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.
4 Reasons to Watch PCORI’s Evolving Role in Healthcare Decision-Making
The Patient Centered Outcomes Research Institute (PCORI) recently announced an open comment period for a new set of proposed national priorities to inform its research agenda. Avalere analysis finds that from March 2019 to September 2020, PCORI directed roughly $259 million to comparative effectiveness research (CER) awards with an increasing share of new projects focused on drugs.
What to Watch for in Medicare Advantage Policy in the Coming Months
As the Centers for Medicare & Medicaid Services (CMS) consider what, if any, changes to propose to Medicare Advantage (MA) through fall rulemaking, stakeholders should consider where the Biden administration’s priorities may differ from the previous administration’s. Topics that may be addressed—either in regulation or via legislation—include health equity, supplemental benefit flexibility, star ratings, payment and risk adjustment, and end-stage renal disease (ESRD).
COVID-19 Pandemic’s Considerable Impact on Skilled Nursing Facilities
The roll-out of the Patient-Driven Payment Model (PDPM) in October 2019 followed quickly by the COVID-19 pandemic presents challenges to understanding the extent to which increases in payment to skilled nursing facilities (SNFs) are due to the changes in the payment system versus changes in the patient populations served during the COVID-19 pandemic. Given the confounding effects of the pandemic and the new payment system, it is important to collect more data before evaluating the transition to the PDPM.
Unprecedented Mid-Year Plan Changes Could Impact Patient Access
While access to insurance has increased for millions, mid-year plan switching can have unforeseen consequences for patients.
Avalere Analysis Examines Part D Program Spending Trends
As Congress renews focus on drug pricing reforms, an Avalere analysis examines recent trends in the Part D program’s subsidy payments and implications on stakeholder liabilities in the program.
Coverage of COVID-19 mAbs Presents Opportunities for Stakeholders
In November 2020, the Food and Drug Administration (FDA) granted Emergency Use Authorization (EUA) to COVID-19 monoclonal antibodies for treatment of mild-to-moderate COVID-19 infection.
US Government Continues Investing in Solutions to Combat AMR
As the COVID-19 pandemic draws to a close in the US, another public health concern is once again coming to the fore: antimicrobial resistance (AMR).
Medicare Expansion Could Have a Mixed Impact on Premiums
New Avalere analysis finds that lowering the Medicare eligibility age from 65 to 60 could expand access to Medicare coverage for an additional 24.5 million individuals, but Medicare premiums may be less affordable in some cases than subsidized exchange coverage.
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.
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.
Interview: 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.
Medicaid Networks More Than 60% Narrower Than Commercial in Some Areas
At a time when more Americans—particularly people of color—are enrolled in Medicaid, new Avalere analysis finds that provider networks for primary care and certain specialties in Medicaid are narrower on average than those of commercial plans in certain metropolitan areas, ranging from 63% smaller in Miami to 18% in New York.
Webinar: Understanding Shifting Insurance Coverage Impacts
Join Avalere’s panel of market access and policy experts to learn about the shifting insurance coverage landscape and how these trends impact manufacturers, payers, policymakers, and providers.
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.
New COVID-19 Treatment Add-On Increases Payment Relative to NTAP
Avalere analysis finds hospitals would receive higher additional payments from Medicare through the New COVID-19 Treatment Add-on Payment (NCTAP) compared to the New Technology Add-on Payment (NTAP).