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.
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#drugpricing #glp1s #weightlossdrugs #branddrugmakers #pbms
https://www.modernhealthcare.com/insurance/mh-novo-nordisk-eli-lilly-waltz-health
Exchange Drama Has Dueling Bills
The saga over the expiring enhanced Exchange subsidies continues. President Donald Trump says he wants a solution by Jan. 30 and wants subsidies to go direct to consumers.
Sen. Rick Scott, R-FL, proposed legislation to “stop giving tax dollars to big insurance companies” and instead redirect premium tax credit amounts to people with a “Trump Health Freedom Account,” in essence a health Savings Account. HELP Chair Bill Cassidy has a similar bill tied to Bronze plans in the Exchange.
Four members of the House from both parties unveiled legislation to extend the enhanced subsidies for two years with some changes to address conservatives’ concerns. The bill would extend the enhanced tax credits through 2027 for enrollees earning less than $200,000 per year for a family of four. The bill would phase out the subsidies for enrollees earning between $200,000 and $300,000 for a family of four. It would also create new guardrails to prevent fraud and so-called ghost enrollees.
Additional articles: https://www.beckerspayer.com/payer/aca/gop-senator-pitches-bill-to-keep-aca-but-stop-giving-tax-dollars-to-big-insurance-companies/ and https://thehill.com/policy/healthcare/5617598-bipartisan-bill-would-extend-obamacare-subsidies/
(Some articles may require a subscription.)
#exchanges #healthcare #coverage
https://www.modernhealthcare.com/politics-regulation/mh-trump-healthcare-plan-january-aca-subsidies
CMS Finalizes 2026 Reimbursement Rules for Medicare Outpatient Services
The Centers for Medicare and Medicaid Services (CMS) finalized its Hospital Outpatient and Ambulatory Surgery Center (ASC) rule with some important reforms – at least a start.
CMS is phasing out the inpatient-only list over a three-year period and expanding the ASC covered procedures list. Trump has proposed this in Trump 45, but Biden backed away from it. This breaks the hospital lobby a bit by allowing more services to be performed at lower-cost settings.
A baby step toward site neutral payments is included too. CMS will align payment rates for certain outpatient services delivered at hospital outpatient departments and off-campus facilities.
On transparency, hospitals will now be required to post actual, consumer-friendly prices — not estimates — in standardized formats, with easier to understand fees and increased penalties for violators.
The agency also will raise outpatient payment rates by 2.6% in 2026 for hospitals that meet quality-reporting requirements.
Additional article: https://www.beckershospitalreview.com/finance/cms-bumps-hospital-outpatient-pay-rates-2-6-in-2026-14-notes/
#medicare #hospitals #ascs
— Marc S. Ryan
