Avalere Health / 2012 CMS Star Ratings: Availability of High Performing Plans for Medicare Beneficiaries
Each year, the Centers for Medicare and Medicaid Services (CMS) conduct a five-star rating system to evaluate the overall efficiency and quality of Medicare Advantage (MA) and Part D plans made available to beneficiaries. In a new analysis, Avalere looks at CMS' landscape file of the 2012 Medicare market to examine the availability of high performing plans for low-income Medicare beneficiaries. The analysis finds a considerable decrease in the number of highly rated plans eligible to offer coverage to beneficiaries who receive the low-income subsidy (LIS). Of the 245 plans that were LIS-eligible in both 2011 and 2012, 67 percent had a decrease in their star ratings in 2012. Of the 47 percent that had 4 or more stars in 2011, 11 were not LIS-eligible, and all of the remaining had a decrease in their ratings in 2012. This decline in star ratings is likely due to this year’s new rating system that places a greater emphasis on clinical outcome measures (e.g., medication adherence) rather than process-oriented measures seen before like how long a person was kept on hold when calling a plan for assistance.
The SCAN Foundation / DataBriefs on Chronically-Ill Seniors
The analyses, produced by Avalere Health and released as part of The SCAN Foundation's DataBriefs series, reveal that seniors with five or more chronic conditions who also need help with activities of daily life, such as bathing, eating and meal preparation, account for nearly twice the Medicare costs as those with the same level of chronic illness, but without a need for daily supports and services. In 2006, Medicare spent $19,763 per person on average to care for seniors who had multiple chronic conditions and also needed assistance with daily living activities compared to $10,133 on seniors with the same medical profile, but who did not need assistance. The analyses conclude that more effective models of coordinated care are recommended to address the needs of this population effectively.
The analyses are based on the 2006 Medicare Current Beneficiary Survey (MCBS) Cost and Use file, an annual, longitudinal survey of a representative sample of all Medicare enrollees. The MCBS also collects information on activities of daily living, instrumental activities of daily living, health services utilization and health spending.
Kaiser Family Foundation / The Role of Clinical and Cost Information in Medicaid Pharmacy Benefit Decisions: Experience in Seven States
The goal of this research was to determine how states evaluate relative clinical and cost information about prescription drugs when making coverage decisions for Medicaid pharmacy benefits. Pharmacy directors at seven states were interviewed and all expressed interest in using clinical comparative effectiveness research (CER) to inform their PDL. However, they noted that the existing evidence base frequently lacks sufficient information to make clear decisions regarding the relative clinical effectiveness of pharmaceuticals used to treat the same condition. Because of these limitations, states often contract out drug reviews to private organizations that cater specifically to the timing and scope of each state's PDL review.
The SCAN Foundation / DataBriefs on Residence Setting, Level of Disability, and Healthcare Utilization
This data, produced by Avalere Health and released as part of The SCAN Foundation's DataBriefs series, illustrates the differences in care coordination, number of hospitalizations, and total Medicare spending on seniors with disabilities who receive care in nursing homes, at their own home or in a community care setting such as assisted living facilities, domiciliary care facilities, or continuing care retirement communities. The data show only 38 percent of older Americans with moderate or severe disabilities reside in nursing homes while another 58 percent choose to receive care at home or in community settings. Americans with disabilities living in community care settings also require more Medicare spending than similar older adults living in nursing facilities or those receiving care at home. The data analyses are based on the 2006 Medicare Current Beneficiary Survey (MCBS) Cost and Use file, an annual, longitudinal survey of a representative sample of all Medicare enrollees.
Avalere Health / Impact of Fiscal Year 2012 Skilled Nursing Facility Final Rule and Potential Medicaid Reductions on Nursing Facility Industry-wide Overall Margin
This analysis by Avalere Health estimates that the Medicare payment rate reduction and change to group therapy policy in the FY 2012 Skilled Nursing Facility (SNF) Prospective Payment System final rule, published by the Centers for Medicare and Medicaid Services, will reduce the nursing facility industry-wide overall margin from 3.8 percent to zero in FY 2012, and from 4.4 percent to 0.4 percent in FY 2014. Potential Medicaid reductions and an additional 2 percent Medicare payment rate cut that could be imposed pursuant to the sequestration in the Budget Control Act of 2011 would further reduce the nursing facility overall margin to -2.2 percent in FY 2014.
Avalere Health / Impact of Fiscal Year 2012 Skilled Nursing Facility Final Rule on Payments to Nursing Facilities
This analysis by Avalere Health finds that nursing homes will lose more than $79 billion in funding over the next 10 years. The reduction in payments stems from a recent rule (FY 2012 Skilled Nursing Facility (SNF) Prospective Payment System) published by the Centers for Medicare and Medicaid Services, which will lower nursing facility payment rates, resulting in a loss of more than $60 billion over 10 years. A change in this rule regarding allocation of group therapy minutes will reduce payments to nursing facilities by an additional $19 billion over the same time period. Furthermore, the analysis estimates the impact on economic activity and finds that the changes in the rule will result in a reduction of almost $7 billion in economic activity nationwide.
Avalere Health / The Affordable Care Act's Impact on Employer Sponsored Insurance: A Look at the Microsimulation Models and Other Analyses
This report, released by Avalere Health, provides analysis of available estimates on the future of employer-sponsored insurance post implementation of key provisions of the Affordable Care Act (ACA) in 2014 and beyond. The study utilized microsimulation model estimates from organizations including RAND, the Urban Institute, and the Congressional Budget Office, augmented by surveys from benefits consultants and other experts, to determine net changes in the employer-sponsored insurance market. Overall, the study concludes that the ACA is likely to have a relatively insignificant effect on employer-sponsored insurance in the short term but that long-term erosion of the employer-sponsored insurance market over the next 10-20 years may be possible under certain circumstances.
While the overall effect of the ACA on employer-sponsored insurance is projected to be relatively small, particular segments of the employer market are likely to experience more significant change. For example, researchers expect that companies that employ low-wage workers are likely to stop offering health insurance since employees can enroll in Medicaid or obtain subsidized coverage through an insurance exchange at relatively low cost. Similarly, small employers are likely to offer health insurance through Small Business Exchanges (SHOPs) which will be implemented in 2014 as required by the ACA.
