Community oncology networks (CONs) are expanding rapidly—and with that expansion comes a shift in how care is delivered, how decisions are made, and who holds influence. As private equity, payers, and artificial intelligence (AI)-driven care models reshape the landscape, the next five years will bring dramatic changes that ripple across stakeholders. 

This transformation will not be linear. Economic pressures, policy shifts, and evolving technology will interact in complex ways. Below are five forces to watch as CONs continue to grow their role as central players in oncology care. 

Financial Pressures Will Fuel Continued Consolidation 

Practice consolidation will likely accelerate, driven by a confluence of financial and structural pressures. Many physicians, facing decreasing reimbursement and retirement, are selling equity stakes in their practices. The Inflation Reduction Act (IRA), particularly its provisions for Part B drug price negotiation in 2028, will catalyze a significant revenue decline in physician reimbursement, prompting further consolidation among CONs and health systems. 

The rise of CONs like US Oncology Network, OneOncology, American Oncology Network, and Navista will continue, offering economies of scale and administrative capabilities that small practices may not be able to sustain on their own. These dynamics may create a tipping point for independent oncology practices, pushing them to seek stability in affiliation models​. 

Artificial Intelligence Will Influence Drug Selection and Pathways 

AI’s footprint in oncology is expanding. Initially focused on reducing administrative burden, AI integration efforts are beginning to support clinical decision-making by offering personalized or optimal treatment pathways for complex patient populations​. 

As these technologies mature, expect CONs to increasingly incorporate AI into pathway design, potentially reducing variation and cost across providers while also reinforcing their leverage with payers and manufacturers. 

Site of Care Shifts Will Redefine Access and Economics 

Complex therapies such as bispecific antibodies, CAR-T and gene therapies, and radioligand therapy, historically more commonly administered in hospitals, are expanding into community oncology practices. Due to the intricate nature of these treatments, additional infrastructure and economic resources are required to offer them. Given access to such resources, larger practices or those affiliated with CONs may be better positioned to facilitate expanded access to these therapies in the community setting. 

Meanwhile, therapies that were once infused—such as immunotherapies—are increasingly available in subcutaneous formulations, and some patients may even have these administered in the home setting. With policymakers and advocates considering expanded support for home infusion, CONs must prepare operationally and strategically to compete or collaborate with these lower-acuity settings. 

Value-Based Care Models Will Get Simpler, Smarter—and Stickier 

New value-based care models will return to a simpler design than the total cost of care models implemented in the past several years. Burdened by administrative costs, complexity, and challenges in measuring value beyond the cost of care, models like the Enhancing Oncology Model have lost favor. In their place, new arrangements are emerging that reward core quality metrics and integrate AI for process tracking, giving them the power to gain traction and stay in place​. 

Importantly, these shifts align with broader payer trends. Commercial and Medicare Advantage (MA) plans increasingly prioritize adherence to pathways, triage programs, and bundled payments, offering community oncology new levers for reimbursement and partnership. 

Payer Management Will Continue to Influence Decision Making 

As payers tighten control to manage costs under the IRA and beyond, CONs that demonstrate both quality and efficiency will be best positioned to win favorable contracts and patient access. 

Payer consolidation and the continued rise of MA enrollment are expanding utilization management (UM) efforts across oncology. While historically less affected by payer management, oncology is now seeing step edits, prior authorizations, tighter formulary management, and preferred drug status for both pharmacy and medical benefits.  

Actionable Takeaways for Stakeholders 

Over the next five to ten years, manufacturers, payers, and providers alike will need to: 

• Prepare for increased aggregation and shifting ownership models
• Anticipate AI’s role in influencing treatment decisions 
• Evaluate product portfolios and support programs for compatibility with new care sites 
• Simplify value-based care offerings while aligning with pathway-driven care 
• Strengthen payer engagement strategies, particularly with MA plans 

Patient advocacy organizations should also monitor these trends to ensure that patients with cancer can maintain access to care in a timely and safe manner. 

How Avalere Can Help 

Avalere supports clients navigating the evolving oncology landscape through tailored market assessments, scenario planning, and strategy development. Whether you’re evaluating the impact of the IRA, building value-based models, or assessing products that fit in CONs, we provide clarity and direction to complex challenges. 

