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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Proposed Changes to Part D Would Increase Beneficiary Costs
Avalere Experts Estimate MedPAC Proposal to Change Calculation of Part D Enrollees' True Out-of-Pocket Spending Would Increase Beneficiary Costs by $4.1 Billion Between 2017-2020
Changing the Way Insurers are Paid Could Increase Stability in the Exchange Market and Beyond
New Avalere report identifies opportunities to refine the risk-adjustment model that could improve the way Affordable Care Act plans are paid
Right-to-Try Bills Grow in Popularity yet Success Is Unclear
Almost every state has introduced Right-to-Try bills to try to offer patients another avenue to access investigational drugs outside of the Food and Drug Administration's (FDA) expanded access program. However, it is unclear whether these laws will impact patient access given their questionable legal standing, reduced patient protections due to lack of FDA oversight, and the risks to manufacturers of providing products under Right-to-Try laws.
More than 70 Percent of Medicare Advantage Enrollees in Plans with Four or More Stars
Percentage of Medicare Advantage enrollees in plans with at least four stars continues to grow.
New Avalere Analysis Finds Profit Margins for Freestanding Skilled Nursing Facilities in Pennsylvania Decreased Almost 30 Percent between 2007 and 2014
According to a new analysis by Avalere, total profit margins for freestanding skilled nursing facilities (SNFs) in Pennsylvania decreased 28 percent between fiscal years (FY) 2007 and 2014, from 3.2 percent to 2.3 percent.
New Analysis Finds Individuals with Major Depressive Disorder Face Multiple Barriers to Optimal Care
Avalere and Mental Health America (MHA) developed a white paper to describe the current state of quality of care for individuals with major depressive disorder (MDD), provide an evidence-based assessment of challenges, and highlight potential opportunities for quality improvement.
Industry Funding Spurs FDA’s Review Activities for Prescription and Generic Drugs
User fees are increasingly central to the funding of the drug and device review programs, and in some cases these fees account for a larger proportion of the Food and Drug Administration's (FDA) budget than congressionally-appropriated monies. For example, user fees account for 68 percent of the FDA's review budget for prescription drugs, while 58 percent of the review budget for generic drugs comes from user fees.
New Analysis Finds Medicare Payments Higher for Episodes Initiated in Hospital Outpatient Departments
A new analysis by Avalere examines differences in Medicare spending for episodes of care before and after cardiovascular imaging, colonoscopy, and evaluation and management services. Avalere applied a risk adjustment methodology to account for differences in patient demographics and patient severity across settings. The findings suggest when care is initiated in the typically higher-paying HOPD setting than in physicians' offices and ambulatory surgical centers, the services that follow also result in higher spending relative to when care is initiated in the office setting.
Veterans Administration and California Medicaid Drug Lists Cover Less than 60 Percent of Drugs Available to California Public Employees
The CalPERS Basic Plan Drug List, which is the formulary for all California public employees, includes 222 brand drugs and 287 generic drugs. In contrast, drug coverage in the Veterans Administration (VA) and Medi-Cal (California's Medicaid program) is far more limited than the CalPERS drug list.
Key Steps to Improve Patient-Clinician Cost-of-Care Conversations
With growing out-of-pocket spending for care, patients are increasingly interested in knowing, upfront, how much their care will cost them, and how it relates to the quality and appropriateness of their care. Yet, various barriers often prevent these conversations from occurring during routine clinical encounters.
Participation in Risk-Bearing Accountable Care Organizations Triples; CMS Proposes Rule on Medicare Shared Savings Program Benchmark Methodology
The Centers for Medicare & Medicaid Services (CMS) announced that 121 new Medicare Accountable Care Organizations (ACOs) have joined the Medicare Shared Savings Program (MSSP) and Next Generation (Next Gen) ACO models. In addition, 147 MSSP ACOs renewed their contracts. The increase in risk-bearing ACOs and the recently released proposed benchmark rule mark CMS' commitment to shifting from volume to value.
Spotlight On: Clinical Trials in the Development of Biosimilars
In Biosimilars, Avalere's Gillian Woollett shares commentary on future considerations for the role of clinical trials in the development of biosimilars.
New Analysis Finds Proposed Telehealth Policy Changes Would Decrease Federal Spending by $1.8 Billion
A new analysis by Avalere Health estimates that three proposed policy changes to expand Medicare reimbursement of telehealth and remote patient monitoring (RPM) would collectively decrease federal spending by $1.8 billion between FY2017 and FY2026.
Spotlight On: Patient Access to Oncology Care in Exchange Plans
In an article published in The American Journal of Managed Care, Avalere's Caroline Pearson and Deirdre Parsons examine provider networks and benefit design for oncology care in health insurance exchanges.
Prescription-Only Pseudoephedrine-Containing Products Contribute to Growing Primary Care Physician Shortage
According to a new analysis by Avalere, a prescription requirement for pseudoephedrine-containing products also fuels the growing shortage of primary care physicians, thereby increasing the cost, time, and difficultly of obtaining the treatment for legitimate users.
2016 Industry Outlook
Get a sense of what to anticipate in the 2016 healthcare landscape in our annual 2016 Industry Outlook: Reducing Cost and Demonstrating Value.
Proposed Exchange Standardized Benefit Designs Expand First-Dollar Coverage for Services and Drugs
As the government considers rules for 2017 insurance plans offered through exchanges, a new analysis by Avalere finds that proposed 2017 benefit designs could increase coverage of certain services and drugs, while lowering out-of-pocket costs for many consumers.
Some Providers Leave Government’s Bundled Payment Program; Those Remaining Expand Participation
A new Avalere analysis finds that participation in the Centers for Medicare & Medicaid Services' (CMS) voluntary Bundled Payment for Care Improvement (BPCI) program remains strong even after the introduction of downside risk.
Proposed Changes in Medicare Advantage Could Cause Large Shifts in Payments
A new analysis by Avalere Health finds that proposed modifications to Medicare Advantage (MA) by the Centers for Medicare and Medicaid Services (CMS) could result in large changes in payments in certain geographic areas.
Spotlight On: Person-Centered Care
As part of an interprofessional panel of eldercare experts, Avalere's Miryam Frieder contributes to commentary published in the Journal of the American Geriatrics Society that better defines "person-centered care" and its key elements.