Avalere Health and the Association of Community Cancer Centers / Barriers to Clinical Practice Guidelines Adherence in the Community Oncology Setting
This abstract, released by the American Society of Clinical Oncology on May 18, examines survey research conducted with community oncology providers on barriers to clinical practice guideline adherence. The study finds that while the majority of providers consult guidelines, they report barriers to delivering guidelines-based care 16 percent of the time citing limited time, limited access to guidelines at the point of care, and limited applicability of the guidelines. Twenty five percent of physicians surveyed reported creating their own practice- or program-level guidelines often or always. The authors conclude that more research is needed on when and why providers deviate from recommended care and generate their own guidelines. This abstract can be found under abstract number e19687 on www.asco.org and www.jco.org.
Avalere Health / Is Provenge a Harbinger for Future CMS Decision Making?
This article, authored by Sung Hee Choe, Tanisha Carino and Dan Mendelson of Avalere Health, explores CMS's national coverage analysis (NCA) on the prostate cancer drug, Provenge, and uses it as a case study to determine how CMS decision-making may evolve in the future given mounting pressures on the program. The authors show how CMS is becoming more interested in evidence that supports the efficacy and effectiveness of new medical technology. And they explore how the government's focus will affect a range of commercial stakeholders. This article appeared in BNA's Medicare Report on May 27, 2011.
Avalere Health and The West Clinic / Patient and Plan Characteristics Affecting Abandonment of Oral Oncolytic Prescriptions
This study, authored by Avalere Health and The West Clinic, examines the economics of cancer patients abandoning their oral oncolytic prescriptions. The study finds that 10 percent of cancer patients are abandoning their medications due to high cost-sharing on the part of the patient, as well as high prescription activity, i.e., the amount of prescriptions filled on a monthly basis. Across the study sample, Medicare coverage and lower income were also related to higher rates of abandonment with 45.5 percent of Medicare patients having cost-sharing greater than $500. This study has been accepted for presentation at the American Society of Clinical Oncology annual meeting on June 6.
Avalere Health / Federal Spending on Brand-Name Pharmaceuticals
This report by Avalere Health analyzes federal healthcare spending on the Medicare and Medicaid programs between 2011 and 2019. The report estimates that revenues to manufacturers of brand-name outpatient prescription drugs represent only 8 percent of the estimated $9.9 trillion. Hospitals comprise 41 percent of this total while payment for physicians' services comprise 19 percent. While drug spending for Part D will represent a larger portion of the total drug spending by 2019 than 2010, Avalere concludes that drug spending will still represent less than 10 percent of total federal spending on healthcare.
Avalere Health / Comparative Effectiveness Research: A Catalyst for Innovation
This paper examines how increases in funding for comparative effectiveness research (CER) has spurred innovation in the insurance and life sciences industries. Most notably, the $1.1 billion allocated to CER by Congress has led to drug manufacturers focusing their efforts on the development of novel and better-differentiated medications and health plans experimenting with new coverage and reimbursement policies. The authors conclude that as more comparative research becomes available, continued innovation is likely.
Leukemia and Lymphoma Society / The State of Multiple Myeloma Care: An Evaluation of Access to Medical Care
This report is the first of its kind to study access to care barriers reported by patients with multiple myeloma (MM), an incurable but treatable cancer that affects nearly 70,000 Americans. Avalere researchers found that seven in 10 (70%) study participants encounter at least one barrier at some point during their treatment - including issues with care coordination/physician knowledge, medical costs or insurance or transportation - and nearly four in 10 (37%) experience multiple barriers. The report authors conclude by proposing potential policies that would better coordinate MM patients' medical care, and provide transportation assistance and other care management improvements.
The SCAN Foundation / Technical Assumptions Informing an Interactive, Web-based Model of Public Long-Term Care Insurance Programs
This paper outlines the technical assumptions behind the Long-Term Care Policy Simulator (LTCPS), a model constructed for the SCAN Foundation to estimate premiums and effects on the Federal budget of a variety of long-term care reform plans. The model allows users to create a mandatory or optional public long-term care insurance plan, with varying benefit amounts, participation requirements, benefit durations and other variables. The technical paper outlines the methods and data sources used to construct the estimates.
Avalere Health / Piloting Bundled Medicare Payments for Hospital and Post-Hospital Care / A Study of Two Conditions Raises Key Policy Design Considerations
The Affordable Care Act requires the Centers for Medicare and Medicaid Services to conduct a demonstration program that would “bundle” payments for an episode of hospital care and for a certain number of days of post-hospital care. CMS must select episode lengths that are appropriate for the clinical needs of potential patients. This self-funded paper examines how many days should be covered under a bundle, using two common conditions that have high rehospitalization rates as a case study. An episode length of 30 days would be appropriate for most joint replacement or COPD patients. However, a quarter of patients with these two conditions have very complex care needs and need treatment for much longer periods. A more tailored bundle design is required for this subpopulation, pointing to important policy questions about how to best address the very clinically complex in a world of bundled payment.
The SCAN Foundation / Long-Term Care in Health Care Reform: Policy Options to Improve Both
This paper, supported by a grant from the SCAN Foundation, makes the case for including long-term care provisions in health reform. Few Americans have insurance coverage for long-term care. In addition, acute care, post-acute care and long-term care are poorly coordinated, especially for the frail dual-eligibles, who are covered by both Medicare and Medicaid. The paper outlines proposals to increase the availability of home- and community-based services (HCBS) in Medicaid, to better coordinate medical and long-term care for Medicare enrollees in general and for dual eligibles in particular, and to establish a public long-term care insurance program. The paper concludes that health reform cannot fully accomplish its goal to improve the health and economic security of American families without addressing long-term care.
Journal of Diabetes Science and Technology / The Role of Reimbursement in the Adoption of Continuous Glucose Monitors
This paper explores the availability and use of continuous glucose monitors (CGMs), which provide ongoing readings of glucose levels. The authors find that, even though growing numbers of insurers are covering the actual devices, lack of reimbursement for time spent acclimating patients to the technology by physicians, nurses, and certified diabetes educators is a barrier to widespread adoption. Noting that CGMs are just one example of the struggle healthcare providers face in balancing high-quality care with reimbursement needs, the authors recommend that health and payment reform discussions focus on better aligning patient needs and provider concerns.