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Individuals with rare disease face unique clinical circumstances that put them at increased risk for poor health outcomes and adverse events. For example, there is limited evidence on how best to deliver care for some rare diseases and specialized providers may only be available at major academic medical centers, which represents a significant barrier to accessing appropriate care. If a provider is less familiar with the patient’s rare condition, care decisions for other health needs may not consider the impact on the disease’s exacerbation or progression. These factors create unique challenges for achieving optimal quality: care that is safe, effective, efficient, equitable, timely, and patient-centered.

To determine whether and to what degree the core commonalities of rare disease care needs are addressed by existing quality improvement efforts and to identify opportunities to enhance rare disease care quality, Avalere conducted a landscape analysis of the existing quality measures, value-based care programs, and quality improvement initiatives. The targeted search aimed to identify major features of the quality landscape specific to rare diseases such as quality measures, improvement programs, and evidence-based care guidelines. Avalere used multiple tools, including the Avalere Quality Measure Navigator®, UpToDate®, and publicly available resources.

Avalere identified 34 active quality measures, 17 quality improvement programs, and 26 evidence-based care guidelines focused on rare diseases. The Up-to-Date database alone has more than 850 disease-specific care guidelines. The few existing quality improvement programs and patient registries for rare disease were spearheaded by patient advocacy groups, with the predominant focus on expediting time to diagnosis for individuals with rare diseases. Other improvement efforts focused on establishing specialized treatment centers designed to mitigate geographic barriers to treatment. Quality measures developed for rare diseases are not widely used or found in high-profile quality payment programs, and many measures have been discontinued or were never integrated into the Centers for Medicare and Medicaid Services’ reporting programs.

There is a clear opportunity for stakeholders to consider rare diseases collectively rather than individually. There are more than 7,000 rare diseases that together affect an estimated 25–30 million Americans, a population size rivaling those of the most common chronic conditions. Developing quality improvement initiatives, building rare disease common care guidelines, or implementing quality measures are strategies relevant for multiple stakeholders, and could have significant impact in improving care for these patients.

Download the free white paper.

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In December 2023, the American Diabetes Association (ADA) released its 2024 Standards of Care in Diabetes (2024 SOC). For 35 years, the ADA has developed and disseminated evidence-based clinical practice recommendations. These standards are updated annually and serve as a foundational resource for patients, providers, payers, researchers, policymakers, and other stakeholders seeking to provide quality care for people with diabetes (PWD).  

Since 2022, the ADA has recommended continuous glucose monitoring (CGM) beginning with diagnosis of type 1 diabetes (T1D) and type 2 diabetes (T2D) requiring insulin management. This is intended to promote detailed tracking and to allow for appropriate lifestyle modifications to improve disease management.  

In the latest guidance, the ADA underscores the benefit of emerging technologies, recommending that all PWD be offered any type of diabetes device, regardless of insulin use status. Furthermore, the 2024 SOC was updated to highlight device integration between CGM and automated insulin delivery systems (AIDs), outline the benefits of real-world data, and provide recommendations for facilitating the interpretation of CGM data.  

Overall, the 2024 SOC:  

• Highlights the importance of cultural sensitivity within the framework of person-centered care 
• Enhances language to provide healthcare providers with actionable insights (Section 12. Retinopathy, Neuropathy, and Foot Care) 
• Emphasizes the heterogeneity in older adult populations and corresponding need for personalized treatment goals 
• Includes costs of insulin and glucose monitoring devices, along with information on lowered insulin prices (Section 1. Cost Considerations for Medication-Taking Behaviors)   
• Centers language on the actions of healthcare professionals, rather than PWD 

The 2024 SOC includes several recommendations that will impact quality measurement and emerging technologies (Table 1).  Notably, there are 10 new recommendations, further highlighting the potential impact of diabetes technology on real-world clinical management for PWD. 

