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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Exchanges off to a Slow Start; Medicaid Expansion Continues
Insurance exchanges were set to launch October 1, but technical glitches and enrollment delays have plagued most exchanges.
Avalere Reviewing New Medicare Advantage Plan Star Ratings on Medicare.gov
The Centers for Medicare and Medicaid Services (CMS) posted the star ratings for 2014 Medicare Advantage (MA) and Part D plans on the Medicare.gov website. Avalere Health is available to answer questions about this new information.
CMS Solicits Comments on Revised 2013 Gapfill Payments for MolDx Tests and Denies Payment for MAAA Codes
On September 30, CMS posted revised gapfill prices for molecular pathology Current Procedural Terminology (CPT®) codes, including calculations of the 2014 National Limit Amounts (NLAs).
Largest PBM Enhances Formulary Control with “Not Covered” List
Express Scripts Inc., the world's largest PBM for employers and health plans, recently released a list of 44 drugs that they will now exclude from coverage beginning January 1, 2014.
More Variable Molecular Diagnostic Rates Likely
As molecular diagnostics become more common in treating certain diseases - especially cancer - their reimbursement will be an important part of value messaging for many drug therapies.
In 26 States, Plans Serving Medicaid Beneficiaries Will Also Offer Exchange Coverage
Health insurance exchange marketplaces opened on October 1 for enrollment across the country, as well as premium subsidies for those with limited incomes.
Analysis on Health Plan Offerings on the Federally-Facilitated Marketplace
Avalere Health is carefully analyzing the landscape file of health plan offerings on the federally-facilitated marketplace recently released by the Department of Health and Human Services (HHS).
Despite Lower Than Expected Premiums, Exchange Consumers Will Face High Cost-Sharing Before the Out-of-Pocket Cap
Initial data suggest that exchange plans under the Affordable Care Act (ACA) will include high out-of-pocket costs for enrollees-including deductibles and cost-sharing for medical services and prescription drugs-before consumers reach their out-of-pocket maximum.
Avalere Spotlight: Life Sciences in 2014
The 2014 market will be characterized by challenge and transformation across payers, providers, and patients which will create pressures for the pharmaceutical and medical device industries to:
Half of States Will Not Expand Medicaid in 2014
To date, 24 states and the District of Columbia have committed to expanding Medicaid sometime in 2014.
Avalere Analysis Reveals First Drop In Medicare Advantage Offerings Since 2011
Medicare Advantage HMO offerings grow while PPO and PFFS offerings are exiting the market. Analysis also shows significant variation in PDP premiums in 2014; five out of top 10 prescription drug plans have double digit increase
Evaluating the Usability of CER for Patient and Provider Decision Making
Comparative effectiveness research (CER) has the potential to inform many decisions. While a common threshold for determining whether a CER finding should be disseminated to the public is its methodological quality, a study with high methodological quality is not necessarily one that patients and providers will find usable for their decision making.
CMS Medicare Landscape Files: Low-Cost PDPs Poised to Compete; Attention Focused on MA Plan Participation
Today, the Centers for Medicare & Medicaid Services (CMS) released the 2014 landscape files containing data on plan participation, premiums and benefit designs for the Medicare Part D and Medicare Advantage (MA) markets.
September Issue of Medicaid Monthly Released
Avalere examines states participating in the ACA expansion that may reduce eligibility levels for some current beneficiaries.
Avalere Analysis of Exchange Rates for 2014
One of the most anticipated questions about exchanges has been what the impact of rate shock will be on the market.
Pioneer ACOs First Year Results: Better Success in Improving Quality than Lowering Costs
The Centers for Medicare and Medicaid Services (CMS) released long-awaited data about the first-year of the Pioneer ACO program.
New Issue of State Reform Insights Released
States, HHS Focus on Final Details as Exchanges Ready for Launch
The Joint Commission and AMA Identify Five Medical Treatments that May Be Overused
The Joint Commission and the American Medical Association (AMA) Convened Physician Consortium for Performance Improvement® released a report on July 8, which was previously under an embargo, focusing on the overuse of tests, treatments, or procedures that provide zero to negligible benefit and expose patients to risk of harm.
Exchange Operational Models for 2014
In 2014, most states are relying on the federal government for some or all exchange operational functions.
Labs May See Payment Cuts if CMS Revalues Medicare CLFS Codes
CMS plans to revalue the oldest laboratory service codes first. An Avalere analysis found pre-1997 codes accounted for nearly 37% of Medicare Clinical Laboratory Fee Schedule (CLFS) spending in 2011.