Fred Bently

Medicare Advantage and Medicaid Managed Care Growth Present Risks and Opportunities for Post-Acute Care Providers

The payer landscape continues to evolve for post-acute care (PAC) providers. Fueled by lower annual costs and expanded benefit options relative to the Medicare fee-for- service (FFS) program, Medicare Advantage (MA) is growing rapidly, now encompassing more than one-third of all Medicare beneficiaries. At the same time, nearly half the states have implemented managed care plans to provide Medicaid long-term care benefits.

  • Fred Bentley
  • Heather Flynn

2020 Election: Healthcare Coverage Landscape Varies in Early Primary States

As the early presidential primaries unfold, healthcare remains a top issue among voters. As recently as the November Democratic primary debate, polls showed that 24% of Democrats or Democratic-leaning independents said healthcare was the number one issue they wanted to hear discussed, ahead of the environment (12%), immigration (6%), jobs and the economy (5%), education (4%), and gun control (4%).

  • Chris Sloan
  • Neil Rosacker

CMS’s Healthy Adult Opportunity Program Includes Significant Changes to Medicaid Drug Benefit

The Centers for Medicare & Medicaid Services (CMS) announced the Healthy Adult Opportunity, a new Section 1115 demonstration initiative allowing states to shift toward capped Medicaid financing models with an opportunity for shared savings. If the option is chosen by states, it could be the largest change to Medicaid since the ACA.

  • Megan West (Olsen)
  • Tiernan Meyer
  • Margaret Scott
  • Neil Rosacker

Avalere Statement on CMS’s Healthy Adult Opportunity Program

CMS’s Healthy Adult Opportunity program, a new Section 1115 demonstration initiative, will allow state Medicaid programs to move toward capped financing models for some non-disabled adult beneficiaries with an opportunity for shared savings and additional flexibilities.

  • Megan West (Olsen)
  • Margaret Scott
  • Tiernan Meyer

Healthcare Organizations See Reduction in ED Visits and Inpatient Admissions when Focusing on Value

Avalere worked with a healthcare organization to assess the impact of their quality improvement program over a 4-year period. The organization prepared primary and specialty care providers/practices to transition from fee-for-service (FFS) to value-based payment arrangements. Avalere’s analysis found participation in the program led to a reduction in both emergency department (ED) visits as well as inpatient (IP) admissions over the period reviewed.

  • Natascha Dixon Edelin
  • Joanna Young

CMS RADV White Paper Outlines Potentially Significant Program Changes

CMS is considering changes to its commercial market Risk Adjustment Data Validation (RADV) program to improve the accuracy of risk adjustment transfers and to increase stability and predictability for issuers. This follows issuer experiences with the 2017 RADV process in which some issuers saw substantial, unforeseen changes to their risk adjustment transfers. These RADV changes have the potential to impact issuer participation and premiums in future years depending on the direction (positive or negative) and magnitude of those transfers.

  • Sean Creighton
  • Chad Brooker

USMCA Compromise Drops Key Biologics Exclusivity Provisions

The replacement to North American Free Trade Agreement (NAFTA), the United States-Mexico-Canada Agreement, was originally proposed to increase biologics exclusivity in Mexico and Canada to 10 years. As part of the Administration’s compromise with the House of Representatives, these provisions have been removed from the amended version that was recently agreed to by the US, Mexico, and Canada. While exclusivity in the US remains unchanged at 12 years, that it is not increased for Canada and Mexico may impact market entry for biologics ex-US.

  • Zachary Zalewski
  • Kelly L. George
  • Nick Diamond
  • Jay Jackson

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