Table 1. 2024 SOC Updates Impacting Quality Measurement and Emerging Technologies 

Table 2. ADA Grading System  

The Evidence Cycle: Standards of Care and Quality Measurement 

There is a symbiotic relationship between standards of care and quality measurement. Both rely on a well-established evidence base. Given the lag between evidence and implementation, quality measures can serve as a fulcrum to encourage and incentivize best practices. Quality improvement efforts and quality measures data can in turn generate new evidence, upon which standards can be refined, modified, and updated. Quality measures are developed based on evidence-based guidelines like the 2024 SOC, and thus should reinforce the guidelines. However, there are few existing diabetes quality measures that reflect the guideline’s increasing focus on technological advancements, patient education, and patient-centered care.  

Guidelines are critical in informing policy and coverage decisions, and strongly influence clinical practice. While the 2024 SOC account for emerging technologies and patient preferences for PWD more than previous iterations, there is more work to be done in establishing updated measures that improve diabetes quality of care. 

Piloting Novel CGM Measures 

The Improving Diabetes Quality Initiative (iDQI), established in 2021 by Avalere, Beyond Type 1, and the Association of Diabetes Care & Education Specialists, is a national effort to improve diabetes care in the era of emerging technologies.  

iDQI’s initial phase of work involves the launch of a mixed-methods pilot study in a large academic medical center. The primary objective of this study is to test the feasibility of collecting data on a set of three new CGM-related measure concepts through completion of a feasibility scorecard that assesses data availability, standardization, and ease of extraction. Secondarily, the study aims to understand CGM workflow and standards of care through qualitative interviews with staff. This data will inform refinements to the measure specifications and elucidate current practices related to diabetes technology.  

iDQI’s measure concepts align closely to recommendations in the 2024 SOC. Several of the added recommendations and text related to personalized treatment goals, cultural sensitivity, and education emphasize the importance of shared decision making, while the focus on improving CGM interpretation highlights the importance of CGM data review. While iDQI is currently focusing on a specific subset of standards related to CGMs, the initiative plans to explore measurement for a broader range of innovative technologies in the future. 

Preliminary results of the pilot study will be shared at the upcoming International Conference for Advanced Technologies & Treatments for Diabetes.

To learn more about iDQI is’ activities or to get involved, please email Naila Wahid. To learn more about diabetes or quality improvement, connect with us. 

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Without a national value assessment agency like the UK or Germany, independent third-party health technology assessment (HTA) organizations in the US inform coverage decisions, formulary placement, and pricing. The most prominent of these HTA organizations is the Institute for Clinical and Economic Review (ICER), a non-profit entity that conducts similar value assessments as those conducted in Europe.

ICER’s framework is influential in plans and policymakers’ understanding of drug value. It measures cost effectiveness using the incremental cost-effectiveness ratio, which is the cost per unit of health benefit gained from one treatment compared to an alternative. ICER uses equal value life year gained (evLYG) as its primary measure of health gain. In its 2020 framework, ICER’s primary health benefit unit was the quality-adjusted life year (QALY), a unit that faced substantial opposition from patient advocates and policymakers, arguing that QALYs have inherent bias due to disparities in care, given that QALYs adjust the value of each life year based on age and disability status; evLYGs do not make this adjustment and are positioned as a better alternative. Using the incremental cost-effectiveness ratio, ICER determines the maximum price at which a drug would be cost-effective given values of $100,000 and $150,000 per evLYG.

The Generalized Risk-Adjusted Cost-Effectiveness (GRACE) framework attempts to capture patient preferences related to severity. Proposed in 2020, GRACE is based on the understanding that health produces happiness with diminishing returns, and that seemingly equivalent improvements in quality of life should hold greater weight for patients with more severe conditions. ICER is the first HTA agency in the world to implement the GRACE framework. The framework is expected to bring significant changes to the scope and outputs of ICER’s assessments, embedding the impact of illness severity on quality of life into value assessment. GRACE aligns with traditional economic thinking on diminishing returns and allows decision thresholds to account for patient-centered considerations like health equity and patient risk aversion in health consumption.

Another indication of the growing influence of patient-centered value can be found in the Inflation Reduction Act (IRA), which gives the Centers for Medicaid and Medicare (CMS) the authority to negotiate lower drug prices for Medicare. The IRA’s introduction of government price negotiation will formalize value assessment during later stages of the product life cycle and require manufacturers to develop an evidence-generation program to support the shifting value requirements over the entirety of the product life cycle. CMS may also use this value assessment to avoid fiscal challenges and navigate investment decisions.

