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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 through the end of 2027 before proceeding with the model.

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

United To End Most PAs On Rural Hospitals

Responding to the rural health crisis and its own bad PR, UnitedHealthcare says it will exempt rural hospitals from most prior authorizations. This will apply across all lines of business. United will also accelerate payments by up to 50% for about 1,500 rural hospitals and all critical access hospitals across the country.

Additional article: https://www.beckerspayer.com/payer/unitedhealthcare-pares-back-prior-authorizations-speeds-up-payments-for-rural-providers/

#unitedhealthcare #priorauthoriztaion #ruralhealthcare

https://www.fiercehealthcare.com/payers/unitedhealthcare-unveils-pilot-accelerate-payments-rural-hospitals

PCP Stability In Doubt

Elation Health finds that over 80% of primary care physicians (PCPs) are concerned about financial stability over the next several years. The company surveyed 280 PCPs from Jan. 31 to Feb. Fifty-two percent of respondents were fully independent and 48% have some affiliation. 

About 64% cite government and commercial payer reimbursement as their top concern. Staffing costs, workforce challenges, technology and IT costs and rising operational costs are also challenges.

Despite all this, 93% of respondents report remaining committed to primary care. Only 2% report planning to leave the practice. 

#providers #physicians #margins

https://www.fiercehealthcare.com/providers/over-80-pcps-concerned-about-financial-stability-over-next-several-years-elation-health

Trump Getting Serious On Affordability

There was a clear sign today that the Trump administration is worried about the impact of the lack of healthcare affordability. The Trump administration created a top-level healthcare position that will be a de facto affordability czar. Health and Human Services Secretary Robert F. Kennedy, Jr. has named Casey Mulligan as chief economist and chief regulatory officer of the agency. He’ll advise Kennedy and other agency leaders on affordability issues.

Mulligan was on the Council of Economic Advisers during the first Trump administration and was most recently the U.S. Small Business Administration’s chief counsel for advocacy.

Meanwhile, healthcare policy group KFF issued a briefer on Americans’ views of healthcare. Just under half of U.S. adults say it is difficult to afford healthcare costs, and about three in ten say they or a family member in their household had problems paying for healthcare in the past 12 months. Further, 36% of adults say that they have skipped or postponed getting healthcare they needed because of cost. About 75% of uninsured adults under age 65 say they went without needed care because of cost.

KFF also just added an employer insurance chapter to its online resource on healthcare. It dives deep into all things employer coverage.

Additional articles: https://www.kff.org/health-costs/health-policy-101-employer-sponsored-health-insurance/?entry=table-of-contents-resources and https://www.kff.org/health-costs/americans-challenges-with-health-care-costs/

#affordability #healthcare #healthcarereform #coverage

https://www.axios.com/2026/04/16/hhs-health-care-affordability-midterms

— Marc S. Ryan

Chronic Care Cost-Sharing Targeted

A new bill would eliminate Medicare cost-sharing on care coordination services. Supporters argue the cost-sharing on the services creates financial barriers to deploying such services for many. They also argue charging seniors for the behind-the-scenes services is confusing. Further, the services have documented savings, but utilization is low due to the cost-sharing impediment. About 40 healthcare and patient groups have endorsed the measure.

#chroniccare #medicare

https://www.fiercehealthcare.com/providers/providers-back-new-bipartisan-bill-eliminating-medicare-chronic-care-management-cost

Bill Would Force Insurers To Count DTC Drugs Against Deductible, MOOP

North Carolina Republican Rep. Greg Murphy, MD, has introduced a new bill that would compel insurers to apply the cost for drugs purchased from direct-to-consumer (DTC) platforms to deductibles and out-of-pocket maximums (MOOPs) in insurance. Using these platforms, patients can often find prices that cost far less out-of-pocket, especially for brand drugs, Murphy’s office said.

#drugpricing #dtc #branddrugmakers #healthplans

https://www.fiercehealthcare.com/regulatory/bill-seeks-force-payers-apply-dtc-drug-purchases-patient-deductibles

Healthcare Costs Vary Across Regions

A new report titled the Health Cost Landscape from the Health Care Cost Institute found that healthcare spending per person with employer coverage was $6,711 but the figure can vary significantly by region. Spending was 70% higher than the national average in Charleston, West Virginia, while costs were 41% below the national average in Bakersfield, California.

