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Deeper Dive On 2025 Medicare Drug Price Negotiations

The Trump administration announced the results of the second round of Medicare drug price negotiations, taking credit for the 2025 process that it says led to much deeper price reductions than in 2024’s process. The 2025 set prices will go into effect in 2027.

The administration said $12 billion in federal savings would occur due to the negotiations in 15 drugs. That is computed at 44% off of net (after rebates) costs, compared with 22% or $6 billion under Biden’s negotiations in 2024 for ten drugs. Under another calculation, the 2025 savings is $8 billion or 36%. Consumers would save an estimated $685 million in out-of-pocket costs. The medications are used by about 5.3 million Medicare beneficiaries. The negotiated savings range from 38% to 85% off the drugs’ list prices. Total spending on the drugs is about $42.5 billion.

The administration reached agreement with brand drug makers on all 15 drugs, which include treatment for cancer and a number of disease states such as diabetes and asthma.

 It appears that the prices obtained on some GLP-1s, Ozempic and Wegovy, are not as low as what President Trump struck with Novo Nordisk earlier.

All this said, it must be remembered that drug prices will remain markedly above other developed countries even with these negotiations. Right now, Americans pay over three times more generally and over four times more for brand drugs than those in other countries. Our per capita spending is well more than double those nations. Despite the year-over-year drug price reduction progress, I believe most-favored-nation pricing must come quickly and cover all drugs in all lines of business. The savings from Medicare drug price negotiations or even Trump’s direct discussions is simply not enough.

Additional articles: https://www.politico.com/news/2025/11/25/trumps-cms-touts-12b-savings-from-medicare-drug-price-negotiations-00669231 and https://www.healthcaredive.com/news/medicare-price-negotiation-wegovy-ozempic-trelegy-2027/806578/ and https://www.cms.gov/files/document/fact-sheet-negotiated-prices-ipay-2027.pdf and https://www.medpagetoday.com/publichealthpolicy/medicare/118727 and https://www.kff.org/quick-take/understanding-the-trump-administrations-negotiated-drug-prices-for-medicare/ and https://thehill.com/policy/healthcare/5623364-trump-medicare-drug-price-negotiation/

#drugpricing #ira #branddrugmakers #cms #medicare #partd

https://www.fiercepharma.com/pharma/medicare-unveils-price-reductions-15-drugs-including-novos-semaglutide

CMS Revamps Star Program For Medicare Advantage

The Centers for Medicare and Medicaid Services published a draft Medicare Advantage (MA) and Part D rule for 2027 that would make sweeping changes in the MA Star program. Beginning primarily in the 2027 measure year (MY) or Star Year (SY) 2029, CMS proposes to remove 12 (really 14) measures, largely focused on administrative processes or those that no longer show variability in quality among plans. (The call center measures will be removed in MY 2026/SY 2028.)

These are:

Administrative/Operational measures removed:

• Two Part C Appeals
• Part C and D Call Center
• Part C Special Needs Care Management HRA completion
• Part C and D Complaints
• Part C and D Disenrollment
• Medicare Plan Finder Price Accuracy

No longer showing variability:

• Diabetes Care – Eye Exam
• Statin Therapy for Patients with Cardiovascular Disease
• CAHPS Customer Service
• CAHPS Rating of Health Care Quality

The above has the effect of transferring so-called Star power to clinical, drug, and remaining CAHPS survey and HOS survey measures.

The Excellent Health Outcomes for All (EHO4all, the former Health Equity Index), will not be implemented for SY 2027 (MY 2025). The Reward Factor would be maintained for consistently high-performing plans.

CMS also proposes to introduce a new Depression Screening and Follow-Up measure that would begin with MY 2027/SY 2029.

The changes could have a huge impact on plans. CMS says this is the estimated impact on Star ratings:

• 62% of contracts will have no impact to Star ratings
• 13% of contracts will have an increase of one-half Star
• 25% of contracts wll have a decrease of one-half Star
• One conract would drop by one Star

CMS proposed a number of other changes for MA in the draft rule and issued three requests for information.