Although stakeholders are primarily focusing on patient perspectives on the value of healthcare services, some are pushing back on established value frameworks. As previously mentioned, some stakeholders are looking to ICER to reduce or remove the use of QALY/evLYG shortfalls as a proxy for disease state severity. Stakeholders were also looking to ICER to incorporate additional quantitative elements of value (e.g., those described in the International Society for Pharmacoeconomics and Outcomes Research’s Value Flower) in its methodologies. However, ICER did not propose these changes. True patient-oriented value assessment requires quantifying and integrating patient-centered outcomes, treatment preferences, and the full spectrum of patient costs into the quantitative methods used to calculate value. While these methods have emerged recently and continue to be refined, they are not being implemented by ICER, the American Society of Clinical Oncology, or ex-US HTAs such as the UK’s National Institute for Health and Care Excellence.

Look for future Avalere Insights and webinars on top trends in HEOR, including policy’s pressure on HEOR and HEOR as a differentiator, and view the related webinar on value assessment for HEOR. To learn more about how Avalere’s evidence and strategy experts can help you stay on top of this evolving landscape and support your HEOR initiatives, connect with us.

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Figure 1. Rates of Unique Medicare FFS Patients with a Home Dialysis Service in the Given Quarter

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Figure 1. Difference in Total Healthcare Spending and OOP Costs PMPM by BMI Group

Figure 2. Difference in Total Healthcare Spending PMPM by BMI Group and Comorbidity

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Methodological Gaps Addressed by GRACE

Current CEA practices, including those adopted by ICER, do not allow monetary decision thresholds to vary by disease, leaving HTAs with uncertainty about when exceptions to traditional thresholds should be made, such as in the case of rare diseases or end-of-life care. This uncertainty leaves decision making to the discretion of HTA bodies. Critics of traditional CEA argue that HTA bodies often fail to use these discretionary powers and therefore discriminate against severely ill and disabled individuals.

GRACE introduces the concept of diminishing returns to health so that individuals with severe illness will be recognized as benefiting from greater incremental value of therapy. An equal increase in QoL is considered to hold more weight among individuals with severe conditions than among those with milder diseases, and decision thresholds are therefore increased accordingly for more severe states. GRACE also incorporates the assumption that those with more severe conditions are more willing to trade remaining life expectancy for increased quality of life. Furthermore, GRACE accounts for the effects of uncertain health outcomes through inclusion of risk aversion of health.

In response to growing interest from international HTA programs in capturing risk aversion and severity, in 2021 the GRACE developers proposed updates to the framework to ease implementation. These updates included simplifying the methods for estimating life expectancy versus QoL trade-offs, updating methods for estimating risk preference, and expanding the risk preferences included, along with a step-by-step guide for implementation.

ICER is the first HTA agency internationally to implement the GRACE framework. This change is expected to bring significant changes to the scope and outputs of ICER’s assessments, embedding the impact of illness severity on QoL into value assessment outcomes in order to guide reimbursement decisions for the first time. Numerous questions remain, however, regarding feasibility of data input collection and weighting of these inputs within a CEA, among others.

Estimating New Parameters

GRACE introduces new modeling parameters that are intended to expand from traditional CEA modeling to account for disease severity and disability through the incorporation of the impacts of diminishing returns to health and the increasing willingness to pay as QoL decreases, based on an index of illness severity.

GRACE requires estimation of a new parameter for relative risk aversion in health, allowing initial untreated health status to influence willingness to pay for health gains. This has not been previously estimated directly, though methods exist that could support estimation, which would need to be applied globally across treatments and therapeutic areas to support broader application of GRACE.

Severity of illness is estimated in burden of illness literature and does not require new specialized estimation. New criticisms may arise in the comparability of these estimates across studies and therapeutic areas when CEA uses these estimates to adjust the value of health gains based on initial health state.

Conclusion

ICER’s approach to piloting GRACE remains to be seen, and several questions are outstanding, including whether a new evidence base needs to be established for estimating new parameters before evidence is generated that may be leveraged by decision makers. While this new method does account for patient risk aversion in health consumption and preferentially treats health gains for disability and severe illness, concerns exist about the methods used to compare burden across illnesses and how risk aversion is measured and varies for patients of different health states with different diseases characteristics.