Robert Wood Johnson Foundation / An Emerging Middle Ground? An Analysis of Health Reform Positions
This report examines how health reform discussions to date have paved a path toward legislative compromise. The report looks at eight reform areas under scrutiny, outlining opposing views held by various stakeholders and describing the middle ground that lawmakers are approaching. Although there remains disagreement on some key elements as Congress debates the details of a reform package, the authors identify an emerging consensus across several coverage, payment, and delivery issues that may contribute to a comprehensive, bipartisan solution for reforming the US healthcare system.
Henry J. Kaiser Family Foundation / Closing the Long-Term Care Funding Gap: The Challenge of Private Long-Term Care Insurance
This report provides an overview of long-term care (LTC) insurance offerings, using expert interviews, 2008 premium data from the largest carriers, and a literature review to explore key challenges policymakers face in widening the role of private LTC insurance. According to the report, cost is a significant barrier to obtaining LTC insurance and becomes a bigger hurdle as people age. For individuals with no partner, the annual premiums for a typical policy averaged $2,329 at 60 and $4,515 at age 70. According to the report, policymakers interested in making private LTC insurance more affordable could consider supplementing coverage, offering tax credits toward purchase of LTC insurance, or providing direct premium subsidies.
The Alliance for Home Health Quality and Innovation / Medicare Spending and Rehospitalization for Chronically Ill Medicare Beneficiaries: Home Health Use Compared to Other Post-Acute Care Settings
This analysis estimates the cost reductions associated with early use of home healthcare services for Medicare beneficiaries with chronic conditions. Avalere researchers found that early use of home health for individuals with diabetes, chronic obstructive pulmonary disease, or congestive heart was associated with a $1.71 billion reduction in Medicare post-hospital spending over the 2005-2006 period and that wider use of home health for this patient population could have reduced spending by an additional $1.77 billion. The analysis also found that odds of hospital readmission were significantly lower for beneficiaries with any of these three conditions who used early home health services. These findings indicate that home healthcare can be a cost-effective way to deliver post-acute care to certain Medicare beneficiaries.
University of Michigan Center for Value-Based Insurance Design (VBID) / Value-Based Insurance Design in the Medicare Prescription Drug Benefit / An Analysis of Policy Options
This white paper presents options for advancing a VBID approach within Medicare’s prescription drug benefit (Medicare Part D). Avalere and its research partners examined how VBID can be implemented in the current environment and whether legislative or regulatory changes are necessary. According to the analysis, Medicare Part D plans currently have three options for immediately implementing VBID, while two other options exist that require changes to existing legislation or regulation. The paper’s findings may help guide policymakers considering VBID as a potential approach to reforming Medicare or organizations focused on benefit design, such as health plans, pharmacy benefit managers, and employers.
SCAN Foundation / Long-Term Care --- an Essential Element of Healthcare Reform
This chart book examines the role of long-term care in broader healthcare reform efforts. Through original and secondary research, the authors focused on four key points: long-term care users constitute the majority of Medicaid spending; home health and hospice Medicare post-acute care services may fill-in for long-term care; Medicare and Medicaid spending for dual eligible beneficiaries is often uncoordinated; and a significant amount of long-term care has been financed privately. Researchers conclude that reform efforts should carefully consider the healthcare needs of the long-term care population as well as leveraging private financial resources in order to strengthen the long-term care system.
Henry J. Kaiser Family Foundation / The Emerging Role of Group Medicare Private Fee-for-Service Plans
The issue brief explores the Medicare Private Fee-for-Service Plans (PFFS) environment, paying particular attention to how changes in regulation, statute, and the marketplace have driven employers' interest in PFFS plans as an option for their retirees. Avalere researchers found that, between 2006 and 2008, the number of Medicare beneficiaries enrolled in Medicare Advantage group plans nearly doubled from 900,000 to nearly 1.7 million, with most of the growth attributable to employers contracting with PFFS plans. The issue brief chronicles how PFFS plans became widely utilized and explores how recently enacted legislative and regulatory changes might diminish future growth of these plans.
Medicare Access for Patients-Rx / Trends in Medicare Part D Coverage of Chronic Condition Medications
This paper outlines shifts in Medicare Part D coverage of drugs used to treat chronic conditions. Using Avalere’s proprietary DataFrame database, researchers looked at every Medicare Part D plan available from 2006 to 2008 to evaluate coverage of drugs most often prescribed to treat four chronic conditions: Alzheimer’s disease, rheumatoid arthritis, Type 2 diabetes, and schizophrenia/psychosis. The paper finds that coverage for these drugs shifted considerably during that time, with plans increasing the number of drugs covered but at higher costs to beneficiaries and with more utilization-management tools in place to control access. Beneficiaries and policymakers should remain attuned to these shifts and how they may impact medical compliance and health outcomes.
California HealthCare Foundation / The Medicare Drug Benefit: Changes in California for 2009
This new fact sheet outlines changes to the 2009 Medicare prescription drug benefit in California. Using Avalere Health’s DataFrame® analytic tool and CMS-issued data, Avalere researchers found that Medicare beneficiaries in California will continue to have a wide range of plan options that vary by county—but that low-income beneficiaries will have fewer choices of plans in which premiums are fully subsidized. According to the fact sheet, Californians can also expect a rise in premiums for standalone prescription drug plans and an increase in out-of-pocket costs for individuals who narrowly exceed the low-income subsidy limit.
National Institute for Health Care Management / Getting to Value
This paper outlines four primary barriers to recognizing and rewarding value in the U.S. healthcare system. According to the authors, these four barriers – measuring value, capturing appropriate data, coordinating efforts, and rewarding system-wide improvements – will require extensive coordination among stakeholders and strong leadership from the federal government. The paper concludes with concrete recommendations for addressing these issues and promoting fair, objective, and patient-focused dialogue among stakeholders.
