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.
Featured Content
Premium Content
Premium Content
Step Therapy Can Lead to Higher OOP Costs for Crohn’s Disease Patients
Avalere analysis finds that patients with Crohn’s disease who experience a negative outcome when required to step through a plan’s preferred product may face higher upfront out-of-pocket (OOP) costs and could increase costs to payers.
Election Outcome Will Play Pivotal Role in State Healthcare Priorities
The outcomes of the 2020 elections will hold implications for state policymaking on key healthcare issues that could impact patients’ health insurance coverage status and how they access care.
How Do Biden’s and Trump’s Public Health Platforms Compare?
The November 2020 election is widely anticipated to have important implications for how the US responds to COVID-19.
SCOTUS Ruling on ACA Could Impact Coverage and Policy Outlook
With the US Supreme Court set to hear arguments starting November 10 on California v. Texas, and Judge Amy Coney Barrett’s nomination under consideration in the Senate, questions remain regarding the future of the law.
Mandatory Kidney Care Model Introduces Financial Incentives and Risks
The ESRD Treatment Choice model demonstrates an increased focus on improving health outcomes for Medicare patients receiving dialysis by realigning incentives to favor the adoption of home dialysis and increasing the rate at which patients receive kidney transplants. This mandatory model could lead to significant disruption for stakeholders in the coming years. Understanding the risk and opportunities associated with this model will be critical for patients, providers, and manufacturers alike.
Expanding Patient Access to Digital Mental Health Services & Products
The COVID-19 pandemic is driving greater demand for digital mental health products and services. Stronger scientific evidence is necessary to determine value and increase payer reimbursement.
The COVID-19 Impact on US Routine and Seasonal Vaccine Administrations
Avalere conducted a national survey of more than 200 independent primary care providers concerning the impacts of the COVID-19 pandemic on their ability to support continued vaccination programs for patients. Over 90% of respondents indicated the COVID-19 pandemic has increased operating costs and led to revenue loss. Eighty-two percent indicated that an increase in vaccine administration fees would aid sites in overcoming barriers arising from the COVID-19 pandemic, and 75% expressed interest in implementing new care delivery arrangements to facilitate immunizations during the COVID-19 pandemic.
Avalere Analysis Shows Home Care Services Reduce Medicare Spending
Avalere analysis determined that Medicare Fee-for-Service (FFS) patients receiving home-based care services experienced a decrease in Medicare spending over time when compared to a statistically balanced, matched control group who do not appear to have received home care services. The spending differential was also found to be higher among Medicare beneficiaries with functional limitations and multiple chronic conditions.
ESRD Patient Spending Differences Between Puerto Rico and the 50 States
Avalere analysis finds End Stage Renal Disease (ESRD) spending in Puerto Rico varies substantially, and most spending is related to outpatient dialysis and inpatient services.
COVID-19 Provider Relief Funding and Future Allocation Considerations
The Coronavirus Aid, Relief, and Economic Security (CARES) Act appropriated $100 billion for the Public Health and Social Services Emergency Fund—known as the Provider Relief Fund (PRF)—and subsequent legislation appropriated an additional $75 billion through the Paycheck Protection Program and Health Care Enhancement Act.
Measuring the Effectiveness of Cost-of-Care Conversations
With support from the Robert Wood Johnson Foundation, Avalere assesses opportunities to normalize cost-of-care conversations through measurement.
Anticipated Impact of COVID-19 Treatments on State Medicaid Budgets
Compared to other drivers of state budget pressures during the COVID-19 pandemic—including higher Medicaid program enrollment due to increased unemployment and lower state tax revenues as a result of economic shutdowns—the relative financial impact of COVID-19 therapeutics on state Medicaid budgets will likely be minimal.
“Most Favored Nation” EO Creates New Questions on International Prices
On September 13, the Trump Administration released the much-anticipated “Most Favored Nation” (MFN) Executive Order (EO), calling for models that would cap the price Medicare pays for select Part B and D drugs. The President’s EO underscores the administration’s continued focus on reducing prescription drug price disparities between the US and other developed countries.
Using Diagnostics to Mitigate the COVID-19 Public Health Emergency
Mitigating the public health emergency (PHE) caused by SARS-CoV-2 requires a multifaceted approach.
Dan Mendelson Commentary on Health Equity Featured in Forbes
The COVID-19 pandemic and a summer of focus on racial justice has finally begun to intensify government interest in reducing racial disparities in healthcare. Understanding that healthcare providers and systems tend to respond to the economic incentives that are presented to them, current government decisions on payment options around renal dialysis present an important test case for the Trump Administration.
Avalere Statement on “Most Favored Nation” Executive Order
Yesterday, the Administration released the awaited “Most Favored Nation” Executive Order (EO), which calls for a model that would cap the price Medicare pays for select Part B and D drugs.
Fall Medicaid Outlook: Key Events to Watch
Medicaid will continue to experience considerable changes at the state and federal levels, both in terms of beneficiary demographics and the payer landscape. Stakeholders should consider how upcoming elections, policy proposals, and COVID-19 will impact benefits and payer dynamics.
CMS Finalizes New Reimbursement Method for CAR-T Treatments
Policy changes to Medicare’s CAR-T inpatient reimbursement set a precedent for high-cost durable treatments. Looking ahead, questions and concerns remain for pipeline cell and gene therapies that have high up-front costs.
Declining WIC Participation May Lead to Poorer Health Outcomes
With fewer eligible Americans participating in WIC, increased risk of food insecurity and decreased access to quality healthcare may place a greater burden on our healthcare system. The COVID-19 pandemic further exacerbates the challenges of vulnerable populations in access to food resources and routine and acute care.
CMMI Model Would Increase Gap Discounts for Non-Insulin Products
Avalere analysis finds that 51% of all drug spending for non-LIS beneficiaries using insulins and enrolled in enhanced plans in 2018 was for products not participating in the model.