The report looked at more than 1.3 billion medical claims submitted from 2018 to 2022, with data from 38 million people. The report also found that the price of services, utilization trends and the types of services used all contribute to the spending figures. Prices were the largest driver in variation.

Most of the metropolitan areas included in the study were highly concentrated hospital markets, with 88% either highly or very highly concentrated.

#healthcare #costs #employercoverage

https://www.fiercehealthcare.com/finance/healthcare-spending-varies-widely-between-metropolitan-areas-hcci

New Drug PA Requirements In Government Programs

Notwithstanding the voluntary prior authorization reforms, the Centers for Medicare and Medicaid Services (CMS) issued a new proposed rule that extends recent non-pharmacy prior authorization requirements to retail drug requests. In the case of retail drugs, urgent requests would have to be fulfilled in government programs within 24 hours, with all others in 72 hours. The requirement is within a broader Interoperability Standards and Prior Authorization for Drugs rule. The PA requirements are effective October 1, 2027.

The rule would also require insurers to publicly report certain metrics around prior authorization, including approval and denial rates, appeal outcomes, and decision timeframes. As well, CMS is proposing to require payers to support three National Council for Prescription Drug Programs (NCPDP) standards—the SCRIPT, Formulary & Benefit (F&B), and Real-Time Prescription Benefit (RTPB) standards–beginning October 1, 2027. The proposed standards allow providers to query formulary information, determine real-time coverage information, and exchange electronic prior authorization requests and decisions for drugs.

The proposed rule would additionally: 

• Update health IT standards and implementation guides to align with current versions adopted by ONC for HHS use.
• Expand existing interoperability requirements to small group market QHP issuers on Exchange.
• Add a regulatory definition for “Failure to Report” to strengthen CMS’ oversight authority under the Open Payments program. 

CMS is also seeking public input through five Requests for Information on: 

• Improving electronic event notifications for care coordination. 
• Strengthening healthcare cybersecurity and system resilience.
• Enhancing oversight of payer APIs.
• Streamlining step therapy processes.
• Improving prior authorization for laboratory tests and durable medical equipment, prosthetics, orthotics, and supplies. 

Additional articles: https://www.fiercehealthcare.com/regulatory/proposed-cms-rule-would-set-prior-auth-deadlines-drugs and https://www.cms.gov/newsroom/press-releases/cms-proposes-major-reforms-speed-up-patient-access-drugs-increase-transparency-reduce-administrative and https://www.cms.gov/newsroom/fact-sheets/2026-cms-interoperability-standards-prior-authorization-drugs-proposed-rule

#priorauthorization #medicareadvantage #medicaid #managedcare

https://www.beckerspayer.com/policy-updates/cms-proposes-extension-of-prior-authorization-rule-to-cover-drugs-6-notes/

Priority Health Overpayment Audit

The Health and Human Services (HHS) Office of the Inspector General (OIG) says Priority Health may have collected at least $4.4 million in Medicare Advantage (MA) overpayments throughout 2018 and 2019. The targeted audit focused on ten high-risk diagnosis groups.

Auditors found medical records did not back diagnosis codes across 252 of 300 sampled enrollee-years, prompting $828,010 in net MA overpayments — an 84% error rate. OIG says many codes were for a previous diagnosis that was no longer active.

#medicareadvantage #radv #riskadjustment #overpayments

https://www.beckerspayer.com/legal/priority-health-estimated-to-have-received-4-4m-in-overpayments-audit/

CMS Understood Rate Impact on MA

More evidence that the Centers for Medicare and Medicaid Services (CMS) understood the potential impact of a zero-rate hike on Medicare Advantage (MA) benefits and cutbacks in 2027. The agency raised the rate hike to about 2.5% by amending its proposal for more aggressive risk adjustment and v28 model changes. This means payments will move from basically a zero increase to $13 billion, just over half of what 2026 will see.

CMS clearly listened to plan complaints about the proposed model changes. Plans argued cost recognition would not be correct if the model were adopted. CMS could still adopt this in the future.

And as I noted, most plans will see more than 2.5% because the unlinked chart change that was adopted hits big plans much more given their risk adjustment practices. Experts say UnitedHealthcare faces a $5 billion reduction and Humana $2 billion.

Still, plans and industry trade groups are not necessarily ecstatic given utilization trends. A fourth year of cutbacks is still likely.

(Article may require a subscription.)

#medicareadvantage #rates

https://www.modernhealthcare.com/insurance/mh-cms-medicare-advantage-payment-risk-adjustment