GLP-1 BALANCE Model On Hold
The Trump administration’s effort to bring GLP-1 drugs for the obese to Medicare, BALANCE, is on hold. The Centers for Medicare and Medicaid Services (CMS) planned to negotiate lower GLP-1 prices for Medicaid and Medicare Part D coverage and have health plans and pharmacy benefits managers (PBMs) agree to offer the drugs in the programs. But too few applicants applied to participate, likely due to costs and risk. Critical mass in Part D, covering 80% of Part D enrollment, was not met. The Medicaid portion of the pilot will still move forward. In Medicare, to gather necessary data, CMS now plans on funding coverage via the temporary BRIDGE pilot through the end of 2027 before proceeding again with BALANCE.
At the same time, UnitedHealthcare said it was hoping to participate in both the BRIDGE program in 2026 and in BALANCE.
Additional articles: https://www.beckershospitalreview.com/glp-1s/cms-pauses-weight-loss-balance-model-indefinitely-for-medicare/ and https://www.beckerspayer.com/payer/medicare-advantage/unitedhealthcare-eyes-cms-balance-glp-1-model/
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#glp1s #weightlossdrugs #drugpricing #medicare #partd #medicareadvantage #pdp #medicaid #managedcare
https://www.modernhealthcare.com/politics-regulation/mh-medicare-glp-1-weight-loss-coverage
Cuban Tells Congress: “Don’t Be A Wimp”
Cost Plus Drugs Founder Mark Cuban told Congress: “Don’t be a wimp,” as he challenged Congress to break up the healthcare industry’s biggest conglomerates to restore a competitive and efficient market. He said that the healthcare industry is cowed by major insurers and pharmacy benefit managers (PBMs). He cited the potential fix of passing the Break Up Big Medicine Act, which would tackle vertical integration. He challenged the executive branch to do the same.
#cuban #pbms #healthcare #healthplans
https://www.fiercehealthcare.com/payers/dont-be-wimp-mark-cuban-tells-lawmakers-hesitant-break-pbms
United Beats The Street
Despite certain performance being lower than the previous year’s quarter, UnitedHealth Group beat The Street principally due to conservative projections. Its stock soared as a result. It also boosted its 2026 profit outlook.
It reported $6.28 billion in Q1 profit, down from $6.3 billion in Q1 2025. First-quarter revenue increased 2% year over year to $111.7 billion. United services unit Optum’s first-quarter financial performance decreased 15.3% to $3.3 billion in Q1. UnitedHealth Group’s medical loss ratio (MLR) decreased to 83.9% from 84.8% from Q1 2025.
As part of its recovery plan, United says it expects to lose 1.3 million Medicare Advantage (MA) members and shrink its individual ACA enrollment by roughly one-third in 2026. It was buoyed by a partial rate restoration in MA in 2027.
United will invest $1.5 billion in AI.
Additional articles: https://www.modernhealthcare.com/insurance/mh-unitedhealth-optum-earnings-ai-prior-authorization/ and https://www.beckershospitalreview.com/finance/unitedhealthcares-deliberate-trade-off-for-margin-recovery/ and https://www.beckerspayer.com/financial/unitedhealth-group-reports-6-2b-q1-profit-7-notes/ and https://www.beckerspayer.com/virtual-care/unitedhealth-is-spending-1-5b-on-ai-this-year-heres-where-the-money-is-going/ and https://www.healthcaredive.com/news/unitedhealth-hikes-2026-profit-outlook-q1-results/817993/ and https://www.modernhealthcare.com/insurance/mh-unitedhealth-earnings-outlook-optum-ai/
#healthplans #margins #ai #unitedhealthcare
CMS Orders States To Audit Providers
Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz said his agency will require every state to formulate a plan to revalidate participating Medicaid providers, particularly those in “high-risk” areas. This will include auditing healthcare providers participating in Medicaid to address alleged fraud. Oz noted there may be a state where 5,000 providers are listed as offering services, but fewer than a fifth of that number actually respond to queries about their identities and whether they’re licensed to offer that care. Oz said that states would have 30 days to submit a plan on how they would tackle the revalidations.
Additional article: https://www.beckershospitalreview.com/legal-regulatory-issues/cms-to-require-states-to-audit-medicaid-providers/
#medicaid #fwa #cms #states
Employer Groups Lobby Congress On Healthcare Costs
A curious business coalition is emerging to lobby Congress to reform healthcare given huge cost surges in the employer world. The Small Business Majority, the Purchaser Business Group on Health, the National Alliance of Healthcare Purchaser Coalitions are all lobbying for change. These include small, medium, and large businesses.
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#employercoverage #congress #healthcare #coverage
— Marc S. Ryan