Medical Imaging & Technology Alliance / Diagnostic Imaging / Spending Trends and the Increasing Use of Appropriateness Criteria and Accreditation
This report examines recent efforts by physician leaders, health plans, and manufacturers to optimize the utilization of medical imaging services. Focusing on the development and use of clinical appropriateness criteria, accreditation programs, and physician education, the authors profile forward-leaning efforts to target the right services to the right patients. The report concludes that these non-traditional utilization management strategies may serve as valuable tools for policymakers and researchers contemplating Medicare reform.
Avalere Health / Part D Formularies: Opportunities for Further FDA/CMS Collaboration
This self-funded analysis explores the motivations behind and impact of CMS’s decision to drop more than 1,500 drug codes from its 2008 Part D Formulary Reference File. The action, which prompted commercial plans to drop many of these drugs from their 2008 Medicare offerings, sought to remove hundreds of prescription drugs that were being marketed without FDA approval. While the FDA is making progress in removing products that have demonstrated safety and efficacy concerns, an estimated several thousand unapproved products remain on the market. The report recommends that information on all products – approved or unapproved, repackaged or marketed directly – should be readily accessible to health professionals, plans, and CMS through FDA resources.
Association for Community Affiliated Plans / Medicare Advantage Special Needs Plans / Six Plans' Experience with Targeted Care Models to Improve Dual Eligible Beneficiaries' Health and Outcomes
This report profiles six not-for-profit Medicaid managed care plans and how they are using Medicare's Special Needs Plans (SNP) authorization to develop targeted care models to better serve dual eligible beneficiaries. Despite variation in their geography, plan size, and relationship to their Medicaid programs, all of the profiled plans invest across four key dimensions: coordination of the Medicare and Medicaid benefit, intensive case management for high-risk members, links to community social services, and benefit design to fund enhanced care coordination and fill coverage gaps. These plans' "high-touch" care approach may be instructive for any future efforts to promote managed care offerings to dual eligible and other frail Medicare beneficiaries and make modifications to the SNP program.
California HealthCare Foundation / The Medicare Drug Benefit: Changes in California for 2008
This new fact sheet showcases changes to the 2008 Medicare prescription drug benefit in California. Using Avalere Health’s DataFrame® analytic tool and CMS-issued data, Avalere researchers found that many beneficiaries in California must switch plans during the 2008 open enrollment period to avoid large premium increases – particularly those enrolled in PDPs. Californians who depend on the low-income subsidy will find a sharp drop in plan options in 2008, and the two most popular plans in 2007 are no longer eligible for dual eligible auto-enrollment. Consumers in California will have more overall plan choices in 2008.
National Business Coalition on Health (NBCH)
University of Michigan Center for Value-Based Insurance Design (VBID) / Assessing Value in Pharmacy Benefits / Do Employers Have the Right Tools?
This white paper studies the existing measures available to employers to assess the value of pharmacy benefits they provide their employees. Conducting an in-depth examination of the metrics and tools currently available to employer decision-makers, Avalere and its research partners conclude that employers lack reliable ways to evaluate the value of the pharmacy benefits they purchase. Of the over 175 existing pharmacy benefit related measures identified in the analysis, only 4 percent focus on value. The paper's findings may help guide future development efforts and priority-setting activities by employers, measure developers, and other quality-focused
organizations.
California HealthCare Foundation / The Medicare Drug Benefit in California
This analysis tracks the evolution of Medicare Part D benefit features and enrollment patterns in California, and provides a glimpse into how the Medicare marketplace continues to develop on a regional, state, and national level. Californians choose Medicare managed care drug plan options at a greater rate than the national average, but Medicare private fee-for-service plans are not as prevalent as in the rest of the country. Special needs plans are on the rise in California – a trend that mirrors national activity. Despite more plan choices in 2007 (as many as 95 in Los Angeles County), about half of California’s Medicare beneficiaries are enrolled in plans offered by two commercial sponsors. Given the variance in plan structure and benefit design, the authors conclude that federal and state officials should remain vigilant in tracking issues of informed choice, access, burden of cost, and improved outcomes.
Georgetown University / Linking Medicare and Private Health Insurance for Long-Term Care
This paper proposes that a restructured Medicare could offer catastrophic long-term care coverage if beneficiaries purchase a pre-approved private long-term care insurance policy. The core concept involves two steps: redeploying certain entitlement funding to create catastrophic long-term care coverage and leveraging the purchasing clout of the Medicare population to create a more favorable environment for private long-term care insurance. The authors posit that this public-private approach to long-term care financing reform is a sustainable way to simultaneously protect consumers from catastrophic costs of chronic illness and better develop the private insurance marketplace.
Kaiser Family Foundation / An Examination of Medicare Private Fee-for-Service
This study highlights the rapid rise of Medicare private fee-for-service (PFFS) health plans, their unique congressional history, and distinguishing benefit features. Analyzing recent CMS Medicare enrollment data, the authors describe how PFFS plans have proliferated nationally and are fueling overall enrollment in Medicare Advantage. The authors conclude that PFFS plans have a multi-faceted constituency that includes the managed care industry, rural communities, current enrollees, and right-to-life advocates, all of whom Congress will need to consider within the context of making refinements to Medicare Advantage.
Health Affairs / Federal Initiatives to Support Rapid Learning about New Technologies
This commentary discusses expanded federal efforts to evaluate and monitor the effectiveness of emerging medical technologies, and how broadened federal involvement interacts with private sector initiatives. Medicare Part D has brought a rich new source of drug utilization data to the federal government, and the authors portray a concerted federal effort to use these data to support patient care, physician decision-making, and payer activities. The authors also conclude that the private sector and other stakeholders must play a strong collaborative role for overall rapid learning efforts to succeed in the long-term.
National Commission for Quality Long-Term Care / Long-Term Care in America / An Introduction
This report examines the challenges of providing and financing long-term care against the backdrop of a rapidly aging society and resource-constrained entitlement programs. Created for a broad non-partisan commission, the authors stress the growing diversity of home-like settings with varied levels of federal regulation, transformation of nursing homes into post-medical, rehabilitative centers of care, and dominance of public programs together with donated care and out-of-pocket spending as primary ways to pay for long-term care. The report also focuses on the economic and demographic challenges which may further tax existing long-term care providers and the patients they serve. Policymakers and stakeholders in the long-term and post-acute care settings can use the report as a fact-based platform from which they can make assess system reform proposals and recommendations.
