare Providers
Avalere analysis of the distribution of provider relief funds indicates geographical concentration related to the number of reported COVID-19 cases.
10 Drivers Complicate the Medicaid Outlook Amid the COVID-19 Pandemic
State Medicaid programs face a series of near- and long-term challenges amid the COVID-19 pandemic due to enrollment growth and financial pressures. Stakeholders should evaluate key drivers shaping the state-by-state Medicaid outlook.