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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CMS Proposes Allowing Part D Plans to Implement a New Preferred Specialty Tier
Implementation of a preferred specialty tier could have various impacts on Part D plans’ formulary and benefit designs and could affect manufacturer contracting strategies.
For the First Time, a Majority of Generic Drugs Are on Non-Generic Tiers in Part D
According to a new analysis from Avalere, Medicare Part D plans place generic prescription drugs on non-generic tiers 53% of the time in 2020.
Preventive Care Commentary Featured in Health Affairs Blog
On January 29, Richard Hughes published a piece on the Health Affairs blog discussing the presidential candidates’ opportunities to incorporate preventative services into their healthcare policy platforms.
2020 Election: Healthcare Coverage Landscape Varies in Early Primary States
As the early presidential primaries unfold, healthcare remains a top issue among voters. As recently as the November Democratic primary debate, polls showed that 24% of Democrats or Democratic-leaning independents said healthcare was the number one issue they wanted to hear discussed, ahead of the environment (12%), immigration (6%), jobs and the economy (5%), education (4%), and gun control (4%).
What to Watch for in this Week’s Call Letter and Proposed MA-PD Rule
CMS is set to release its annual proposed changes to Medicare Advantage (MA) this week. Some of the topics that may be addressed include End-Stage Renal Disease (ESRD), network adequacy requirements, payment to MA plans that offer the hospice benefit, and the MA quality bonus program.
CMS’s Healthy Adult Opportunity Program Includes Significant Changes to Medicaid Drug Benefit
The Centers for Medicare & Medicaid Services (CMS) announced the Healthy Adult Opportunity, a new Section 1115 demonstration initiative allowing states to shift toward capped Medicaid financing models with an opportunity for shared savings. If the option is chosen by states, it could be the largest change to Medicaid since the ACA.
Nutrition Support Therapy Could Potentially Save the Medicare Program $580 Million
Avalere’s findings were featured in the Journal of Parenteral and Enteral Nutrition.
Avalere Statement on CMS’s Healthy Adult Opportunity Program
CMS’s Healthy Adult Opportunity program, a new Section 1115 demonstration initiative, will allow state Medicaid programs to move toward capped financing models for some non-disabled adult beneficiaries with an opportunity for shared savings and additional flexibilities.
Addressing Social Determinants of Health Requires a Strategic Approach in an Evolving Healthcare Environment
Increasing pressure on providers to assume accountability for meeting the goals of the Triple Aim has inspired a new focus on the social determinants of health.
Avalere’s Nutrition Experts Featured in Latest Health Affairs Blog Post
On January 24, Avalere’s Christina Badaracco and Senior Advisor Wendy Everett published a piece in the Health Affairs blog highlighting the need to improve malnutrition care and provide possible pathways to a solution.
Variation in Generic Substitution Rates Among Part D Plans
New analysis from Avalere finds 52% of Part D plans achieve generic substitution1 rates above 75%.
Digital Health 2020: 4 Tactics for Successful Collaboration
Digital health remains a powerful focal point in the push towards value-based healthcare. Across multiple domains, emerging technologies provide promising strategies for delivering more effective, efficient, and personalized care.
MSSP Sees Continued Growth in Downside Risk ACOs
New analysis from Avalere finds that more accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) have assumed downside risk as the program matures, with the greatest growth over the past 3 years.
FDA’s Priorities and Approach for Homeopathic Drug Products
On October 24, the FDA released a draft guidance describing the intended risk-based approach for regulatory actions toward homeopathic drug products marketed in the United States without the required FDA approval. The FDA has not approved a single homeopathic product thus far. The agency is currently restructuring its enforcement and regulatory priorities in this space.
Skilled Nursing Facilities Adjust to the PDPM Era
Skilled nursing facilities (SNF) nationwide continue to adapt to the Patient-Driven Payment Model (PDPM), a transformational new approach to SNF Medicare reimbursement that took effect October 1, 2019.
Device Regulation Modernization Efforts Continue to Accelerate
The Food and Drug Administration’s (FDA) efforts to modernize medical device oversight in the agency’s Center for Devices and Radiological Health (CDRH) have continued with the release of multiple draft and final guidances in 2019, as well as a plan for additional releases in 2020.
CMMI’s Financial Impact on Medicare Spending Challenging to Project (Updated)
CMMI’s impact on Medicare spending has not reached earlier projections by the Congressional Budget Office (CBO), demonstrating the difficulty in projecting savings from untested and future unknown alternative payment models
Healthcare Organizations See Reduction in ED Visits and Inpatient Admissions when Focusing on Value
Avalere worked with a healthcare organization to assess the impact of their quality improvement program over a 4-year period. The organization prepared primary and specialty care providers/practices to transition from fee-for-service (FFS) to value-based payment arrangements. Avalere’s analysis found participation in the program led to a reduction in both emergency department (ED) visits as well as inpatient (IP) admissions over the period reviewed.
CMS RADV White Paper Outlines Potentially Significant Program Changes
CMS is considering changes to its commercial market Risk Adjustment Data Validation (RADV) program to improve the accuracy of risk adjustment transfers and to increase stability and predictability for issuers. This follows issuer experiences with the 2017 RADV process in which some issuers saw substantial, unforeseen changes to their risk adjustment transfers. These RADV changes have the potential to impact issuer participation and premiums in future years depending on the direction (positive or negative) and magnitude of those transfers.
Avalere Publishes Manuscript on Validating Preparation for Shared Decision-Making Tool for Advanced Breast Cancer Patients
Avalere’s “Preparation for Shared Decision-Making” (PFSDM) tool aims to help patients with advanced breast cancer (ABC) feel prepared to communicate with their clinicians and engage in decision making aligned with their preferences. The validation study confirms the acceptability and usability of the tool for women with ABC.