I will get into more details on all this in a blog later this week.

Additional articles: https://www.cms.gov/newsroom/press-releases/cms-proposes-new-policies-strengthen-quality-access-competition-medicare-advantage-part-d and https://www.cms.gov/newsroom/fact-sheets/contract-year-2027-medicare-advantage-part-d-proposed-rule

(Some articles may require a subscription.)

#cms #medicareadvantage #stars #quality

https://www.modernhealthcare.com/politics-regulation/mh-medicare-advantage-star-ratings-cms-2027

White House To Unveil Exchange Subsidy Compromise

The White House is expected to reveal a plan to address rising medical costs as well as the expiration of the enhanced Exchange subsidies. It was expected today but was delayed to address concerns by GOP conservatives.

The plan is said to include an extension of the premium subsidies for two years but would include income limits for the subsidies and minimum premium requirements. Incomes are said to go as high as 700% of the poverty limit to still get a subsidy. The plan also would call on Congress to appropriate funds for cost-sharing reductions (CSRs). These were defunded by Trump 45 and led to increases in Silver premium subsidies, actually a greater cost to the government.

The plan also would endorse a conservative approach where Americans would have an option to receive part of their tax credit in a tax-advantaged savings account if they move down to a lower-premium health plan.

Health Affairs has a good blog on the history of the Exchanges, tax credits, subsidy enhancements, and Democratic and GOP extension and reform proposals.

Additional articles: https://www.fiercehealthcare.com/regulatory/white-house-poised-reveal-healthcare-cost-plan-media-reports and https://www.healthaffairs.org/content/forefront/extending-enhanced-premium-tax-credits-things-stand

(Some articles may require a subscription.)

#exchanges #healthcare #coverage

https://www.politico.com/news/2025/11/23/white-house-to-propose-new-health-care-framework-00666701

GLP-1 Drug Makers Go Direct With Employers

Seeing the changes that are coming on drug prices, GLP-1 brand drug makers Eli Lilly and Novo Nordisk plan to sell their popular obesity drugs direct to employers rather than using the traditional drug sales channel that includes pharmacy benefits managers (PBMs) and rebates. In part, this is because price deals with President Trump drop drug costs considerably in Medicare and rebates will go away there. As well, this is to boost sales and get employer groups to keep or expand to obesity coverage for the drugs as opposed to use just for other disease states.

The drug makers will offer Zepbound and Wegovy to companies starting Jan. 1 through Waltz Health, a firm that helps employers purchase cheaper medications. Lilly and Novo already sell direct to cash customers.

While I have applauded the president on his drug agenda, I have doubted parts of the approach because it did not lower price and eliminate rebates for the commercial sector. But this shows that the Trump efforts could over time drop price there. I still think national reform is best, but you have to give credit to Trump for moving intractable Big Pharma – slowly but apparently surely.

(Article may require a subscription.)

#drugpricing #glp1s #weightlossdrugs #branddrugmakers #pbms

https://www.modernhealthcare.com/insurance/mh-novo-nordisk-eli-lilly-waltz-health

Dems Want Medicare Drug Negotiations Expanded

Democrats in the House have introduced a new bill that would expand Medicare’s ability to negotiate drug prices. The Lowering Drug Costs for American Families Act would allow Medicare to negotiate prices for more drugs each year, moving from 20 to 50, and make them applicable to the commercial market.

#drugpricing #ira #branddrugmakers #medicare #partd #commercial #employercoverage

https://www.fiercehealthcare.com/regulatory/house-democrats-introduce-bill-expand-drug-price-negotiation-commercial-market

Fiery Senate Hearing Casts Doubt On Subsidy Extension

Democrats and Republicans battled at a Senate Finance Committee hearing today on the future of the enhanced Exchange subsidies set to expire at the end of the year. The tone and tenor of the GOP suggested that a clean extension was very much in doubt, at least without major sweeping conservative changes to healthcare, if it happened at all.

