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United Moving To Transparency For Its PBM UnitedHealth Group Inc. said it will change its profit structure at pharmacy benefits manager (PBM) Optum Rx. The company handled about 1.7 billion prescriptions last year. Optum Rx plans to shift to a more transparent fee structure that gives clients clarity into payments the PBM gets from drug makers. CVS Health Corp’s Caremark earlier said it would change how it pays pharmacies to make it simpler and more transparent. Cigna’s Express Scripts late last year said it will phase out rebate payments in many private health plans. (Article may require a subscription.) #pbms #drugpricing https://www.modernhealthcare.com/insurance/mh-unitedhealth-optum-rx-pbm-model Kaiser Q1 Profit Down Kaiser Permanente’s Q1 operating performance took a step back in 2026 compared to Q1 2025, although investments and other sources of income offset the bad news. Non-profit Kaiser booked over $2 billion in profit. The integrated delivery system and health plan reported operating income

Exchange Insurers Report On Program Challenges First quarter results for insurers with Exchange lines of business had two trends. First, there generally was lower enrollment because people exited the market due to surging premiums and expiring subsidy enhancements. Second, people moving to less costly and trimmer Bronze and Catastrophic plans. The health insurance companies expect aggregate Exchange enrollment will shrink by at least 20% over the course of the year as more drop out due to affordability. Oscar Health bucked the trend in terms of enrollment growth. Additional articles: https://www.fiercehealthcare.com/finance/aca-exchanges-dominated-q1-earnings-calls-heres-what-payer-health-system-execs-had-say (Some articles may require a subscription.) #exchanges #healthplans https://www.modernhealthcare.com/insurance/mh-aca-enrollment-centene-molina-cigna-oscar Various Rx Studies and Reviews A number of blogs and white papers on various pharmacy developments: Additional articles:  https://www.healthaffairs.org/content/forefront/understanding-cms-s-proposed-rule-regarding-prior-authorization-drugs and https://www.healthaffairs.org/content/forefront/most-favored-nation-drug-pricing-anchoring-moving-target and https://www.healthaffairs.org/content/forefront/amgen-s-retreat-denmark-repatha-and-collision-course-us-mfn-pricing-policy (Some articles may require a subscription.) #priorauthorization #mfn #drugpricing #medicaid #medicare #medicareadvantage #partd https://www.kff.org/medicaid/a-look-at-the-generous-model-and-factors-that-could-impact-medicaid-drug-costs/ — Marc S. Ryan

CMS Could Auto-Enroll Seniors In MA or ACOs STAT reports that the Centers for Medicare and Medicaid Services (CMS) is currently mulling a plan that would automatically enroll beneficiaries into either Medicare Advantage (MA) plans or traditional Medicare Accountable Care Organizations (ACOs). The House GOP has shown interest in the proposal as have a number of right-leaning think tanks. The move would be consistent with CMS’ desire to radically expand value-based care (VBC) penetration in Medicare. #medicareadvantage #acos #vbc https://www.medpagetoday.com/publichealthpolicy/medicare/121161 Wash Post Covers Medicaid Enrollment Drops The Washington Post says Medicaid enrollment continues to drop. Medicaid enrollment has declined by about 3.4 million between January 2025 and January 2026. The newspaper says that application approval timing is taking longer and procedural related reasons for disenrollment were up. As well, applications are down. The immigration crackdown could be part of the reason. All of this is before the changes in the

CVS Health Beats The Street; Raises Guidance CVS Health Beat The Street in its Q1 financial news and raised its full-year projections. Its Aetna insurance division has recovered well from a huge meltdown a few years ago. Revenue should reach at least $405 billion this year. It posed $2.9 billion in profit in Q1. Revenues also grew to $100.4 billion in Q1 2025. Executives said that while the final 2027 Medicare Advantage (MA) rate notice does not meet financial expectations, Aetna is still on track for planned margin improvements by 2028. Additional articles: https://www.fiercehealthcare.com/payers/cvs-health-beats-street-29b-q1-profit and https://www.modernhealthcare.com/insurance/mh-aetna-revenue-cvs-health-earnings-outlook/ and https://www.modernhealthcare.com/insurance/mh-cvs-health-earnings-outlook-aetna/ and https://www.beckerspayer.com/financial/cvs-health-reports-2-9b-in-q1-profit-as-aetna-strengthens/ #aetna #cvshealth #margins #medicareadvantage #healthplans https://www.healthcaredive.com/news/cvs-hikes-outlook-aetna-improved-performance-q1-2026-earnings/819462 Large Plans Plot Continued Recovery The largest insurers spent Q1 continuing to navigate tight revenue and operational times. This interesting Becker’s Payer article covers the major focuses: navigating continued Medicare Advantage (MA) funding pressures, a recovering Medicaid financial picture but uncertain times with coming

