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.
Issue Brief: OOP Costs Among Medicare Part D Enrollees Reaching the Catastrophic Threshold
As policymakers consider reforms to the Part D benefit to address rising out-of-pocket (OOP) costs by adding a maximum OOP cap, an Avalere analysis examines the types of beneficiaries mostly likely to be helped by such a policy.
What’s Next for Biologics Under USMCA?
The USMCA’s intellectual property provisions add additional layers of ambiguity to the already complex issues surrounding biological product exclusivity and its future in US law.
SFC Drug Pricing Proposal Would Increase Part D Manufacturer Discounts for Some Therapeutic Areas
Avalere analysis finds that tying Medicare Part D manufacturer discounts to utilization in the catastrophic phase instead of in the coverage gap would have differential impacts by disease area.
Tom Kornfield Returns to Avalere Health, Expanding Firm’s Depth in Medicare Policy
Healthcare industry veteran brings decades of Medicare Advantage, Part D, risk adjustment, and business expertise to payer, life sciences, and provider clients.
7 State Policy Trends that May Shape Cancer Care in 2020
State healthcare legislation often holds important implications for high-value and high-cost drugs, such as those used to treat cancer patients.
Takeaways from NASHP: What’s Next in the States in 2020
Avalere’s state policy team recently attended the National Academy for State Health Policy’s (NASHP) Annual Conference for 3 days of interactive state health policy discussions and the facilitation of a roundtable on the direction of telehealth in the states.
CMMI Program Savings Fall Below CBO’s 2016 Projections
CMMI’s impact on Medicare spending has so far not reached earlier projections by the Congressional Budget Office, demonstrating the difficulty in projecting savings from new and unknown alternative payment models.
Avalere Experts Discuss 2020 Regulatory Changes to the Insulin Market
On August 6, Avalere’s regulatory experts published an article in BioDrugs highlighting upcoming regulatory changes for insulin.
3.7M Part D Beneficiaries Are Projected to Reach the Catastrophic Phase in 2020
As policymakers consider reforms to Part D, new Avalere analysis shows that congressional proposals to cap out-of-pocket (OOP) costs in the catastrophic phase are likely to reduce OOP for many beneficiaries
States Explore Increasing Access to Telehealth as New Opportunity for Quality Care
States are increasingly seeking to improve access and health outcomes for their underserved, rural, or homebound populations, and many are turning to telehealth as a solution.
Impact of Proposed CMS Methodology for Calculating Payment Errors May Vary Based on Plan Enrollee Characteristics
In 2018, CMS proposed to revise its Risk Adjustment Data Validation (RADV) methodology to exclude the FFS Adjuster in its payment recoupment calculations. New analysis from Avalere finds that the payment impact associated with fee-for-service (FFS) Medicare coding discrepancies would be greater for certain subgroups of beneficiaries (e.g., dual-eligible, those with certain common and potentially serious health conditions) enrolled in the MA program.
The VA National Formulary for Top Medical Benefit Drugs Is Narrower than Current Medicare Part B Drug Coverage
Avalere analysis finds that 24 of the top 50 non-vaccine Part B drugs are not on the U.S. Department of Veterans Affairs’ National Formulary.
Fentanyl Supply Levels Declined in All States from 2014 to 2017 as Deaths from Overdoses Increased
New analysis from Avalere finds that the quantity of retail fentanyl sold across the US dropped by an average of 28%, between 2014 and 2017.
States Taking Action to Ensure Coverage Protection Should the ACA Be Overturned
While the majority of state legislative sessions have adjourned for 2019, at least 11 states (CT, FL, LA, IN, MD, ME, NH, NM, NV, VT, and WA) have enacted laws to create or study coverage protections against pre-existing condition exclusions and coverage of all essential health benefits (EHB) provided for in the Affordable Care Act (ACA).
1 in 5 Medicare Beneficiaries Taking a Part D Cancer Therapy Reached Catastrophic Level in 2017
Avalere analysis finds that a larger proportion of beneficiaries taking a Part D cancer therapy reached catastrophic compared to all Part D enrollees.
Methodology and Analysis of the Center for American Progress’s Medicare Extra Policy Proposal
The Center for American Progress (CAP) commissioned Avalere to evaluate ‘Medicare Extra’ as a package of reform polices implemented and phased in over time across the US healthcare system.
Note on Avalere’s Recent Biosimilars Policy Modeling
Avalere was recently commissioned to project how policy proposals related to biosimilars would impact government spending and patient costs, including modeling and scoring analyses created for 3 proposals publicly released by the Biosimilars Forum in May 2019.
Capped Funding Policies Could Reduce Funding for Children Covered by Medicaid
New research from Avalere finds that capped funding policies could reduce federal funding to states, specifically for children, by $89B to $163B nationally for FY 2020–2029.
Strategic Opportunities for Health Plans: 2020 and Beyond
Health plans today have a range of strategic opportunities that align well with emerging policy themes for 2020.
Transitioning RA Drugs from Part B to Part D Would Increase Catastrophic Benefit Fills
New Avalere analysis finds that shifting Part B-covered rheumatoid arthritis (RA) drugs to Part D benefit would increase the share of prescriptions occurring in the catastrophic phase for impacted beneficiaries by more than 5 times.