Federal & State 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 and state policies that affect insurance coverage, access, and consumer choice so you can see around the bend.
New Avalere report identifies opportunities to refine the risk-adjustment model that could improve the way Affordable Care Act plans are paid
Almost every state has introduced Right-to-Try bills to try to offer patients another avenue to access investigational drugs outside of the Food and Drug Administration's (FDA) expanded access program. However, it is unclear whether these laws will impact patient access given their questionable legal standing, reduced patient protections due to lack of FDA oversight, and the risks to manufacturers of providing products under Right-to-Try laws.
Percentage of Medicare Advantage enrollees in plans with at least four stars continues to grow.
Percentage of drugs in Part D plans that require coinsurance increased significantly since 2014. Medicare Advantage plans require coinsurance far less often than Part D plans.
The Centers for Medicare & Medicaid Services (CMS) will release the Advance Notice and Call Letter describing CMS' proposed 2017 payment policies for Medicare Advantage (MA) plan sponsors on February 19. Based on previously released information in the fall of 2015, CMS is likely to propose modifications to the risk adjustment model and the current MA Star Ratings methodology.
The CalPERS Basic Plan Drug List, which is the formulary for all California public employees, includes 222 brand drugs and 287 generic drugs. In contrast, drug coverage in the Veterans Administration (VA) and Medi-Cal (California's Medicaid program) is far more limited than the CalPERS drug list.
President Obama released his budget for the 2017 fiscal year today. Avalere offers the following observations on the healthcare proposals:
Today, the Department of Health and Human Services (HHS) announced that 9.6 million individuals selected a health insurance plan on HealthCare.gov during the recent open enrollment season. Avalere estimates that 2016 year-end enrollment will slightly exceed the Obama administration's goal of enrolling 10 million people.
In an article published in The American Journal of Managed Care, Avalere's Caroline Pearson and Deirdre Parsons examine provider networks and benefit design for oncology care in health insurance exchanges.
According to a new analysis by Avalere, a prescription requirement for pseudoephedrine-containing products also fuels the growing shortage of primary care physicians, thereby increasing the cost, time, and difficultly of obtaining the treatment for legitimate users.
A new analysis from Avalere Health finds that hospitals and health systems are increasingly taking risk for the cost of Medicare patients and the quality of the care they receive.
A new analysis by Avalere finds that the Centers for Medicare and Medicaid Services (CMS) underpay Medicare Advantage (MA) plans for the costs of treating individuals with multiple chronic conditions.
As the government considers rules for 2017 insurance plans offered through exchanges, a new analysis by Avalere finds that proposed 2017 benefit designs could increase coverage of certain services and drugs, while lowering out-of-pocket costs for many consumers.
FDA oversees access to investigational treatments by eligible patients (compassionate use) through its expanded access program. But how do you decide whether to give these patients the unapproved treatments they seek?
Recently, stakeholders have raised concerns around whether the current star rating methodology appropriately adjusts for the socioeconomic impacts on quality ratings.
The U.S. Food and Drug Administration's (FDA) Advisory Committee (AdComm) process remains a source of significant uncertainty for medical product manufacturers, despite FDA's guidelines in the Code of Federal Regulations (C.F.R.)1 and in guidance.2 While the AdComm process is generally the same across Centers,3 each AdComm is unique and subject to the expertise and opinions of individual panel members, opinions voiced during the public comment period, and challenges exclusive to each new product or indication.
When life sciences companies consider whether to allow compassionate use—access to unapproved investigational treatments outside of clinical trials—there are no easy answers. Brenda Huneycutt gleans insight from Arthur Caplan, PhD, and Alison Bateman-House, PhD, from the New York University Langone Medical Center Division of Medical Ethics on some of the many questions that life sciences companies should ask themselves before implementing a compassionate use policy.
The FDA has shown growing interest in regulating laboratory developed tests (LDTs) to ensure their safety and effectiveness.
The story of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) actually begins in the previous millennium. In 1997, when the Congress passed the Balanced Budget Act, it ushered in the era of the Sustainable Growth Rate (SGR) formula. In theory, the SGR payment adjustment would raise or lower physician reimbursement each year based on spending relative to the target SGR. The caveat, however, was that Congress had the authority to suspend or adjust this benchmark, a "patch" that they regularly deployed through a "doc fix" for nearly two decades.
Believing that states are productive incubators of innovation, the Center for Medicare & Medicaid Innovation (CMMI) launched a State Innovation Model (SIM) grant program in 2013 to encourage state-by-state testing of innovative payment and delivery models.