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Wearables Growing But Not Integrated

The use of wearables for disease monitoring has increased dramatically. About 86% of U.S. physicians report they sometimes review data from their patients’ wearables, including heart physiology, oxygen and breathing, and sleep. But only 6% of doctors say such data is integrated into clinical workflows and that clearly limits growth and  potential. The Trump administration has in part sought to leverage technology and overcome this deficiency by announcing the ACCESS reform pilot, which contracts with technology entities to partner with physicians to monitor chronic disease states.

#chronicdiseases #technology #medicare #access

https://www.healthcaredive.com/news/physician-wearable-data-use-hindered-workflow-reimbursement-challenges-american-medical-association/824640/

Study Says Median Exchange Hike Will Be 14% Thus Far

A Peterson-KFF Health System Tracker analysis finds that preliminary rate filings in the Exchanges will mean a median premium rate hike of 14% in 2027. This follows a final median hike of 20% in 2026 after plan switches. This would amount to a one-third increase over two years. While most of the hike will be covered by premium subsidy increases, the hikes will hurt those with little or no subsidy.

Peterson-KFF looked at 77 insurers across 16 states and the District of Columbia. The healthcare duo calculated the enrollment-weighted average rate change across its offerings in a state. Most plans are requesting increases of between 10% and 20% for the coming year, though 20 payers have requested an increase of more than 20%.

Plans say factors such as high medical costs, the expiration of enhanced exchange subsidies, and tighter enrollment processes are driving the premium hikes.

Additional articles: https://thehill.com/policy/healthcare/5958559-obamacare-premiums-rise-again/ and https://www.beckerspayer.com/payer/aca/aca-premiums-could-jump-14-in-2027-7-things-to-know/ and https://www.fiercehealthcare.com/payers/aca-plans-set-another-year-premium-spikes-preliminary-filings-show and https://www.healthcaredive.com/news/affordable-care-act-premium-increase-2027-kff-peterson-center-healthcare/824695/ and https://www.modernhealthcare.com/insurance/mh-aca-marketplace-plans-premium-2027-kff/ and https://www.kff.org/affordable-care-act/in-preliminary-rate-filings-aca-marketplace-insurers-largely-propose-double-digit-premium-increase-for-2027-following-a-steep-climb-this-year/

#exchanges #affordability #coverage #healthcare

https://www.healthsystemtracker.org/brief/how-much-and-why-aca-marketplace-premiums-are-going-up-in-2027/

— Marc S. Ryan

Pharmacy Group Alleges Price Fixing

A community pharmacy group has filed suit against Prime Therapeutics, alleging that the company colluded with fellow pharmacy benefits manager (PBM) Express Scripts to fix prices and engage in anti-competitive behavior. The suit alleges Prime accessed Express Scripts’ network to slash prices.

Additional article:https://www.modernhealthcare.com/insurance/mh-prime-therapeutics-lawsuit-express-scripts-pbm/

(Some articles may require a subscription.)

#pbms #drugpricing #antitrust #pharmacies

https://www.fiercehealthcare.com/payers/independent-pharmacies-hit-prime-therapeutics-antitrust-suit-over-alleged-price-fixing

ACA Exchange Risk Adjustment Settlements Total $11.7 Billion

Health insurers will shuttle $11.17 billion between them due to the 2025 ACA Exchange risk-adjustment settlements. The settlements recognize differences in risk in the program in a given year. UnitedHealthcare will pay $335 million while Centene will receive $751 million, Elevance Health $312 million, Aetna $216 million, and Oscar Health $189 million.

(Article may require a subscription.)

#exchanges #riskadjustment

https://www.modernhealthcare.com/insurance/mh-aca-exchange-risk-adjustment-payments-2025/

Paragon Proposes Reforms

The influential Paragon Health Institute released a new report calling for federal funding cuts or tax reforms impacting all health plan lines of business and coverage areas. People pay attention to what Paragon says given its influence and impact on government regulations since 2025 as well as in the One Big Beautiful Bill Act (OBBBA).

In summary, Paragon wants to see the following changes:

• Cuts to the federal matching rate in Medicaid, especially equalizing matching rates for historic and expansion populations and lowering the floor to 40%
• Further cuts to Medicaid provider taxes, state directed payments, and intergovernmental transfers
• State and Medicaid managed care penalties for fraud or improper billing patterns
• Site neutral payments in Medicare
• Better target various hospital subsidies
• Redesign the 340B program
• Reversing the 2022 Part D redesign, which destabilized the standalone Part D (PDP) program and to some degree Medicare Advantage (MA)
• MA risk adjustment, benchmark, and quality bonus changes to reduce payments
• Reform Medigap
• Minimum premium payments in the Exchanges
• End automatic re-enrollment into Exchange coverage
• Broker and agent reform in the Exchanges
• Fund cost-sharing reduction subsidies in the Exchanges to save dollars
• Reform Exchange premium tax credits
• Relax medical loss ratio requirements
• Cap the tax exclusion for employer-sponsored health insurance

#medicare #medicaid #exchanges #employercoverage #healthcarereform #healthcare #coverage

https://paragoninstitute.org/medicare/restoring-fiscal-sustainability-to-federal-health-programs-reforming-the-incentives-that-drive-health-care-spending/

MA Star Bonus To Exceed $13B

Healthcare policy group KFF reports that federal spending on Medicare Advantage (MA) quality bonuses will reach at least $13.4 billion in 2026, compared with $12.7 billion in 2025. This is more than four times higher than in 2015. More than two-thirds of Medicare Advantage enrollees (68%) are in plans that qualify for the quality bonus in 2026, down from 75% in 2025. This is the lowest since 2018. The increase ties to more enrollment not better ratings.