The Robert Wood Johnson Foundation and Horizon Blue Cross Blue Shield of New Jersey / The 2006 New Jersey Health Care Almanac
The 2006 New Jersey Health Care Almanac is a comprehensive analysis of variations in healthcare system capacity and healthcare utilization in the state of New Jersey. Using a region-by-region approach, the Almanac arrays a wide variety of comparisons of particular counties’ healthcare data trends within the state, and between New Jersey, national averages, and those from Connecticut – a state with similar social and demographic characteristics. On analyzing the distribution and utilization of hospital, physician, emergency department, community health center, ambulatory surgery center, diagnostic imaging, and long-term care services, the report finds that the New Jersey healthcare system has significant pockets of over- and under-capacity, higher than average rates of hospital admission, and has experienced dramatic growth in the number of free-standing ambulatory surgery and imaging centers over the past 15 years.
National Association of State Medicaid Directors / State Perspectives of Emerging Medicaid Pharmacy Policies and Practices
This original survey, developed by Avalere Health in partnership with the National Association of State Medicaid Directors, comprehensively examines current state-based pharmacy policies and practices. Based on reporting from 47 of 50 states and the District of Columbia, the survey shows how the Deficit Reduction Act and the Medicare Modernization Act have profoundly affected state management of pharmacy benefits. Topics of importance to the states include participation in pharmaceutical purchasing pools, scrutiny of available clinical and economic evidence, and coordination of benefits with Medicare and other public programs.
American Cancer Society / Cost Sharing For Cancer Patients In Medicare: Seven Case Studies
This report examines Medicare cost-sharing for patients with cancer and common co-morbidities using a case study approach. The authors evaluate cost-sharing in Medicare parts B and D for seven common cancer treatment protocols in a sampling of 12 Medicare prescription drug plans with varying premiums, formularies, and benefit designs. While drug plans in the analysis cover these cancer drugs almost universally, cost-sharing can vary dramatically from plan to plan due to differences in copay or coinsurance amounts, coverage in the gap, and other plan features. The findings underscore the importance of beneficiaries critically evaluating their Medicare prescription drug plan options before making a choice.
California HealthCare Foundation / The Medicare Drug Benefit in California: Facts and Figures
This new study profiles 2006 plan offerings for the Medicare prescription drug benefit in California. Using Avalere Health’s DataFrame™ database tool, the study used 2006 CMS-issued plan-level enrollment data and linked them to earlier observations about the variety of prescription drug plans choices available in California. The study finds that most beneficiaries have drug coverage and many of those without known drug coverage appear to be eligible for the low-income subsidy. Medicare Part D enrollment was heavily concentrated in five commercial sponsors’ plans. The study creates a benchmark from which future consumer trends in the Medicare prescription drug benefit can be evaluated.
Health Affairs / Medicare’s Coverage of Colorectal Cancer Drugs: A Case Study in Evidence Development and Policy
This case study, self-funded by Avalere Health, evaluates CMS’ pursuit of coverage with evidence development (CED) policy and its potential impact on clinical evidence generation and beneficiary access to medical innovations. The authors describe steps that led to CMS’ efforts to require clinical trial participation to access colorectal cancer drugs, what evidence that process has generated to date, and how this policy may ultimately lead to changes in the availability of medical technology for Medicare beneficiaries. The study concludes that CMS’ CED efforts are a harbinger for future evidence-based medicine policies in both the public and private sectors.
Health Affairs / Access to Cancer Drugs Under Medicare Part D: Formulary Placement and Beneficiary Cost Sharing in 2006
Using the proprietary DataFrame™ database, this self-funded Avalere Health study evaluates the breadth of cancer drug coverage under the new Medicare prescription drug benefit. It finds that CMS policies have ensured that beneficiaries with cancer have broad access to cancer therapies, with the 20 most commonly prescribed cancer drugs enjoying almost universal coverage. When available, generics enjoy a wider breadth of coverage (99% provided under Part D) and lower cost sharing. The authors also conclude that policy makers need to ensure that variation in cost sharing levels and policies to restrict access to some drugs do not adversely affect beneficiary health.
The Commonwealth Fund / Assessing Medicare Prescription Drug Plans in Four States: Balancing Cost and Access
This issue brief examines Medicare stand-alone prescription drug plans in the four most populous Medicare states—California, Florida, New York, and Texas. While there are similar offerings in all four states, there is wide variation in the number of drugs covered, how drugs are accessed by beneficiaries, and prior authorization requirements. Plans with lower premiums are more likely to have additional formulary tiers and no coverage in the "doughnut hole"—the gap faced by the majority of beneficiaries between $2,250 and $5,100 in costs.
Agency for Healthcare Research and Quality / Evolution of State Health Information Exchange: A Study of Vision, Strategy, and Progress
This federally-funded study profiles various states’ health information exchange (HIE) initiatives to benchmark progress, best practices, and challenges in integrating information technology into local healthcare systems. The report highlights a critical gap between national goals to rapidly advance HIE and the local reality of achieving sustained progress. While select states have achieved notable early successes, most are still unable to exchange actual clinical data and are struggling to establish sustainable funding, common technology platforms, and unified community support. Federal and state policymakers must work together to bridge the gaps between national goals and local realities in order to advance HIE.
Kaiser Family Foundation / Frontline Perspectives on Long-Term Care Financing Decisions and Medicaid Assets Transfer Practices
This report examines Medicaid asset transfers rules, and how recent legislative changes to tighten asset transfer practices will impact seniors and Medicaid. The study, which features interviews with long term care planners in six states, found that most people have not planned for their long-term care needs and are unaware of their options; private long-term care insurance is too expensive for low and middle-income families; and personal resources and family care-giving play important roles in providing long-term care services, but have limits. Current legislative efforts to tighten asset transfers must be coupled with enhanced national consumer education efforts and the creation of more affordable options to effectively reduce seniors’ reliance on Medicaid funding.
