More Brand Drug Makers Scramble To Make Deals With Trump
Big brand drug makers are scrambling to make deals with President Trump after Pfizer scored White House praise for making drug price concessions. Some of the other firms are upset with Pfizer as it increases pressure on them to cut deals as well. The White House says agreements could be announced as soon as this week, but the timing could slip.
I have a blog coming tomorrow on drug price reform so far this year and why the brand drug makers are hoodwinking Trump and his advisors with these deals. See it at the blog tab tomorrow.
In other news, a federal appeals court unanimously rejected a Novo Nordisk challenge to Medicare’s drug price negotiation program for 2025 negotiations. The ruling will allow the government to lump together products with the same ingredients for the purpose of choosing drugs for negotiation. Novo Nordisk argues the government was limited to negotiating 15 drugs and could not bundle some together, such as insulins and GLP-1 weight loss drugs.
Judges have ruled against drug makers and their supporters at least 15 times since the Medicare drug negotiation law came into effect.
Final guidance for the third round of Medicare drug price negotiations (2026 negotiations for 2028 prices) was also announced and Health Affairs Forefront blog does a good job outlining it. The 2025 negotiation results for 2027 pricing of 15 drugs will come out in late November.
Additional articles: https://www.statnews.com/2025/10/07/appeals-court-ruling-medicare-price-negotiations-novo-nordisk/ and https://www.healthaffairs.org/content/forefront/administration-releases-medicare-drug-price-negotiation-program-final-guidance-2028
(Some articles may require a subscription.)
#drugpricing #branddrugmakers #ira #trump
https://www.statnews.com/2025/10/07/trump-drug-pricing-deals-with-pharma-companies-after-pfizer/
Government Shutdown Saga Continues
The government shutdown continues with no movement on funding or agreement on healthcare issues. Democrats rejected the idea of a one-year extension floated by some Republicans. A permanent extension is likely something the Republicans will not do. President Trump also seemingly backed away from his soft statements on healthcare talks, saying Democrats need to agree to government funding first. But there is a clear fracture growing in the GOP on the extension of Exchange enhanced premium subsidies. There are also hints of quiet talks between lawmakers on each side of the aisle to reopen government and address some healthcare issues.
More data coming out on the impact of the subsidy expiration: Healthcare policy group KFF has a briefer and column on Exchange premium hikes. Subsidized enrollees are facing an average 114% hike between filed rate hikes (18% on average) and lost enhanced credits.
Health Affairs Forefront blog traces the damage that has already been done by not acting to extend in time. Premiums likely are already higher than they should be and cannot be rolled back in full. Soon, enrollees will learn of premium hikes and make decisions to abandon coverage. While extending the credits is important, the delays have already had their impact. KFF also indicates it may be too late to change rates for 2026, but extending the credits would take most of the sting out.
In other news, states are already ratcheting down provider payments in Medicaid due to state budget pressures and anticipated reductions at the federal level. Idaho and North Carolina have lowered Medicaid payments and other states are expected to follow suit to offset budget shortfalls.
As well, because the federal government is doing nothing about the severe erosion of primary care, states, educational institutions, and health systems are attempting to fill the void. This includes free tuition and some other funding.
And dueling facts on the Exchanges subsidies. Health plan lobby AHIP extols the virtue of the subsidy enhancements in terms of popularity and affordability. It discusses the huge surge in premiums and the fact that fraud prevention was already tackled in the One Big Beautiful Bill Act (OBBBA). But the conservative Paragon Institute continues to add to its studies on the massive fraud and phantom enrollees it sees due to the subsidy changes during COVID. The think tank argues: “So long as free or nearly free plans are available, fraudsters will continue to exploit this loophole to game the system, abuse innocent citizens, and collect billions from taxpayers.”
Additional articles: https://www.modernhealthcare.com/providers/mh-primary-care-shortage-funding/ and https://www.modernhealthcare.com/providers/mh-state-medicaid-reimbursement-rates-cuts/ and https://thehill.com/homenews/house/5543942-enhanced-subsidies-gop-democrats/ and https://www.healthaffairs.org/content/forefront/damage-inaction-aca-tax-credits-has-begun-and-grow-further-delays and https://www.kff.org/quick-take/a-steep-subsidy-cliff-looms-for-older-middle-income-enrollees-if-aca-enhanced-tax-credits-expire/ and https://www.kff.org/quick-take/is-it-too-late-for-aca-insurers-to-change-their-premiums/ and https://www.ahip.org/news/articles/the-facts-about-health-care-tax-credits and https://paragoninstitute.org/private-health/ghostbusting-aca-fraud-millions-who-dont-use-their-health-insurance-expose-abuse-in-the-program/
(Some articles may require a subscription.)
#governmentshutdown #congress #trump #healthcare #coverage #exchanges #medicaid
https://www.medpagetoday.com/washington-watch/washington-watch/117849
Physicians Enraged Over Downcoding At Cigna, Aetna
Physicians and hospitals are enraged over a series of downcoding policies from health plans. The two recent ones are from Cigna and Aetna. Providers argue the policies are simply meant to reduce payments and will lead to major administrative costs for them. Plans argue the practices will reduce aggressive coding.
Under a policy Cigna is rolling out, six Current Procedural Terminology Evaluation and Management (CPT E&M) billing codes are being automatically downcoded for services such as office visits and outpatient consultations.
Aetna has a more targeted downcoding related to some Medicare Advantage (MA) hospital admissions. They will be automatically approved but reimbursed at lower observation rates later if the health plan does not believe criteria are met. A recent MA prior authorization reform puts decision-making on inpatient admissions in the hands of physicians but does maintain health plans’ ability to scrutinize claims payment.
(Article may require a subscription.)
#medicareadvantage #healthplans #priorauthorizations #claimsdenials
https://www.modernhealthcare.com/insurance/mh-aetna-cigna-downcoding-policy-explainer
— Marc S. Ryan