Republicans largely indicated they wanted to see the subsidy enhancements expire and instead work on conservative reforms, including expansion of Health Savings Accounts to allow individuals to purchase healthcare of their choice. This comports with President Trump’s views that subsidies should be sent to Americans directly. Sen Bill Cassidy, R-LA and Chair of the HELP Committee, has proposed pairing beefed up HSAs with low-level, high-deductible Bronze Exchange plans. HSAs currently cannot be used to pay for premiums.

Democrats argue the HSA payments would be nowhere close to buy affordable and comprehensive insurance. They also indicated that time does not allow a major overhaul – millions are nearing a doubling of their premiums.

Where Republicans have some solid points is that the fallout from the expiration of the temporary enhancements do point to larger issues with the Affordable Care Act in terms of affordability. Republicans say markets have become overly regulated and very inflationary.

GOP moderates favor a short-term, one-year extension of the enhanced subsidies with some small changes to appeal to conservatives. They say broader reforms can be tackled later.

Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-republicans-hsa-aca-subsidies-insurance/ and https://www.modernhealthcare.com/politics-regulation/mh-senate-finance-committee-hsa-aca-subsidies/ and https://thehill.com/policy/healthcare/5611836-trump-republicans-aca-subsidies-health-care-plan/ and https://www.healthcaredive.com/news/aca-subsidy-unlikely-republican-opposition-senate-finance/805942/

#exchanges #healthcare #coverage

https://www.fiercehealthcare.com/regulatory/republicans-press-hsa-expansion-aca-subsidy-reform-senate-hearing

Trump Says He Wants Direct Subsidies In Healthcare

President Donald Trump declared on social media that he would only consider approving legislation that provides direct healthcare payments to Americans. “THE ONLY HEALTHCARE I WILL SUPPORT OR APPROVE IS SENDING THE MONEY DIRECTLY BACK TO THE PEOPLE, WITH NOTHING GOING TO THE BIG, FAT, RICH INSURANCE COMPANIES, WHO HAVE MADE $TRILLIONS, AND RIPPED OFF AMERICA LONG ENOUGH,” Trump wrote on Truth Social. “THE PEOPLE WILL BE ALLOWED TO NEGOTIATE AND BUY THEIR OWN, MUCH BETTER, INSURANCE. POWER TO THE PEOPLE! Congress, do not waste your time and energy on anything else. This is the only way to have great Healthcare in America!!! GET IT DONE, NOW,” he added.

Senate Minority Leader Chuck Schumer, D-NY, dismissed Trump’s statement as “unhinged ramblings” that will “do nothing to lower” costs. He added the president has no idea how anything works.

Meanwhile, Senate Health, Education, Labor, and Pensions Committee Chair Bill Cassidy, R-LA, is working on a bill that would allow the federal government to contribute directly to individual health savings accounts to help people afford insurance in the Exchanges. Cassidy’s proposal would allow people who sign up for Bronze Plans on the marketplaces to get prepaid accounts to make up for the projected lapse in enhanced subsidies next year. “Who would not want to spend 100 percent of the dollars on the patient choosing the health care she wants, as opposed to 100 percent going to insurance companies and the 80 percent being spent on health care … and that health care is what the insurance company decides that you need?,” Cassidy told reporters.

Of course, both Trump and Cassidy have looked past any number of problems with the schemes. Will the Affordable Care Act (ACA) be changed? While costs are high in the Exchanges, their scheme could force premiums up even more as insurers would be uncertain as to enrollment in the devolved system. The system would be more complicated than even the current one. Do either understand that the premium subsidies and cost-sharing subsidies are only obtained on behalf of the enrollee? What are the insurance alternatives if any? Isn’t Cassidy leveraging the same Exchange system?

