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.
CMS is considering changes to its commercial market Risk Adjustment Data Validation (RADV) program to improve the accuracy of risk adjustment transfers and to increase stability and predictability for issuers. This follows issuer experiences with the 2017 RADV process in which some issuers saw substantial, unforeseen changes to their risk adjustment transfers. These RADV changes have the potential to impact issuer participation and premiums in future years depending on the direction (positive or negative) and magnitude of those transfers.
The replacement to North American Free Trade Agreement (NAFTA), the United States-Mexico-Canada Agreement, was originally proposed to increase biologics exclusivity in Mexico and Canada to 10 years. As part of the Administration’s compromise with the House of Representatives, these provisions have been removed from the amended version that was recently agreed to by the US, Mexico, and Canada. While exclusivity in the US remains unchanged at 12 years, that it is not increased for Canada and Mexico may impact market entry for biologics ex-US.
Scenario analysis of varying levels of negotiation under H.R.3 (as released on September 19) finds that the bill could reduce federal spending by $790B to $1,055B and decrease manufacturer revenues by $1,125B to $1,520B for CY 2020–2029.
In a recent post on the RISE website, Sean Creighton examines the methodology and evidence behind CMS’s proposal to eliminate the Fee-for-Service (FFS) Adjuster from Risk Adjustment Data Validation (RADV) audit methodology.
Restrictive network plans comprise over 75% of the exchange market.
Avalere analysis finds that payment to Medicare Advantage (MA) plans for end-stage renal disease (ESRD) patients in highly populated regions may be significantly below actual patient costs.
Medicare Advantage (MA) plans continue expanding coverage of supplemental benefits following administration’s policy changes from a year ago.
New Avalere analysis finds that practices currently participating in the Oncology Care Model (OCM) would be more likely to receive a Novel Therapy Adjustment (NTA) in the newly proposed Oncology Care First (OCF) Model.
Are you interested in a career in healthcare consulting? Are you passionate about solving the challenges of the healthcare system? Avalere Health, a leading healthcare consulting firm, held an informational webinar on November 18 to provide information about the company and our Associate Immersion Program.
Avalere analysis finds that, despite substantial list price decreases across the PCSK9 inhibitor class, out-of-pocket costs for the majority of 2020 Part D beneficiaries remain significant
A shifting policy landscape and emerging market forces could introduce significant disruption in the kidney care space in the coming years. Understanding the risks and opportunities that these changes may present will be critical for patients, providers, payers, and manufacturers alike.
New analysis from Avalere finds that over 96% of counties with exchanges operated by HealthCare.gov have free plan options for low-income consumers.
Join Avalere experts on our webinar on October 29, 2019, to unpack CMS’ 2020 Star Ratings and look at what’s to come for 2021.
As Medicare Advantage enrollment grows and benefits continue to evolve, beneficiaries must keep pace with these changes and investigate plan options amidst current healthcare debates.
With the 2020 presidential election nearly 1 year away, healthcare reform remains one of the top issues for voters heading into the election year.
As policymakers consider reforms to the Part D benefit to address rising out-of-pocket (OOP) costs by adding a maximum OOP cap, an Avalere analysis examines the types of beneficiaries mostly likely to be helped by such a policy.
The USMCA’s intellectual property provisions add additional layers of ambiguity to the already complex issues surrounding biological product exclusivity and its future in US law.
Avalere analysis finds that tying Medicare Part D manufacturer discounts to utilization in the catastrophic phase instead of in the coverage gap would have differential impacts by disease area.
Healthcare industry veteran brings decades of Medicare Advantage, Part D, risk adjustment, and business expertise to payer, life sciences, and provider clients.
CMMI’s impact on Medicare spending has so far not reached earlier projections by the Congressional Budget Office, demonstrating the difficulty in projecting savings from new and unknown alternative payment models.