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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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.
Advancements in Cell Therapies Require New Patient Support Solutions
Manufacturers seeking Food & Drug Administration (FDA) approval for cell therapies will need to assess the financial and logistical burden on patients and develop novel solutions to help alleviate these challenges.
The Need for a Centralized Immunization Information System
Immunization Information Systems (IIS), or immunization registries, are used across the US to provide consolidated and complete accounts of patient immunization history in a given city, state, or region.
PACHA Highlights Need to Address HIV PrEP Coverage Disparities
On March 8–9, the Presidential Advisory Council on HIV/AIDS (PACHA) discussed avenues to achieving equitable access to HIV prevention products for at-risk populations as well as next steps in revising the National Strategic Plan to End the HIV Epidemic.
2021 State Drug Pricing Legislation: The Evolution Beyond Transparency
The majority of state legislatures are currently in session, and many states are taking steps to address prescription drug spending and prices through a range of legislative proposals. While states have historically focused on price transparency, state policymakers are now moving beyond those measures to more directly control prescription drug prices through reference pricing, affordability review boards setting upper payment limits, and other price control mechanisms.
Majority of Part D Spending Is on Brand Drugs in Classes with Generics
With Congress likely to consider a second reconciliation bill in the near future that may include various drug-pricing and Medicare Part D reform policies as spending offsets, an updated Avalere analysis examines spending across classes with various availability of brand and generic drugs.
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.
OCM, OCF, and the Future of Cancer Care: 5 Things to Look Out For
As the Oncology Care Model (OCM) approaches its conclusion, stakeholders are anxiously awaiting the details of the Center for Medicare & Medicaid Innovation's (CMMI’s) next oncology episodic payment model, Oncology Care First (OCF).
Three Considerations for 2021 Drug Pricing Reform Outlook
A second reconciliation package could include significant drug pricing reforms as a means to pay for permanent coverage expansion and other top priorities.
Assessing the Reach of Oncology Clinical Pathways
Avalere analysis finds that approximately 1 in 5 Medicare beneficiaries with advanced urothelial carcinoma (UC) or renal cell carcinoma (RCC) see a physician that has access to McKesson Value Pathways or Elsevier ClinicalPath vendor clinical pathways programs
Differences in Spending and Demographic Profiles in Medicare KCC Model
The Kidney Care Choices (KCC) model, a new alternative payment model launched by the Center for Medicare and Medicaid Innovation (CMMI), is scheduled to begin on January 1, 2022. This model will provide population-based payments for beneficiaries with both advanced-stage chronic kidney disease (CKD) and end-stage renal disease (ESRD) to improve patient health outcomes and lower Medicare fee-for-service (FFS) spending.
RWE Strategy Leads to Support for Avalere-Developed Composite Measure
Avalere was pleased to partner with the nutrition community to develop and test the Global Malnutrition Composite Score, which has now received conditional support from the Measure Applications Partnership (MAP)—pending endorsement by the National Quality Forum (NQF)—for inclusion in the Hospital Inpatient Quality Reporting (IQR) Program.
Measuring Scope of COVID-19 Relief Coverage Expansion Provisions
Avalere analysis finds that Congress's healthcare reforms under the COVID-19 relief bill could expand exchange coverage subsidies for up to 18.3 million individuals.
Generic Drug Placement on Part D Generic Tiers Declines Again in 2021
A new analysis from Avalere finds that in 2021, Medicare Part D plans place generic prescription drugs on generic tiers 45% of the time, a decrease from 64% in 2016.
Incorporating Clinical Factors Could Improve OCM Cost Prediction
An Avalere analysis found that among high-risk breast cancer episodes, those in later stages of the disease had higher episode expenditures relative to their benchmarks compared to those in earlier stages.
Copay Accumulator and Maximizers: Evolving Policy Landscape
Implementation of copay accumulator and maximizer programs continues to increase; recent policy provisions finalized through federal rulemaking and state-level legislation have created new uncertainty for the future of these programs and the stakeholders they affect.
Strengthening Our Public Health Infrastructure: COVID-19 Lessons
Amid the continuing pandemic and calls for healthcare reform, the new administration seeks to confront the myriad public health issues facing our country today.
Kidney Care Policy, Market Shifts in Light of New and Old Challenges
The COVID-19 public health emergency, new policy changes, and existing unmet patient needs will pressure the evolving payer, provider, and reimbursement landscape for kidney care in 2021.
Lengthening Episode Duration Would Not Improve OCM Performance
An Avalere analysis found that lengthening episode duration from 6 months to a year would not have a large impact on the relationship between episode expenditures and benchmark costs, meaning that performance on longer episodes would not improve relative to shorter episodes.
mAb Utilization for COVID-19 Remains Low, Despite Availability
Since the beginning of the Public Health Emergency (PHE), manufacturers have been developing monoclonal antibodies (mAbs) and other treatment modalities to prevent and treat COVID-19.