ICER’s Value Assessment Framework does not provide insight into how the organization intends to address these questions but notes that it will engage with its Health Economics Council, Methods Advisory Group, and international HTA bodies to test the feasibility and impact of shifting to this new CEA approach.

Navigating the Evolving US HTA Landscape

ICER has indicated that it may issue an interim update formalizing the systematic use of this framework. Avalere’s expertise in value assessment and HTA can help pharmaceutical manufacturers, advocacy groups, patients, and other stakeholders proactively develop position statements, analyze the impact of ICER’s proposed new method, and develop preparation and response strategies including health economic modeling in the event of an HTA review.

To learn how Avalere can support you with analysis, strategy development, and response planning, connect with us.

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• Thousands of rare diseases fragmented into small patient populations make it more onerous to understand the clinical manifestations and patient impacts of each rare disease.
• Small patient populations also pose challenges in clinical trial recruitment, where issues around equity, access to care, and representation may be exacerbated due to lacking availability of trial sites.

• The diagnostic journey for patients with rare diseases is long compared to more common diseases, with a high likelihood of initial misdiagnosis.
• Patients and their caregivers may face additional cost burdens associated with testing and treatment options.
• Delayed diagnosis can result in diagnosis at a later stage, with greater impacts on the patient; this is especially relevant for conditions that have cumulative non-recoverable degenerative impact.

• The lack of approved treatments in most rare diseases poses ethical challenges with placebo arms in randomized control trials, requiring innovative approaches to control groups and use of real-world data.
• Patients may face delays in navigating insurance coverage and support programs for high-cost drugs with small target patient populations.

• Specialists who have the experience and knowledge to diagnose and treat a rare condition are usually located only at major academic medical centers.
• A lack of expertise at local providers and healthcare systems may result in a delayed diagnosis, disruptions in treatment, or inappropriate care.
• Rare diseases have disproportionate and severe impacts on children and require significant time and resources from caregivers.

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Key Findings

• MA serves a higher proportion of beneficiaries with clinical and social risk factors than FFS.
• MA serves a higher percentage of beneficiaries who identify as a racial or ethnic minority than FFS (28.1% in MA vs. 12.8% in FFS).
• Regardless of condition, MA beneficiaries in the chronic condition subgroups spend less overall on healthcare than FFS beneficiaries.
• MA beneficiaries in the study had lower utilization rates of high-cost services such as inpatient stays and emergency room visits than FFS beneficiaries.

While additional research is necessary to explore the factors driving differences between MA and FFS, the findings suggest that demographic differences between these Medicare populations exist, that spending on care is lower in MA, and that outcomes on select quality measures are comparable to FFS.

 Read Avalere’s full report on this BMA-commissioned analysis.

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Figure 1. The Hospital at Home Model

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iDQI’s mission is to improve the quality of diabetes care and change the standards of care in an era of new and emerging diabetes technology. iDQI aims to create a multi-stakeholder diabetes community united in advancing evidence-based, high-quality, person-centered, and equitable access to care, technology, and services. As one of its initiatives, iDQI convened a TEP in 2021 to curate a diabetes quality measures portfolio of existing measures and novel measure concepts. The TEP prioritized three concepts for further development:

1. Shared decision making regarding CGM initiation to assess the value of initiating CGM for disease management
2. CGM utilization to address disparities in access and use of CGM
3. Review of CGM data to mitigate clinical inertia, while encouraging collaborative review between clinicians and people with diabetes ongoing management and care plans

Next Steps for Measure Development

Following the publication of the measure specifications, iDQI is now preparing to conduct feasibility testing of these quality measures in a clinical setting to refine the specifications and to better understand evolving standards of care for diabetes technology. The measure development and testing is part of a broader initiative managed by Avalere Health in conjunction with the Association of Diabetes Care & Education Specialists and Beyond Type 1, with support from Abbott Diabetes Care and Dexcom. ​

Learn More

Avalere applies our expertise in stakeholder convenings, real-world evidence generation, learning collaboratives, and diabetes technology to help healthcare stakeholders understand the diabetes landscape to reach their corporate objectives. To learn more about iDQI or how to get involved, connect with us.

