Insights & Analysis
There’s one constant in healthcare: change. Count on us to break down the trends so you can stay up to date. Follow our take on each piece of this deep, intertwined, and often perplexing industry to find opportunities and practical approaches to move healthcare forward.
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Avalere Survey: Over Half of Health Plans Use Outcomes-Based Contracts
In September 2021, Avalere conducted an online survey of 51 US-based health plans and pharmacy benefit managers (PBMs), representing roughly 59 million covered lives. The survey indicates that 56% of payers have executed an outcomes-based contract (OBC) as of September 2021.
Air Pollution Connected to Adverse and Inequitable Health Outcomes
Worse air quality leads to preventable negative health outcomes that increase healthcare costs. Further, urban and minority populations are often exposed to disproportionate pollution risks, leading to impaired health and increased financial burden on both individuals and broader health and social systems.
Survey Shows Potential, Challenges, and Solutions for Broad PDT Access
A recent Pear Therapeutics–Avalere survey of 30 payers and 10 employer self-insured groups identified numerous insights to direct future efforts for broader adoption and coverage of prescription digital therapeutics (PDTs).
The Impact of ARPA Exchange Subsidies on Consumers Ages 50–64
Consumers ages 50–64 could see higher exchange premiums starting in 2023 without extension of ARPA subsidies.
Prescription Digital Therapeutics Bring New Treatments to Healthcare
Prescription Digital Therapeutics (PDTs) are a growing and unique treatment modality that can provide expanded options for treatment to patients. As the landscape for these treatments develop across multiple therapeutic areas, challenges related to coverage, reimbursement, and access will need to be solved to advance broader adoption and utilization across key stakeholders.
Understanding the Seasonality of Part D Expenditures Under the OCM
In the OCM, a total cost-of-care model, episode-level Part D expenditures include the amount the government pays for low income cost-sharing subsidy and reinsurance for beneficiaries who reach the catastrophic portion of the benefit once they have accumulated sufficient OOP costs. The latter leads to a seasonality effect in how Part D payments are captured in OCM episodes, which may have implications for how trends in OCM performance are assessed over time and how the OCM benchmark price is constructed.
Part D Redesign Would Reduce OOP Costs Across Non-LIS Beneficiaries
New Avalere analysis finds Part D redesign via PDPRA would reduce average OOP costs by 23% for non-LIS beneficiaries, especially for certain drug classes and beneficiary groups by race and reason for entitlement.
Avalere Research Highlights Alternative Settings for Vaccination
The CDC recommends HBV vaccinations for persons with a history of current or recent injection drug use, but uptake remains low. Avalere research shows an opportunity to leverage alternative care settings to address the growing rates of HBV infection.
Most Significant Healthcare Legislation Since ACA Possible this Fall
As Congress considers the bipartisan infrastructure package and budget reconciliation agenda, the coming months are likely to include debate on what could be the most significant federal healthcare legislation in over a decade. Additionally, the Biden administration is expected to release several important healthcare rules this fall, including the details necessary to implement the new law banning surprise billing and regulations to protect and strengthen Medicaid and the Affordable Care Act (ACA).
Impact of Removing Part D Vaccine Cost-Sharing on the Federal Budget
The COVID-19 pandemic has brought renewed attention and urgency to mitigating access barriers to recommended vaccines.
CMS Updates CAR-T Reimbursement for 2022 in IPPS Final Rule
Finalized policy for Medicare’s CAR-T inpatient reimbursement builds on policies solidified in last year’s rulemaking. Looking ahead, stakeholders will continue to weigh the appropriateness of payment.
Disparities in Medicare Mortality Rates Occurred During the Pandemic
Avalere analysis shows that the COVID-19 pandemic had disproportionate impacts by race and ethnicity on Medicare enrollees.
Avalere Analysis of Disparities in Kidney Care Service Utilization
In light of proposed changes to the ESRD Treatment Choices Model to address health disparities, an Avalere analysis of Medicare claims found gaps in access to and utilization of specific dialysis-related services by patient race, ethnicity, and socioeconomic status.
Vaccination Rates Among Medicaid Adolescents Declined During Pandemic
A new claims-based analysis from Avalere examined vaccine uptake among low-income adolescents enrolled in Medicaid Managed Care and found a 26% decline in routine vaccinations when comparing March–October 2019 to the same period in 2020.
CMS Proposes Changes to Radiation Oncology Model Timing and Design
On July 19, the Centers for Medicare & Medicaid Services (CMS) released the CY 2022 OPPS/ASC Proposed Rule, which includes a number of proposals to modify the timing and design of the Center for Medicare & Medicaid Innovation’s forthcoming Radiation Oncology (RO) Model. The design proposals include changes to the set of included modalities and cancer types, reduction of the CMS discount factors applied to the prospective payments, and adoption of an extreme and uncontrollable circumstances policy. Looking ahead, stakeholders should continue to assess the model payment methodology and design in the context of evolving care delivery and practice patterns.
Earlier Cancer Detection Improves Quality of Life and Patient Outcomes
Cancer has been the second-leading cause of death in the US for over a decade. Patient survival and quality of life depend to a large degree on stage at diagnosis, making early detection critical. However, most cancers have limited or no early screening technology available, reducing the opportunity to detect them early and leading to worse survival rates.
Malnutrition MIPS Improvement Activity Included in QPP Proposed Rule
In the recently released Centers for Medicare & Medicaid Services (CMS) proposed rule for the CY 2022 Medicare Physician Fee Schedule, CMS proposed to include an Avalere-submitted malnutrition-focused improvement activity (IA) in the Merit-based Incentive Payment System (MIPS).
Considerations for a Shift from Pandemic to Endemic COVID-19 Landscape
Stakeholders in the COVID-19 pandemic response face regulatory and commercial uncertainties as emergency operations transition and market access of products face both emergency use and full licensure.
Some Part D Beneficiaries May Pay Full Price for Certain Generic Drugs
Avalere analysis finds that when generics in Part D are placed on the preferred brand tier some patients pay the full cost for their drugs.
Avalere Health Hires HEAA Researchers Joseph Tkacz and Jason Swindle
Duo joins as principals, bringing years of expertise in health economics and outcomes research.