Avalere Health / Understanding the 2006 Medicare Part D Marketplace: An Analysis of Commercial Response and Consumer Choice
Using the proprietary DataFrame database, this study analyzes the 2006 Medicare Part D marketplace to provide a better understanding of the commercial response to the new program, and choices facing beneficiaries. Many Medicare drug plans have made significant departures from typical commercial plan offerings, using more utilization control tools such as advanced tiering, step therapy, prior authorization, and quantity limits. Plans vary widely in their design, monthly premiums, and in number of drugs covered. Beneficiaries must evaluate plans across all of these dimensions when deciding which, if any, plan best meets their individual needs. Given the dynamic marketplace and variety of business strategies in 2006, plans will likely alter their benefit designs and strategies moving forward.
Kaiser Family Foundation / Dual Eligible Home and Community-Based Waiver Program Participants and the New Medicare Drug Benefit
This study compares the protections afforded to low-income Medicare beneficiaries in nursing homes under the new drug benefit with the protections afforded to a group of Medicare beneficiaries who resemble nursing home residents medically but remain at home using services provided through the home and community-based (HCBS) waiver program. Nursing home residents were granted more protections than HCBS waiver participants despite their medical similarities, which may limit HCBS’ participants access to medication and pharmacy services, cause increased financial hardship and costly medical complications, and create the unintended consequence of encouraging infirm Medicare beneficiaries to become institutionalized. Policy suggestions to state and federal policymakers focus on means to monitor and identify any hardship, and to eliminate the disparities in protections between waiver participants and their institutionalized peers.
Diabetes Technology & Therapeutics Journal / A Strategic Action Plan for Achieving Uncompromising "Treat to Target" in Individuals with Insulin-Dependent Diabetes: A Report by the Center for Insulin-Dependent Diabetes Access' Blue Ribbon Panel
This report summarizes the work of a recently convened expert Blue Ribbon Panel assembled to identify barriers to achieving universal treatment-to-target in people with insulin-dependent diabetes, and to recommend solutions for addressing those barriers. The report’s series of recommendations to achieve optimal diabetes care include the need to adopt a “team” approach to treatment of diabetes, increased reimbursement for new technologies and services provided by the team approach (especially non-face-to-face care), as well as calling for innovations in patient education, outreach, and patient-centric care. The Blue Ribbon Panel was convened by Avalere Health on behalf of the Juvenile Diabetes Research Foundation, and was funded by an unrestricted grant by the Medtronic Foundation.
Kaiser Family Foundation / The Impact of Enrollment in the Medicare Prescription Drug Benefit on Premiums
Using Congressional Budget Office (CBO) estimation techniques and secondary data, this study assesses the effects that selective enrollment might have on average Medicare drug premiums, holding all other factors constant. The analysis shows that premiums may rise between 25% and 42% in 2007 should relatively healthy beneficiaries opt out in the flagship year of the drug benefit and that federal costs remain relatively constant when enrolling relatively healthy beneficiaries in addition to those with higher drug spending. The study highlights the importance of education and outreach efforts across the full spectrum of people eligible for the Medicare drug benefit.
American Diabetes Association / The Impact of the Medicare Prescription Drug Benefit on People with Diabetes
This white paper examines out-of-pocket exposure for people with diabetes under the new Medicare drug benefit. The analysis shows wide variation in impacts by income; people with incomes at 150% of poverty spend an estimated 21% of their income on diabetes medications and blood glucose screenings. Monitoring all Medicare beneficiaries with diabetes as they transition into private drug plans is critical as many of them will be experiencing formularies for the first time, and non-compliance with their drug regiment can result in costly medical complications.
Health Affairs Journal / Medicare's Next Voyage: Encouraging Physicians to Adopt Health Information Technology
This peer-reviewed publication, authored by Avalere staff, concludes that federal policy makers have not fully leveraged the unrivaled power of the Medicare program to promote adoption of meaningful and cost-effective health information technology. It reviews the options available to Medicare through regulation and legislation, and concludes that the program should assume a leadership role in encouraging the uptake of HIT by clarifying its technology objectives, engaging the physician community, shaping the development of standards and technology certification criteria, and creating concrete payment systems to promote adoption of meaningful technology that furthers the interests of Medicare beneficiaries. This work was self funded by Avalere Health.
Kaiser Commission on Medicaid and the Uninsured / The Use of Oregon’s Evidence-Based Reviews for Medicaid Pharmacy Policies: Experiences in Four States
This issue briefly describes how four state Medicaid programs used reports developed by Oregon’s Drug Effectiveness Review Project (DERP) to develop pharmacy policies. The report finds that the influence of DERP reports on state policy was significant in all states, but varied from being the most prominent clinical evidence used in development of a preferred drug list, to being one of many clinical references used to create provider education tools. Concerns raised by stakeholders include what type of evidence is considered to promote regionally sensitive policies, and the importance of open processes to ensure accountability. This paper is one of several recent Health Strategies’ studies conducted on evidence-based medicine and its impact on public policy and business.
State Medicaid Disease Management / Lessons Learned from Florida
Disease management (DM) has garnered significant attention as a potential method for reducing Medicaid costs and improving health outcomes. This paper evaluates the Florida: A Healthy State program, the first DM program for low-income and disabled beneficiaries to tailor case management to Medicaid, through interviews with policy makers and other key stakeholders. The unique nature of the Medicaid population, physician buy-in, and difficulty in long-term evaluation pose obstacles to implementing successful DM approaches. These lessons may be applied by states as they implement DM programs, as well as by new Medicare Part D plans serving low-income and disables populations.
The Kaiser Family Foundation / Follow the Pill: Understanding the U.S. Commercial Pharmaceutical Supply Chain
This report explains how pharmaceutical drug products get from manufacturers to consumers. In addition, it outlines the complex financial flows between and among manufacturers, wholesalers, and health plans, including descriptions of various rebates and discounting arrangements between the parties, and how these flows ultimately affect a drug’s eventual price to the consumer. This educational primer is a resource for the policy community to support rational decisions regarding Medicare and Medicaid, as well as to consumers interested in why the price of pharmaceuticals varies.
Health Affairs Journal / Evidence-Based Medicine In The United States — De Rigueur Or Dream Deferred?
Although evidence-based medicine (EBM) is an important concept for promoting value in healthcare, meaningful application of EBM tools in commercial settings has proceeded slowly. Barriers to the use of EBM include patient preference, physician resistance, the lack of automated decision support systems, managed care failures, lack of research on which to base decisions, and the inherent subjectivity of interpretations of evidence. Political concern has mirrored these barriers; consequently, Medicare still lacks clear authority to apply many evidence-based decision tools. Dialogue and consensus will be critical in bridging public concern and the eagerness of researchers to apply EBM.