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Figure 1. iDQI Activity to Date

Figure 2. Potential Opportunities for iDQI

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MA Plan Considerations for Increasing Enrollment of Patients with ESRD

With this enrollment growth, many MA organizations have reevaluated their care-management approaches with the goal of reducing financial risk for the costly and complex treatment of this disease. While MA plans are paid an adjusted rate to cover enrolled patients on dialysis, a previous Avalere analysis indicated that MA plans may be paid at rates below the actual costs paid by Medicare FFS. Further, studies have shown that MA organizations pay a higher per-dialysis treatment rate to dialysis facilities than Medicare FFS. Despite calls by certain stakeholders to modify the payment methodology to MA plans for enrollees with ESRD, CMS has not modified this risk-adjustment methodology. Most recently in the Calendar Year 2024 MA and Part D Advance Notice released in February 2023, CMS proposed to continue paying plans on a statewide basis, as opposed to a smaller geographic area.

For MA organizations, the potential underpayment for covering these beneficiaries, compounded with the higher reimbursement rates to dialysis providers, presents new challenges as enrollment for this population has grown in recent years. To allow MA organizations additional flexibility when contracting with dialysis organizations, CMS updated network adequacy standards by removing outpatient dialysis facilities from the types of providers that must meet time-and-distance requirements beginning in 2021.

Approaches to New and Innovative Partnerships

To offset some of the costs of providing care to patients with ESRD, MA plans have turned to partnerships with new and innovative kidney care management companies (e.g., Interwell Health, Somatus, Monogram Health, Strive). Through these partnerships, plans aim to provide high-touch care to both patients with ESRD and patients with CKD who have not initiated dialysis. To attempt to reduce the total cost of care, these organizations have focused on addressing existing barriers to care, including providing care coordination and care management services, offering in-home and remote care, supporting patient education, and conducting analytics aimed at earlier disease diagnosis.

MA plans and these care management organizations typically engage in value-based arrangements, though the terms of these contracts are highly variable as kidney care management companies have differentiated capabilities. For example, a third-party care management company could take on financial risk associated with patient management, in return for the opportunity to earn shared savings payments. Despite these entities’ recent entry into the kidney care landscape, they have established value-based and risk-bearing contracts with payer organizations. For example, Somatus recently expanded its care partnership with UnitedHealth Group to additional markets, and Monogram expanded its home-focused program with Cigna to all patients covered under Cigna MA plans.

Many of these partnerships are still in their early stages, and it remains unknown if these value-based arrangements will translate to meaningful improvements in care delivery and cost reduction. Importantly, this increased focus in care management and value-based care mirrors efforts created by the Center for Medicare & Medicaid Innovation through a series of mandatory and voluntary models seeking to facilitate better care and reduced costs for the treatment of these conditions. These models seek to propel increases in kidney transplant rates, home dialysis utilization, and other measures to drive higher-quality care at reduced costs to the Medicare program.

Looking Ahead

Avalere leverages deep expertise in policy, market access, data analytics, and quality disciplines to assess MA enrollment and broader kidney care trends. To learn more about the evolving kidney care environment and how Avalere can help your business drive access and continuity of care, connect with us.

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Traditional methods of assessing diabetes management—blood glucose monitoring (BGM) and A1C— are average measurements that do not reflect glycemic variability or hypoglycemic events. Newer technologies like continuous glucose monitoring (CGM) devices and automated insulin delivery systems that pair with CGMs can provide longitudinal data that depict glucose variability and other valuable metrics, including percentage of time spent in, above, and below target ranges.

Evidence suggests that wearing a CGM that assesses real-time blood sugar results may be beneficial for improving glycemic control, understanding variability, and promoting lifestyle changes. However, standards of care for diabetes have not yet been updated to reflect this evidence.

Overview of Standards

On December 12, the American Diabetes Association (ADA) released its 2023 Standards of Care in Diabetes (Standards of Care). For over 30 years, ADA has played a major role in the development and dissemination of the latest evidence-based clinical practice recommendations. Updated annually, the Standards of Care are considered the gold standard for healthcare stakeholders (e.g., patients, providers, payers, researchers, policymakers) seeking to provide quality care for people with diabetes. The Standards of Care offers recommendations for diabetes prevention, screening, diagnosis, treatment, and optimal management of related complications, with each recommendation assigned a rating of A, B, C, or E (expert opinion) based on the quality of the evidence reviewed. Evidence-based guidelines are critical in developing quality measures, making relevant policy decisions, influencing coverage decisions, and changing clinical practice.