As usual, the GOP here is endorsing stunts rather than real reform for affordable, comprehensive coverage.

Additional article: https://thehill.com/homenews/senate/5611143-schumer-trump-health-care-payments/?tbref=hp

#healthcare #exchanges #aca #obamacare #coverage

https://thehill.com/homenews/administration/5610525-trump-direct-healthcare-payments/?tbref=hp

Capitol Hill Abuzz With Exchange Negotiations

Washington, D.C is abuzz with at least some compromise talk on finding a way to extend the enhanced Exchange subsidies Dr. Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services (CMS), said that the Trump administration is “willing to look at all options” regarding the subsidies. “But we have some major flaws with the way these COVID-era subsidies were added. And just so everyone’s on the same page in this issue, our goal is to get people covered,” he added.

At the same time, President Donald Trump wants to send payments to Americans directly instead of to insurers and allow them to purchase their own insurance. The president said he has been talking with Democrats about a direct health care payment plan as one way to tackle rising health insurance premiums. “The insurance companies are making a fortune,” he said. “Their stock is up over a thousand percent over a short period of time. They are taking in hundreds of billions of dollars, and they’re not really putting it back, certainly like they should.” Not quite, Mr. President.

Republicans on the House Ways and Means Committee are considering a bill that aligns with Trump’s pitch, yet they want to tackle what they see as huge fraud in the Exchange program.

Last, Sen. Chris Murphy, D-CT, said he believes it was a mistake for Democrats to reopen the government without a solution on the subsidies.

Additional article: https://thehill.com/policy/healthcare/5608268-dr-oz-comments-aca-flaws/ and https://www.beckerspayer.com/payer/aca/house-republicans-weigh-sending-aca-dollars-to-consumers/ and https://thehill.com/homenews/senate/5608324-murphy-criticizes-democrats-aca-government-funding/

#exchanges #healthcare #coverage

https://thehill.com/policy/healthcare/5608731-trump-democrats-direct-healthcare

Aetna Delays And Changes Downcoding Policy

After major pushback from lawmakers and providers, Aetna is easing a controversial “downcoding” policy for inpatient Medicare Advantage (MA) claims. The insurer said the policy’s start date has been delayed to Jan. 1, 2026 and that its severity review would now apply to urgent or emergent inpatient hospital stays that include at least one midnight but fewer than five. As part of the reimbursement approach, Aetna will approve these inpatient stays without a medical necessity review and cover the claim at a rate that aligns with observation services. Stays of five or more midnights will not be subject to a severity review in the updated policy.

Additional articles: https://www.fiercehealthcare.com/payers/american-hospital-association-urges-aetna-rescind-new-inpatient-policy-payment and https://www.modernhealthcare.com/insurance/mh-aetna-medicare-advantage-downcoding-policy/

(Some articles may require a subscription.)

#aetna #hospitals #claimsdenials #priorauthorization

https://www.beckerspayer.com/payer/aetna-delays-new-inpatient-reimbursement-policy/

Healthcare Costs Continuing to Surge

WTW’s 2026 Global Medical Trends Report indicates that healthcare increases remain “significantly higher” than the 7.6% seen in 2024. Further, healthcare cost increases are projected to rise 9.6% in the U.S. in 2026, only a little less than the 9.7% experienced this year.

Globally, the average cost of health benefits is predicted to rise 10.3%, up from 10% in 2025 and 9.5% in 2024.

Employers add that they believe elevated costs will continue for more than three years, driven by medical costs, regional pressure on pharmacy and outpatient services, and global structural factors. About three-quarters said new medical technologies as the top reason for medical inflation, followed by the decline of public health systems (52%) and advancements in pharmaceuticals (49%).

Cancer tops the list of cost drivers globally.

#healthcare #costs

https://www.healthcaredive.com/news/us-healthcare-cost-increases-expected-to-fall-in-2026/805340