The Pew Charitable Trusts / The Long-Term Care Partnership Program: Issues and Options
In the context of Medicaid reform and state budget crises, policy makers are debating the merits of expanding the Long-Term Care Partnership Program, currently limited to four states, to all fifty states. The Partnership was designed to shift some of the financing of long-term care (LTC) from public sources to the private sector by encouraging individuals to purchase long-term care insurance. This issue brief examines the program goals of the four Partnership states and concludes that the Partnership should be considered as one of many tools states can employ in their efforts to reform Medicaid financing of LTC.
The Alliance for Quality Nursing Home Care / Implementing the Quality First Pledge
As part of a broader initiative to improve the quality of nursing home care in the United States, the Alliance for Quality Nursing Home Care ("the Alliance") developed the Quality First Pledge and Code of Conduct in July 2002. Based on seven principles, the Quality First Pledge and Code of Conduct outline specific and measurable steps that Pledge signatories must take to improve quality outcomes in nursing facilities over time. This report outlines the findings from a baseline assessment of the Alliance member organization’s progress toward meeting the elements of the Quality First Pledge. This assessment was intended to assist participating organizations and the Alliance leadership in identifying (1) where companies have successfully met the elements of the Pledge, (2) where companies are not successfully meeting the elements of the Pledge, and (3) which recommendations may help Alliance companies make progress toward fully implementing each element of the Quality First Pledge.
California HealthCare Foundation / Medicaid Disease Management Overview
Disease management continues to garner the attention of health policymakers as more and more states look to disease management initiatives to improve quality outcomes for beneficiaries with chronic conditions and to reduce health costs. This slide presentation, completed on behalf of the California HealthCare Foundation, provides an overview of disease management in Medicaid and incorporates lessons learned from some of the first Medicaid disease management programs.
Center for Insulin-Dependent Diabetes Access / Special Paper: The Center for Insulin-Dependent Diabetes Access Reimbursement Advisory Panel Meeting Summary
This paper, published in Diabetes Technology & Therapeutics, summarizes the proceedings of a panel on patient access to existing and new treatments for Type I diabetes. Panelists noted that despite clinical evidence, many important therapies are unavailable to patients due to reimbursement barriers. Panelists also discussed new technologies for the treatment of Type I diabetes such as islet cell transplantation, and identified possible next steps to obtain widespread coverage and payment for these technologies.
Center for Medicare and Medicaid Services / Generic Drug Cost Containment in Medicaid
In Medicaid, generic drug cost containment revolves around two programs: the Federal Upper Limit (FUL) and State Maximum Allowable Cost Programs. This article, published in the Health Care Financing Review Spring 2004 edition, analyzes state drug spending data and finds considerable variation in both size and pricing aggressiveness of these programs across states.
The Kaiser Family Foundation / Recent Growth in Medicaid Home and Community Based Service Waivers
This report describes changes in Medicaid home and community-based (HCBS) waiver program spending and participation over the last decade. The report also describes the unique attributes of HCBS waiver programs and how states use these attributes to target specific populations groups such as the physically disabled and persons with developmental disabilities. Based on a survey of waiver program administrators with details about the size and average time spent on waiting lists in 2002 for 171 HCBS waiver programs, the report concludes that use of this authority has expanded significantly over the past decade.
Foundation for eHealth Initiative / Financial Incentives: Innovative Payment for Health Information Technology
Misaligned incentives and payment policies have long been considered a major barrier to widespread adoption and diffusion of information technology in the US healthcare system. Those who pay for health information technology (HIT) are often not the ones who directly benefit from the technology investment. This report studies a range of private sector models that promote HIT investment and adoption. The use of HIT financial incentive programs is an active area in healthcare and one that continues to evolve. The report identifies the most common types of incentive models currently in use; presents details on specific programs associated with each type; highlights criteria for designing financial incentive models; and characterizes the various design decisions that providers and communities should consider when examining HIT incentive programs.
The Pew Charitable Trusts / Linking Reverse Mortgages and Long-Term Care Insurance
This report is intended to educate policymakers and major stakeholder groups about reverse mortgages, long-term care insurance, and the opportunities and challenges of implementing the program linking the two. The report concludes that using a reverse mortgage to fund long-term care insurance will be suitable for only a limited number of consumers, and that consumer education and counseling are critical for the appropriate implementation of this policy.
IBM Center for Healthcare Management / Health Information Technology Policy: Legislative and Regulatory Progress in 2003, and Prospects for the Future
Congress and federal agencies made significant progress on Health Information Technology (HIT) in 2003, particularly with passage of the new Medicare prescription drug benefit. However, serious obstacles to widespread HIT adoption in the healthcare delivery system remain. This report, sponsored by the IBM Center for Healthcare Management, reviews the legislative and regulatory record for 2003 and identifies key issues that remain as implementation of e-prescribing, disease management demonstrations, standards initiatives, and other new policies proceed.
Center for Insulin-Dependent Diabetes Access / Reimbursement of Diabetes Services and Supplies in Five State Medicaid Program
This brief analyzes Medicaid reimbursement for diabetes-related services and supplies to determine whether access is being unnecessarily restricted in the drive to cut costs. It provides an overview of benefit guidelines and reimbursement levels in five states — California, Colorado, New Jersey, Texas, and Washington. The brief also examines diabetes disease management programs in the five states. It concludes that Texas and California have potentially restrictive policies in place for the coverage of insulin pumps, and that access to these technologies needs to be monitored proactively going forward.
Kaiser Family Foundation / Oregon's Medicaid PDL: Will an Evidence-Based Formulary with Voluntary Compliance Set a Precedent for Medicaid?
Oregon's Practitioner-Managed Prescription Drug Plan differed from other state approaches to drug cost containment in that it established an evidenced-based drug review process and voluntary compliance for physicians. This case study (1) describes Oregon's cost containment policy; (2) assesses Oregon's results relative to two other Medicaid PDLs; and (3) presents key Medicaid stakeholder perspectives on the policy and its implementation. The Oregon policy is of significance because it will serve as a precedent for other state Medicaid programs and the Medicare prescription drug benefit.