Since 2021, the ADA has recommended CGM access from the outset of a diabetes diagnosis (e.g., type 1 diabetes, type 2 diabetes requiring insulin management) to promote detailed tracking and to allow for appropriate lifestyle modifications. The ADA has also recommended uninterrupted access to CGM devices to prevent worsening of outcomes.

Below is a summary of revisions that are most relevant to quality measurement and emerging technologies in the 2023 edition:

The inclusion of recommendations related to CGMs and automated insulin delivery systems in the 2023 Standards of Care provides a starting point for evidence-based progress in diabetes care.

Translating Standards into Quality Measures and Initiatives

When designing quality measures, measure developers (e.g., the Centers for Medicare & Medicaid Services, the National Committee for Quality Assurance) may refer to evidence-based recommendations like the ADA Standards of Care. However, existing diabetes measures do not reflect the recent shift in clinical recommendations accounting for technological advancements and patient preferences.

The healthcare sector has been slow to adapt to changes in technology because clinical practice, reimbursement, and measurement tend to follow evidence-based guidelines. The lag between the development of new technologies and changes to the standards suggests a need to generate evidence to account for emerging technologies and other innovations in care delivery. As diabetes stakeholders call for updated measures to improve diabetes management and quality assessment, the most recent Standards of Care editions have started to reflect emerging technology for people with diabetes.

Along those lines, several initiatives have been launched in an effort to match the changing diabetes landscape. For example, the National Committee for Quality Assurance recently revealed plans to update its diabetes recognition program and develop new diabetes measures.

Introducing the Improving Diabetes Quality Initiative

Following the example set by leading diabetes stakeholders, in 2021, Avalere Health—along with Beyond Type 1 and the Association of Diabetes Care & Education Specialists—launched the Improving Diabetes Quality Initiative (iDQI). The iDQI is a national effort to improve diabetes care in the era of emerging technology, such as CGMs.

As an initial phase of work, the iDQI is testing the feasibility of a set of CGM-related quality measures in a pilot study to identify individuals who may benefit from emerging technologies for diabetes management, elucidate disparities in access and uptake of diabetes technology, and encourage patient-provider shared-decision making.

iDQI’s measure concepts align closely to recommendations in the 2023 Standards of Care. For example, the ADA’s recommendation for patients to choose a CGM device based on their circumstances, preferences, and needs supports the shared-decision making measure. While the iDQI is currently focusing on a specific subset of standards relevant to evolving the landscape of diabetes care, the initiative plans to explore measurement for a broader range of innovative technologies in the future.

The iDQI seeks to advance care delivery and quality that is reflective of the current diabetes technology environment. Generating real world evidence on the barriers and facilitators to diabetes technology use can support a shift in recommended standards, which will likely have downstream effects on payers and providers regarding the adoption of modern diabetes technology.

Additional information about the iDQI can be found in the program invitation. If you have any questions about iDQI or are interested in learning more about ways to get involved, please email Naila Wahid.

To learn more about quality improvement, connect with us.

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About Laura Housman

Laura brings extensive expertise in strategy, evidence generation, reimbursement and pricing, patient communications, population health, and personalized medicine to drive access to innovation across healthcare.

Before joining Avalere, Laura was chief commercial and operations officer of the diagnostic company Olaris. She also founded Access Solutions Consulting, which serves an extensive network of pharmaceutical, medical device, and diagnostic companies. Prior to that work, Laura developed a function and led a team developing novel real-world evidence, population health initiatives, and market access solutions for a broad range of diagnostic assays at Exact Sciences. She also led the Market Access, Pricing, and Health Economics & Outcomes Research group within Novartis Pharmaceutical Corporation’s global pharma/molecular diagnostics unit and was executive director of marketing for Charles River Laboratories, focused on the commercialization of its worldwide preclinical, first-in-human, and biopharmaceutical services. Additionally, Laura served as director of marketing for Genzyme Genetics, where she spearheaded marketing and commercialization strategies in support of managed care outreach.