In another briefer, KFF updates on MA coding intensity.

Additional article: https://www.kff.org/medicare/decoding-medicare-advantage-coding-intensity/

#medicareadvantage #radv #riskadjustment #stars #quality #cms

https://www.kff.org/medicare/medicare-will-spend-more-than-13-billion-on-the-medicare-advantage-quality-bonus-program-in-2026/

House Wants To Rein In Private Equity

A bipartisan House bill would require extensive reporting on private equity firms’ healthcare holdings and ownership structures. The reporting is aimed at identifying financial arrangements that may impact the financial health of the healthcare entity as well as impacts on healthcare delivery. The bill is similar to state laws on transparency in private equity. Other states have gone deeper and ruled out certain financial arrangements by private equity for acquired healthcare entities.

(Article may require a subscription.)

#healthcare #congress #privateequity

https://www.modernhealthcare.com/politics-regulation/mh-private-equity-healthcare-congress-transparency

States Sue on Work Requirements

Democratic governors and attorneys general from 25 states and Washington, D.C. are suing the Trump administration over the proposed Medicaid work requirements regulation. States argue the rule narrows exemptions for medically frail Medicaid beneficiaries and creates administrative barriers that could cause eligible people to lose coverage. The plaintiffs say the rule goes well beyond the statute by requiring people with serious health conditions to prove their condition significantly impairs their ability to meet work requirements.

Additional: https://www.beckershospitalreview.com/legal-regulatory-issues/25-states-sue-trump-admin-over-medicaid-work-requirements-7-things-to-know/ and https://www.modernhealthcare.com/politics-regulation/mh-medicaid-work-requirement-lawsuit-democrats-bonta/

(Some articles may require a subscription.)

#medicaid #workrequirements #states

https://thehill.com/policy/healthcare/5946392-lawsuit-trump-medicaid-exemptions/

Exchange Enrollment Falls Dramatically

A number of analyses have predicted that Exchange enrollment nationally will fall in 2026 after dropping from 24.3M in 2025 to 23.1 in January 2026. The analyses said that enrollment would drop to as low as 17.5M as people would not be able to afford their premiums throughout the year. Sure enough, the predictions seem to have come true, and the news may be being buried.

Today, a Health and Human Services (HHS) website posted an analysis on fraudulent and phantom enrollments and deep in the release were latest enrollment figures. HHS says around 19.2 million people are enrolled in the Exchanges as of now, a drop of about 4M since January.

HHS says millions are inappropriately receiving subsidies, including individuals misstating their income to gain access to free plans and phantom enrollees (those who are unknowingly enrolled in free plans by unscrupulous brokers or are auto enrolled). HHS says improper, phantom and fraudulent enrollment peaked at 5.6 million people in 2025.

While it did not trace the enrollment losses exactly to efforts to reduce inappropriate enrollments, HHS says it has deployed new regulations and tools to root out fraud and inappropriate enrollments. Administration program integrity efforts stopped about 1.5 million enrollees from receiving subsidies they did not qualify for and ended or blocked another 1.4 million through February 2026. HHS says 2.6 million improper and phantom enrollments remain.

#exchanges #enrollment

https://aspe.hhs.gov/reports/aca-exchange-enrollment-2026#:~:text=Enrollment%20that%20is%20improper%20or,by%20brokers%20or%20auto%20enrolled

Cassidy Wants 340B Reform

Sen. Bill Cassidy, R-LA, unveiled a draft for 340B reform today and challenged the public to offer comments for the possible passage of legislation later in the year. This would be the first time any statutory changes to 340B would be made in 15 years.

There are numerous reforms aimed at controlling costs, reining in inappropriate use of the program, reducing duplicative discounts, and ensuring savings are actually passed through to needy consumers. The hospital lobby and others oppose any changes. Numerous studies show that 340B hospitals tend to have higher prices than non-340B ones. Changes would include the ability of drug makers to offer upfront discounts or retrospective rebates, claims submission, and mandatory pass-through of the rebates. There would also be a set number of contract pharmacies within each geographic region that a qualifying provider could have.

Additional article: https://www.fiercehealthcare.com/providers/cassidys-new-plan-reform-340b-rebates-contract-pharmacy-limits-and-more

(Some articles may require a subscription.)

#340b #drugpricing #hospitals #branddrugmakers

https://www.modernhealthcare.com/politics-regulation/mh-bill-cassidy-340b-bill-rebate-claims