Center for Health Care Strategies / Integrating Quality Into Pharmacy Cost Containment Initiatives in the Nursing Home Setting
The implementation of prescription drug cost-containment strategies in nursing homes represents new ground for states seeking to reduce Medicaid spending. As more states look to control spending in this environment, understanding how quality components can be integrated into emerging program designs becomes increasingly important. This brief provides an overview of the issues involved with designing and implementing clinical pharmacy management programs in nursing homes as well as examines successful examples of nursing home clinical pharmacy management programs.
Kaiser Family Foundation / Designing a Medicare Drug Discount Card: Implications of Policy Choices For Medicare Benficiaries and Card Sponsors
A Medicare sponsored drug discount card program has the potential to save beneficiaries money and also improve the quality of care by introducing drug use review programs that can prevent dangerous drug interactions. There are, however, important a range of policy design issues that will need to be addressed by the Congress and the Administration to ensure that the program will be viable. This study discusses the policy choices that need to be addressed from the perspective of the Medicare beneficiary.
Duke University / Medicaid Cost Containment and Potential Effects on Diabetic Patients
Diabetes is the sixth leading cause of death among adults, and one of the major cost drivers in the Medicaid program. This study assesses whether states that implemented cost containment for diabetic patients are also tracking the quality of patient care. It finds that most states are not collecting or studying data on HbA1C levels, and are not monitoring the effects of restrictive preferred drug lists (PDLs) on Medicaid beneficiaries with diabetes. It concludes that states and the federal government need to ensure that resources are available to monitor and assess quality under PDLs.
National Coalition for Cancer Survivorship / Industry Roundtable: Why Reimbursement Matters
Reimbursement is the process through which new medical technologies are assessed for coverage, coding conventions, and payment levels. Adequate reimbursement is critical for acceptance of new cancer therapies. This white paper explores the importance of reimbursement for cancer therapies and ways in which disease groups can become involved to help ensure that new therapies are available to patients.
Center for Health Care Strategies / Clinical Quality Initiatives in Medicaid
In light of budgetary pressures, states are focusing increased attention on pharmaceutical costs. The purpose of this study was to identify and profile the subset of Medicaid pharmaceutical cost containment techniques that promise to improve quality and reduce costs. A diverse group of stakeholders, including state and federal Medicaid officials, pharmaceutical companies, pharmacies, and health policy researchers participated in our process and had involvement in the study. Based on this report, the CHCS will fund other states to develop similar successful programs.
Center for Health Care Strategies / Dual Eligibles and Managed Care
Those dually eligible for Medicare and Medicaid tend to have more serious and complex medical, social, and long-term care needs than other Medicare and Medicaid beneficiaries. As a result, they generate higher healthcare costs and must often navigate within a complicated set of multiple payers and providers to obtain their care. This study describes the limitations associated with integrating Medicare managed care with Medicaid. The study looks closely at the barriers encountered by providers and states in the PACE program, Medicare demonstration waivers, and Medicare+Choice. It also recommends several methods policy makers can employ to change the existing programs and improve services, administration, and financing for providers that care for dual eligibles.
Kaiser Family Foundation / Michigan Medicaid's Pharmaceutical Cost Containment Program.
Based on interviews with individuals involved with or affected by the Medicaid pharmacy program in Michigan, the study (1) describes the preferred drug list and the process by which it was established; (2) gathers key stakeholder perspectives on the new policy and implementation of the program, particularly from the beneficiary standpoint; and (3) describes stakeholder views about how the new program may affect beneficiary health.
Medical Technology Leadership Forum / Local and National Medicare Coverage Policy
Coverage policy is a critical component of Medicare operations, as beneficiary access to new therapies, stewardship of the Medicare trust fund, and the ability of physicians to choose among competing effective technologies are dependent on timely and thoughtful coverage reviews. Currently, there are two non-exclusive pathways for obtaining Medicare coverage of new technologies: local coverage, via Medicare contractors (carriers and fiscal intermediaries); and national coverage, via the formal National Coverage Decision (NCD) process. This study describes both of these pathways in detail and discusses proposed options for modifying the process through legislation and agency regulations.
Kaiser Family Foundation / Florida’s Medicaid Prescription Drug Benefit: A Case Study
As states confront growing Medicaid deficits, Medicaid directors are looking toward their program’s prescription drug programs to help curb spending. Florida has been at the forefront of such activity, and in 2001 created a preferred drug list and mandatory prior authorization program expected to save the state $214 million/year. This case study describes Florida’s recent Medicaid prescription drug initiatives and incorporates the views of people involved with the passage and implementation of these initiatives regarding how the changes might impact the health of Medicaid beneficiaries.
Medical Technology Leadership Forum / Clinical Information Technology
Clinical Information Technology describes new and emerging medical systems that allow a remote interface to collect and transmit data between a patient and provider. This report summarizes a 2-day leadership forum on this subject, describing: the technology; perspectives of major stakeholders including patient groups, government payers, and technology companies; and the challenges that clinical information technology faces. It concludes with a series of policy options.
National Health Policy Forum / Prescription Drug Use in Nursing Homes: Facts and Issues
Although quality and cost issues related to prescription drugs have received increased attention in recent years, little is known about the specific issues related to prescription drug use in nursing homes. This policy brief explores various topics surrounding prescription drug utilization in nursing homes, including drug therapy, financing, the supply-chain, and quality issues specific to this setting.
Center for Health Care Strategies / The Essential Elements of Cost Estimation
Responding to the U.S. Supreme Court's Olmstead v L.C. decision, states are moving toward establishing or expanding home or community-based long-term care programs. This toolkit can help states identify the factors that determine the costs for these programs. The toolkit also provides examples and suggests data sources for collecting information states will need as they estimate their programs' effects.
Robert Wood Johnson Foundation / Health Information Technology Market
The healthcare industry has only recently begun to realize the efficiencies that incorporating information technology can afford and as a result, the healthcare landscape is undergoing a variety of technology-driven changes. This presentation identifies some of the most popular health information technology trends emerging as of October 2000, as well as some of the barriers that health plans, providers, vendors, and consumers will face as they attempt to embrace these new products.
