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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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.
New Study Analyzes FDA Advisory Committees’ Trends in First Three Years of Current User Fee Era
The US Food and Drug Administration's (FDA) Advisory Committee (AdComm) process remains a source of significant uncertainty for medical product manufacturers, despite FDA's guidelines in the Code of Federal Regulations (CFR)1 and in guidance.2 While the AdComm process is generally the same across Centers,3 each AdComm is unique and subject to the expertise and opinions of individual panel members, opinions voiced during the public comment period, and challenges exclusive to each new product or indication.
Health Insurance Premium Increases Largely Mirror Spending
A new analysis by Avalere finds that causes of health insurance premium increases in 2016 generally mirror the distribution of healthcare spending in the individual and small group market. Specifically, inpatient and outpatient hospital services are modestly driving premium increases, while physician and other professionals make up less than their expected portion of premium growth. Prescription drugs' contribution to 2016 premium increases is roughly in line with their costs in 2014. Overall, premiums for 2016 will rise an average of $25.26 per month, with $5.44 of that increase caused by outpatient hospital services.
New Analysis Finds Cost-Effectiveness Models for Hepatitis C Drugs Often Overlook Market-Based Prices
In recent years, several new U.S. Food and Drug Administration-approved, direct-acting antiviral medications to treat the chronic hepatitis C virus (HCV) have entered the market. Because of the potential impact on health plan and pharmacy budgets, researchers have conducted economic analyses, including cost-effectiveness analyses, to understand the value of the new medications.
Patient Access to HIV Drugs in Exchange Plans Is Limited Compared to Other Sources of Coverage
New analysis from Avalere finds that only 16 percent of silver exchange plans in 2015 cover all top HIV drug regimens with cost sharing less than $100 per month per regimen. While almost half of plans include all 10 of the most commonly used HIV regimens on their formularies, many plans charge higher out-of-pocket costs for these drugs.
New Analysis Identifies Factors That Can Facilitate Broader Reimbursement of Pharmacist Services
Pharmacists are increasingly providing direct patient care based on each state's scope of practice regulations in a variety of settings spanning inpatient, outpatient, and community pharmacies. Examples of these direct patient care services include immunizations, wellness and prevention screening, medication management, chronic condition management, and patient education and counseling. While opportunities for pharmacists to provide direct patient care services emerge, options for obtaining reimbursement for these services continue to be limited. Avalere Health assessed the current healthcare delivery and payment landscape to identify factors that can facilitate broader reimbursement of pharmacist services.
Fewer PPOs Offered on Exchanges in 2016
A new Avalere analysis finds fewer insurers are offering preferred provider organization (PPO) networks on exchanges in 2016. Specifically, from 2014 to 2016, the percentage of plans offering PPO networks dropped from 39 percent to 27 percent. This represents a 31 percent decline over the three year period. Meanwhile, use of health maintenance organization (HMO) and exclusive provider organization (EPO) networks has increased. In general, PPOs include a wider network of providers and cover more out-of-network care than HMOs and EPOs.1
New Avalere Analysis Compares Varying Breast Cancer Screening Recommendations
In October, the American Cancer Society (ACS) released its recommendations for breast cancer screening. The guidelines, which apply to women with average breast cancer risk, recommend annual screening from age 45 to 54, with biennial screening recommended for women over age 55. This represents a notable departure from its 2003 guideline, which advocated annual mammography for women at age 40 and older. The dramatic change in screening recommendation is in line with the growing evidence of benefits and harms of breast cancer screening. However, varying guidelines from organizations, such as the U.S. Preventive Services Task Force (USPSTF) and National Comprehensive Cancer Network (NCCN) reveal that experts have not come to a complete agreement on this issue.
Listen In: Dan Mendelson Talks to Marketplace Morning Report About Valeant Cutting Ties with Philidor Rx Services
David Brancaccio of American Public Media's Marketplace Morning Report interviewed Dan Mendelson after Valeant Pharmaceuticals International ended its relationship with Philidor Rx Services.
Avalere Analysis: 2016 Exchange Premiums
New analysis from Avalere Health examines the 2016 Federal Exchange Premium File. According to HHS, more than 8 in 10 (86 percent) of current enrollees can find a lower premium plan in the same metal level by returning to the exchange and shopping for 2016. As a result, tables and figures below examine the lowest cost options in two metal levels:
Avalere Observations: What to Watch for in 2016 Exchange Open Enrollment
The third annual open enrollment period for exchanges will kick off on November 1. As patients and the healthcare industry prepare for the 2016 plan year, below are critical questions for the future of exchanges:
What’s on the Horizon for Physician Quality Measurement?
In recognition of National Healthcare Quality Week, we sat down with Avalere expert Nelly Ganesan to discuss upcoming trends and developments for physician quality measurement.
New Transparency Tools Are Aimed at Improving Patient Sensitivity to Healthcare Costs
There is increasing consensus that comprehensive transformation of the healthcare system cannot be achieved without the engagement of patients, their families, and healthcare consumers. One stream of thought is that arming consumers with actionable cost and quality data could activate them as partners in controlling healthcare costs, which are expected to grow from 17.4 percent of the U.S. economy in 2013 to 19.6 percent in 2024.1 Although evidence remains mixed, some studies have shown that when patients are given easily digestible cost- and quality-of-care data, they choose high-value options.2,3
Avalere’s Josh Seidman Answers Your Questions on the MACRA Request for Information
Recently, CMS released a Request for Information (RFI) inviting public comment on three provisions related to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)-the Merit-based Incentive Payment System (MIPS), Alternative Payment Models (APMs), and Physician-focused Payment Models (PFPMs). Comments are due to CMS by November 17, 2015. We sat down with Avalere's Josh Seidman to discuss what to expect from the RFI.