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.
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.
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.
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.
Surprise and balance billing reform efforts have been a subject of ongoing debate at the federal level.
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.
He brings healthcare tech, data, advocacy, and strategy experience to the firm.
Avalere assessed the impacts of select policies to expand low-income subsidy (LIS) eligibility under Medicare Part D
New analysis of trade data finds that 54% of API, in dollars, used in domestically consumed medicines came from the US in 2019.
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.
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.
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.
An analysis of CMS’s Hierarchical Condition Category (HCC) model shows that fully dual-eligible beneficiaries have the highest risk scores.
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.
With the release of the 2021 Medicare Advantage (MA) and Part D Final Rule, the details of the upcoming policy change that allows beneficiaries with end-stage renal disease (ESRD) to enroll in MA are set. Stakeholders need to adapt quickly to be prepared.
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.
New Avalere analysis finds that Medicare Part D patients taking brand prostate cancer drugs enrolled in Employer Group Waiver Plans (EGWPs) have more prescriptions in the coverage gap than patients in non-employer plans.
Health plans, including Medicare prescription drug plans, commonly apply utilization management (UM) tools to manage spending on prescription drugs.
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.
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.
1115 Waivers approved by CMS allow state Medicaid programs to better address substance use disorders among beneficiaries.