United Limiting PAs UnitedHeathcare said it would eliminate prior authorization (PA) requirements for 30% of services that previously required payer approval. It plans to roll out the changes by the end of the year. Services seeing removal of PA will be outpatient surgeries, diagnostic tests, and chiropractic care. I will have a blog on Thursday on ongoing PA reforms. In other news, the California Hospital Association sued to stop Elevance Health from implementing a policy that would cut payments to hospitals that refer some members to out-of-network providers. Additional articles: https://www.fiercehealthcare.com/payers/unitedhealthcare-reduce-prior-auth-requirements-30 and https://www.modernhealthcare.com/insurance/mh-unitedhealthcare-prior-authorization-cuts/ (Some articles may require a subscription.) #unitedhealthcare #elevancehealth #priorauthorization #healthplans https://www.modernhealthcare.com/insurance/mh-california-elevance-out-of-network-penalty-lawsuit/ Oz’s PA Reform Push Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz published a blog where he featured prior authorization (PA) limits and urged continued reforms. His blog began: “A common practice imposed by health insurers on patients and providers is their intrepid

ACCESS Model Examined Fierce Healthcare dives deep into the Trump administration’s new Advancing Chronic Care with Effective Scalable Solutions (ACCESS) Model, which is a 10-year value-based-care (VBC) payment program to encourage the use of technology to treat chronic diseases. It teams technology companies with traditional Medicare fee-for-service (FFS) providers. About 150 digital health companies were approved to participate in the first cohort, which launches as early as July 5. The Center for Medicare and Medicaid Innovation (CMMI) announced the model in December and pays recurring payments for technology used to treat diabetes, hypertension, chronic kidney disease, obesity, depression and anxiety. It then awards a VBC bonus if outcomes are met. This could be improvement or stability in disease states. The ACCESS Model aligns with the Centers for Medicare and Medicaid Services’ (CMS) goal of having all traditional Medicare beneficiaries in an accountable care relationship by 2030. The model shifts away from

Alignment Posts Q1 2026 Profit Medicare Advantage (MA) plan Alignment Healthcare reported Q1 2026 revenue of $1.2 billion, a 33% increase from Q1 2025. MA membership reached 284,800 at the end of Q1, up 30.9% from Q1 2025. The insurer posted net income of $11.4 million, compared to a net loss of $9.4 million in Q1 2025. The company’s medical loss ratio (MLR) was 88.2%. The company raised its guidance for the year. #medicareadvantage #alignment #margins https://www.beckerspayer.com/payer/medicare-advantage/alignment-posts-11m-profit-in-q1 AHIP Publishes New Analysis To Support MA Health plan trade group AHIP published a study championing the value of Medicare Advantage (MA). Main points of the study include: #medicareadvantage #quality https://ahiporg-production.s3.amazonaws.com/documents/202604_AHIP_1P_MA_Affordability4149.pdf — Marc S. Ryan

Cigna Beats The Street; Will Exit Exchanges The Cigna Group beat The Street on both earnings and revenue in Q1 2026, posting $1.65 billion in profit. That’s up from $1.3 billion in Q1 2025. Revenues in the quarter were $68.5 billion, up from $65.5 billion haul in Q1 2025. Cigna’s medical loss ratio (MLR) decreased from 82.2% to 79.8%. Cigna is predominantly commercial. But Cigna will exit the individual market for the 2027 plan year given troubles with membership and risk. And the company is likely to sell its company EviCore, which specializes in prior authorization services. Its Express Script PBM revenue was down given the transition to net pricing. Additional articles: https://www.fiercehealthcare.com/payers/cigna-posts-165b-profit-q1-earnings-beat and https://www.modernhealthcare.com/insurance/mh-cigna-aca-exchanges-2027/ and https://www.healthcaredive.com/news/cigna-exit-aca-exchanges-despite-q1-2026-profit-growth-ci/818873/ and https://www.beckerspayer.com/financial/cigna-to-exit-aca-individual-business-posts-1-65b-q1-profit/ (Some articles may require a subscription.) #healthplans #margins #cigna https://www.modernhealthcare.com/insurance/mh-cigna-earnings-outlook-evernorth-health 340B RFI Comments The Health Resources and Service Administration solicited input on its next try at a 340B reform pilot and

Another Model Deadline Extended The Centers for Medicare & Medicaid Services (CMS) is extending the application deadline for drug manufacturers to apply to the GENErating cost Reductions fOr U.S. Medicaid (GENEROUS) Model. The deadline was extended by the agency to June 11 from April 30. CMS says the reason was due to overwhelming interest from prescription drug manufacturers. However, it cites that more time will help small to mid-sized firms to join. Participation agreement deadlines will be extended from June 30 to July 17. CMS is also extending the deadline for states to apply to the GENEROUS model from July 31 to September 10 and to finalize participation agreements from August 31 to September 30. The program intends to have the federal government negotiate with drug makers to obtain a most-favored-nation (MFN) price. MFN drug pricing is also being set up in Medicare under the GLOBE and GUARD models. Read my

Site Neutral Stunner On Capitol Hill Health system CEOs faced a grilling on a range of hospital issues today on Capitol Hill, but in a stunning turn of events the executives said that they are willing to discuss reasonable changes to their long-standing opposition to site neural payments in Medicare. Under site neutral, the same services at all locations are paid the same rate, which would drop hospital payments dramatically. What emerged was some consensus on moves to site neutral that would recognize hospital differences in some cases and changes that might be phased in so as not to undermine finances at health systems. Lawmakers, mostly on the GOP side, otherwise accused health systems of driving high costs and reducing competition. Democrats focused on the cuts in the One Big Beautiful Bill (OBBBA). The Trump administration finalized another small step on site neutrality, but Capitol Hill has always been stymied