“I have dedicated my career to driving access to healthcare innovation for patients,” says Laura. “Evidence of positive impact of interventions through rigorous study, patient-reported outcomes, and scalable strategies is fundamental to broad access, and I am thrilled to be joining Avalere Health to further build the exceptional Evidence & Strategy team and its expertise in support of our clients.”

In addition to her work within the industry, Laura spent a decade leading health services evaluation, contracting, and provider profiling initiatives as a director within not-for-profit healthcare insurance plan Blue Cross Blue Shield of Massachusetts. Laura is also an active advisor on a number of industry and volunteer boards, including serving as a Merit Reviewer for the Patient-Centered Outcomes Research Initiative.

Laura holds a Master of Public Health, a Master of Business Administration, and a bachelor’s degree in economics from Boston University. She is currently a candidate for Doctor of Public Health at Boston University.

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Shareef provides due diligence and advisory support to financial sponsors investing in the healthcare sector and their portfolio companies. His work focuses on assessing the policy, regulatory, reimbursement, and commercial considerations that may impact investment opportunities across the spectrum of healthcare services, pharmacy, managed care, and digital health.

From 2012 to 2016, Shareef worked closely with healthcare investors and stakeholders as part of Avalere’s emerging due diligence advisory services team. Prior to rejoining in 2023, Shareef held a variety of leadership roles within growth-stage digital health organizations, building expertise in value-based care enablement, health plan administration and cost containment, and employer-sponsored benefits.

“Avalere has consistently been a crucial voice in this ever-changing healthcare market,” says Shareef, “and I’m grateful to have the opportunity to work alongside this amazing team once again.”

Shareef holds a Master of Business Administration from the University of Chicago and a bachelor’s degree in public health from The Johns Hopkins University.

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• MA patients with prediabetes who later developed type 2 diabetes received their type 2 diagnosis earlier (relative to the date of the prediabetes diagnosis) than FFS patients.
• MA patients with incident diabetes were more likely than FFS to fill prescriptions for medications to treat diabetes and related conditions within the first year of diagnosis.
• While similar rates of primary care provider visits occurred between MA and FFS patients with chronic diabetes, MA patients were more likely to receive diabetes-specific preventive care, including diabetes-related office visits and testing for kidney disease.

Funding for this research was provided by Better Medicare Alliance.

To learn more about how policy affects outcomes, connect with us.

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Two objectives of the QIP are to promote transparency and influence decision-making for healthcare consumers; as such, dialysis facilities are required to post their QIP scores, and CMS publicly reports all scores. CMS also annually evaluates quality measures for inclusion based on importance, validity, and performance gap, and publishes proposed and final changes in its annual ESRD payment rule. This has been particularly relevant in the last three years in light of the COVID-19 pandemic and the focused lens on health equity.

The QIP has evolved drastically over the last 10 years, driven by rising healthcare costs and drug prices, the disproportionate and expanding impact of ESRD on racial and ethnic minorities, and worsening clinical outcomes that continue to highlight ESRD as one of the most expensive conditions to treat in the US health care system. The QIP began with three measures and currently includes 14, weighted and distributed across four measure domains:

1. Patient and Family Engagement (e.g., In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems)
2. Care Coordination (e.g., Standardized Readmission Ratio)
3. Clinical Care (e.g., Standardized Fistula Rate)
4. Safety (e.g., Medication Reconciliation)

The QIP has received scrutiny in recent years, showcasing in some studies that the incentives from the QIP disproportionately penalize facilities serving the most vulnerable populations. To address this, CMS has explored improvements in data collection methods, such as the possibility of building an ESRD facility equity score that would synthesize results for a range of measures using multiple social risk factors, such as the dual-eligibility status, race, and ethnicity of the Medicare beneficiaries a facility serves. CMS continues to collect feedback for future development and expansion of health equity quality measurement efforts.

Avalere continually monitors updates and changes to the QIP to advise our clients how those changes could impact various stakeholders. For more information on how Avalere can help to provide support on quality issues and the ESRD market, connect with us.

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Figure 1. Enrollment Distribution Across MA-PD Contracts by Star Rating, 2020–2023*

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