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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Most Hospitals Selected for Medicare’s First Mandatory Bundled Payment Model Are Disadvantaged by Regional Pricing Averages
A new Avalere analysis of CMS' proposed Comprehensive Care for Joint Replacement (CCJR) bundled payment initiative finds that 65% of selected hospitals will be subject to target prices based on regional episode spending averages that are lower than hospital-specific spending averages.
New Medicare Advantage Market Entrants Diversify Consumer Choice
A new Avalere analysis finds that 28 organizations who entered the Medicare Advantage market between 2012 and 2015 currently offer plans to beneficiaries. Together, these new players offer 104 plan options, which are available to 13.6 million beneficiaries in 24 states.
Spotlight On: Mobile Health in Diabetes Care
In The American Journal of Managed Care, Avalere's Kathy Hughes shares commentary on the potential impact of mobile health on evidence-based practice in diabetes care.
Providers Rush to Assume Medicare Risk under Bundled Payment Program
Orthopedic, Pulmonary, and Cardiovascular Conditions Most Likely To Be Treated under CMS Bundled Payment Program
More than 2 Million Exchange Enrollees Forgo Cost-Sharing Assistance
A new Avalere analysis finds that more than 2 million exchange enrollees eligible for cost-sharing reductions (CSRs) are not receiving the subsidies because they have selected a non-qualifying plan. In addition to the more publicized tax credits that lower consumers' monthly premiums, exchange enrollees with incomes between 100 and 250 percent ($11,770 - $29,425) of the federal poverty level are eligible for CSRs. Exchange consumers must enroll in a plan on the silver metal level to access CSRs.
Spotlight On: Clinical Laboratory Diagnostic Tests
The American Journal of Managed Care featured perspectives from Avalere experts on reimbursement policies for clinical laboratory diagnostic tests.
MACRA and the Promise of Better Patient/Family Engagement in Post-SGR World
The story of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) actually begins in the previous millennium. In 1997, when the Congress passed the Balanced Budget Act, it ushered in the era of the Sustainable Growth Rate (SGR) formula. In theory, the SGR payment adjustment would raise or lower physician reimbursement each year based on spending relative to the target SGR. The caveat, however, was that Congress had the authority to suspend or adjust this benchmark, a "patch" that they regularly deployed through a "doc fix" for nearly two decades.
New Study Finds that Clinical Pathways Are Being Used to Improve Quality and Control Cost but Concerns Remain
A new white paper from Avalere finds wide variation in how organizations develop and use clinical pathways (CPs)-multidisciplinary plans that provide specific guidance on the sequencing of care steps and the timeline of interventions. While CPs have the potential to improve quality and reduce cost, their growing use prompts a range of questions and concerns from patient advocates and healthcare providers. Specifically, Avalere's new work examines the lifecycle of a CP and explores the potential implications of growing use of these tools for payers, providers, and patients.
Medicare Advantage: 2015 National Snapshot
This fact sheet examines the current state of choice and competition in the Medicare Advantage program.
CMS Releases Comprehensive Care for Joint Replacement (CCJR) Model
Recently, CMS took a significant step in its campaign to shift Medicare fee-for-service payments to alternative payment models by proposing the first mandatory bundled payment model-the Comprehensive Care for Joint Replacement (CCJR) model-which will pay hospitals in 75 markets a bundled payment for hip and knee replacements beginning in 2016. We sat down with Avalere's Brian Fuller to discuss the proposed rule.
Innovative Approaches to Accessing, Extracting, and Aggregating Electronic Health Records Data
Avalere's latest research, funded by The Pew Charitable Trusts, finds innovative approaches to accessing, extracting, and aggregating electronic health records (EHR) data associated with operating registries. Researchers interviewed various medical device registries and analyzed findings to identify common themes and innovative practices.
Exchange Plans Include 34 Percent Fewer Providers than the Average for Commercial Plans
New analysis from Avalere finds that the average provider networks for plans offered on the health insurance exchanges created by the Affordable Care Act (ACA) include 34 percent fewer providers than the average commercial plan offered outside the exchange. The new data quantifies anecdotal reports that exchange networks contain fewer providers than traditional commercial plans.
Where Are the States Going on Payment and Delivery Reform? Tracking SIM Grant Developments
Believing that states are productive incubators of innovation, the Center for Medicare & Medicaid Innovation (CMMI) launched a State Innovation Model (SIM) grant program in 2013 to encourage state-by-state testing of innovative payment and delivery models.
Focus on Innovation: FDA’s Rare Pediatric Disease Priority Review Voucher Program
On June 30, 2015, Gayatri R. Rao, MD, JD, of the FDA's Office of Orphan Products Development (OOPD) presented an overview on the Rare Pediatric Disease Priority Review Voucher Program. Dr. Rao discussed the background and purpose of the program, application and review process, sunset provision, and what's next for the program followed by a short question and answer session.
Dan Mendelson Talks to NPR About Aetna’s $37 Billion Deal to Buy Rival Humana
The health insurance company Aetna announced Friday it will buy rival Humana for $37 billion. The merger comes as other health insurers consider consolidating to cut costs. Read NPR's interview with our founder, Dan Mendelson.
Improving Obstacles to Quality Patient Care Increases Medication Adherence and Reduces Avoidable Healthcare Spending
Avalere recently partnered with Third Way to estimate the cost savings of increasing medication adherence among Medicare beneficiaries by improving and expanding the current Part D Medication Therapy Management (MTM) program to target and address adherence issues for specific conditions.
VA National Formulary Covers 16 Percent Fewer Top Prescription Drugs than Medicare Part D Plans
New Avalere analysis finds that the VA National Formulary covers 163 of the top 200 most prescribed Medicare Part D drugs, compared to an average of 191 drugs for Medicare prescription drug plans (PDPs) and 194 drugs for Medicare Advantage prescription drug plans (MA-PDs).
Do CMS Measures Measure Up?
Recently, Avalere presented on the issue of quality measures and clinical practice guidelines at Academy Health. We sat down with one of the researchers, Avalere's Minnie Song, to discuss this research.
Consumer Premium Contributions to Increase $3,300 on Average in 2015 if Supreme Court Rules for King; 6.4 Million Current Enrollees Could Be Impacted by Loss of Subsidies
Consumers could face average annual premium contribution increases of $3,300 in 2015, if the Supreme Court rules tax credits are illegal in states with a federal exchange, according to new analysis from Avalere.1
The Spectrum of Accountability and Alternative Definitions of Alternative Payment Models
Secretary Burwell set the healthcare community abuzz January 26 when she announced the Department of Health and Human Services' (HHS) plan to set 30 percent of fee-for-service payments to alternative payment models (APMs) by 2016 and 50 percent by 2018.