Federal and State Policy
As the largest US healthcare payer, the federal government plays a dominant role in shaping the healthcare marketplace, while states take center stage when it comes to developing novel policy approaches. Our experts track, interpret, and model policies that affect insurance coverage, access, and consumer choice so you can see around the bend.
Interview: Medicare Part D, Part I: Key Trends and Pressures
Tune into the first episode of the Avalere Health Essential Voice miniseries focused on Medicare Part D. In this segment, our Policy and Market Access experts discuss Part D trends and pressures in the currently evolving drug pricing environment.
Video: Medicare Part D, Part I: Key Trends and Pressures
Tune into the first episode of the Avalere Health Essential Voice miniseries focused on Medicare Part D. In this segment, our Policy and Market Access experts discuss Part D trends and pressures in the currently evolving drug pricing environment.
Part D Redesign Would Reduce OOP Costs Across Non-LIS Beneficiaries
New Avalere analysis finds Part D redesign via PDPRA would reduce average OOP costs by 23% for non-LIS beneficiaries, especially for certain drug classes and beneficiary groups by race and reason for entitlement.
Video: What’s Next for Health Policy on Capitol Hill?
Tune into another episode of Avalere Health Essential Voice. In this segment, Avalere policy expert Matt Kazan discusses what he expects to see from a legislative perspective this fall on Capitol Hill.
Interview: The Coverage Gap and Medicaid Expansion
In this segment, our experts discuss the forthcoming debate around the coverage gap in non-Medicaid expansion states, potential policy options, and the impact on key stakeholders.
Most Significant Healthcare Legislation Since ACA Possible this Fall
As Congress considers the bipartisan infrastructure package and budget reconciliation agenda, the coming months are likely to include debate on what could be the most significant federal healthcare legislation in over a decade. Additionally, the Biden administration is expected to release several important healthcare rules this fall, including the details necessary to implement the new law banning surprise billing and regulations to protect and strengthen Medicaid and the Affordable Care Act (ACA).
Ryan Urgo Joins Avalere Health as Managing Director
Seasoned health policy professional brings significant expertise in federal legislation, drug pricing policy, delivery system reform, and federal and state programs that affect insurance coverage.
Higher Gap Discount Payments for Employer Part D Plans
Avalere’s analysis shows differences in payments between employer and non-employer Part D plans.
4 Reasons to Watch PCORI’s Evolving Role in Healthcare Decision-Making
The Patient Centered Outcomes Research Institute (PCORI) recently announced an open comment period for a new set of proposed national priorities to inform its research agenda. Avalere analysis finds that from March 2019 to September 2020, PCORI directed roughly $259 million to comparative effectiveness research (CER) awards with an increasing share of new projects focused on drugs.
What to Watch for in Medicare Advantage Policy in the Coming Months
As the Centers for Medicare & Medicaid Services (CMS) consider what, if any, changes to propose to Medicare Advantage (MA) through fall rulemaking, stakeholders should consider where the Biden administration’s priorities may differ from the previous administration’s. Topics that may be addressed—either in regulation or via legislation—include health equity, supplemental benefit flexibility, star ratings, payment and risk adjustment, and end-stage renal disease (ESRD).
COVID-19 Pandemic’s Considerable Impact on Skilled Nursing Facilities
The roll-out of the Patient-Driven Payment Model (PDPM) in October 2019 followed quickly by the COVID-19 pandemic presents challenges to understanding the extent to which increases in payment to skilled nursing facilities (SNFs) are due to the changes in the payment system versus changes in the patient populations served during the COVID-19 pandemic. Given the confounding effects of the pandemic and the new payment system, it is important to collect more data before evaluating the transition to the PDPM.
Unprecedented Mid-Year Plan Changes Could Impact Patient Access
While access to insurance has increased for millions, mid-year plan switching can have unforeseen consequences for patients.
Avalere Analysis Examines Part D Program Spending Trends
As Congress renews focus on drug pricing reforms, an Avalere analysis examines recent trends in the Part D program’s subsidy payments and implications on stakeholder liabilities in the program.
Coverage of COVID-19 mAbs Presents Opportunities for Stakeholders
In November 2020, the Food and Drug Administration (FDA) granted Emergency Use Authorization (EUA) to COVID-19 monoclonal antibodies for treatment of mild-to-moderate COVID-19 infection.
US Government Continues Investing in Solutions to Combat AMR
As the COVID-19 pandemic draws to a close in the US, another public health concern is once again coming to the fore: antimicrobial resistance (AMR).
Medicare Expansion Could Have a Mixed Impact on Premiums
New Avalere analysis finds that lowering the Medicare eligibility age from 65 to 60 could expand access to Medicare coverage for an additional 24.5 million individuals, but Medicare premiums may be less affordable in some cases than subsidized exchange coverage.
President Biden’s Address to Congress Highlights Healthcare Priorities
In his first address to Congress, President Biden signaled that healthcare will continue to be a high priority for his administration, specifically highlighting pandemic response, drug pricing priorities (e.g., Medicare negotiation), and Affordable Care Act (ACA) enhancements.
Part D LIS Patients Have Lower Rates of Specialist-Prescribed Drugs
For prescription drug fills across 4 therapeutic areas, Avalere analysis finds that Medicare Part D beneficiaries who receive the Low-Income Subsidy (LIS) have those drugs prescribed by a specialist less frequently than those who do not receive LIS.
Interview: Healthcare Price Transparency
Tune into another episode of Avalere Health Essential Voice in our Start Your Day with Avalere series. In this segment, our policy experts discuss the topic of healthcare price transparency in terms of policy, compliance, and the potential impact of making previously confidential pricing information public.
OPPS 340B Policy Reversal Lowers Hospital Payment and Increases Copays
A new analysis from Avalere estimates the impact of reverting back to the Calendar Year (CY) 2017 Medicare Outpatient Prospective Payment System (OPPS) payment policy that reimbursed all separately payable drugs at average sales price (ASP) plus 6%. Key findings suggest beneficiary cost sharing for separately payable drugs at 340B OPPS hospitals would increase by $472.8 million. Also, 82% of all OPPS hospitals—specifically 89% of rural, 80% of urban, and 49% of 340B hospitals—would see net total payment decreases.