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April 22, 2025

Elevance Reports Mixed But Better News Than United Elevance Health reaffirmed its 2025 earnings outlook, but did report some mixed news. Elevance beat The Street with revenue of $48.9 billion, up almost 15% year over year. It had profit of $2.2 billion, down 3% year over year. Elevance spent less money on medical care than analysts expected in Q1. Elevance did see higher costs in the first quarter, but premium hikes covered the trend. Still, the company advised it will approach 2025 cautiously. Elevance noted it is ramping up care coordination with new members to prepare for medical cost trends that have dogged the health insurance sector. I have noted that plans will begin to pivot from utilization management to care management moving forward. Additional articles: https://www.modernhealthcare.com/insurance/elevance-health-cost-predictions-medicare-advantage and https://www.healthcaredive.com/news/elevance-brushes-off-medicare-advantage-cost-fears-q1-2025/745961/ and https://www.modernhealthcare.com/insurance/elevance-health-lower-medical-costs and https://www.beckerspayer.com/payer/medicare-advantage-costs-manageable-for-elevance-health-8-notes/ (Some articles may require a subscription.) #medicareadvantage #healthplans #elevancehealth #margins https://www.fiercehealthcare.com/payers/elevance-health-beats-street-22b-q1-profit-elevated-cost-trends-pressure-industry Health Insurer CEO Salaries Despite financial woes,

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April 21, 2025

Supreme Court Leans Toward Safeguarding Preventive Services After oral arguments before the Supreme Court on whether preventive services will be protected, many are speculating that the nod goes to the government’s defense of the free services decided by several task forces wihin the Department of Health and Human Services (HHS). Plaintiffs are challenging the provision on religious grounds and arguing that those who decide what services should be provided are not properly appointed to make such decisions. The government argues the task forces have the right oversight and correctly appointed officials have the final say. It is important to note that conclusions reached by reading the tea leaves from justices’ questions does not always match the final ruling. Additional article: https://www.medpagetoday.com/publichealthpolicy/publichealth/115218 and https://insidehealthpolicy.com/daily-news/scotus-appears-poised-back-uspstf-s-role-free-preventative-services and https://www.modernhealthcare.com/legal/supreme-court-aca-case-prep and https://insidehealthpolicy.com/health-insider/house-ec-plans-post-recess-budget-markup-scotus-appears-sympathetic-aca-preventative and https://thehill.com/policy/healthcare/5259118-supreme-court-obamacare-insurance/ (Some articles may require a subscription.) #prevention #preventiveservices #aca #obamacare https://www.fiercehealthcare.com/payers/supreme-court-appears-willing-save-aca-preventive-services-task-force Arkansas Bars PBM Operation If Parent Owns Pharmacies Arkansas Gov.

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Expect Big Things From Donald Trump On Drug Prices

Trump executive order on drug pricing is both populist and shows policy sophistication Despite his drug price proposals during his first administration, many felt like President Donald Trump would shy away from attacking Big Pharma and potentially even work against the Inflation Reduction Act’s Medicare drug price negotiations. After all, he went back and forth on the issue in the presidential campaign. But since re-taking office, Trump has sent clear messages he wants to pursue drug price reform for America. First, after taking office, the Centers for Medicare and Medicaid Services (CMS) issued a statement indicating it was readying and taking seriously round two of negotiations, although it wanted greater transparency and input. Next, on Super Bowl Sunday, Trump appeared on Fox News bemoaning the price of GLP-1s. He even quoted statistics that GLP-1s in America were ten times more than prices in the U.K. Now, he has issued an

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April 18, 2025

United MA Troubles Cloud MA Industry Prospects The fallout from UnitedHealth Group’s poor quarterly financials is creating worry throughout the industry. While Elevance Health reaffirmed its earnings forecasts, some are wondering if United is just the first shoe to drop as investor calls for the quarter roll out. United blames some of the problems at its insurance and service entity on the new risk model that was rolled out in Medicare Advantage (MA) along with major utilization. Previously, United indicated it was not too worried about the change. The United financials and similar trends expected in some other MA plans show that the 5% hike for 2026 will not cure all ills in the industry. It helps with the financial realignment of many, but discipline will still be needed to get back to profitability. Additional article: https://www.beckerspayer.com/payer/unitedhealth-shifts-tone-on-medicare-advantage-as-cms-changes-impact-earnings/ (Some articles may require a subscription.) #medicareadvantage #unitedhealthcare #rates #margins #elevancehealth https://www.modernhealthcare.com/insurance/unitedhealth-group-medicare-advantage-earnings-2025 Trump

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April 17, 2025

UnitedHealth Group Hits Financial Pothole The fiscal crisis that other insurers saw in 2024 has now hit UnitedHealth Group. Its stock dropped sharply after the insurance giant slashed its earnings outlook for 2025. Not only did United’s stock drop, but so did the stock of other big health players. And the entire market went down as well Thursday. United is now seeing the high utilization of other plans in its insurance business. This is especially explosive in Medicare Advantage (MA). MA costs have increased twice as much in 2025 as they did in 2024. United only just learned of this. Not only did its insurance business suffer, but so did its Optum services business, which saw its patient profitability drop as its health plan clients struggled with their finances. Ironically, United went into the 2025 MA enrollment season excited to enroll a large number of beneficiaries. It performed well. The

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Star Changes In 2026 Final Rule And Announcement For Medicare Advantage

A lot changed in the final rule, but not in the final announcement NOTE: This Medicare Advantage Stars blog is co-published with Lilac Software ( https://lilacsoftware.com and https://lilacsoftware.com/guide-to-the-2026-medicare-advantage-part-d-star-final-announcement/ ). On April 7, the Centers for Medicare and Medicaid Services (CMS) issued the 2026 Final Announcement for Medicare Advantage (MA) and Part D plans. This annual announcement outlines the rates and other technical rate-setting details for the coming year as well as the final Star measures and details for Star Year 2026. In addition, the notice outlines potential changes to Star and display measures moving forward. Little changed of significance between the January Advance Notice and the April Final Announcement on the Star front except for renaming the Health Equity Index (HEI). Substantive comments were included in the final announcement. Although we wrote about this before, we have combed the final announcement and slightly altered our summary and analysis below for

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April 16, 2025

Trump Executive Order Wants Deeper Drug Price Cuts In yet another sign President Donald Trump will keep the Medicare drug price law, he issued an executive order that strives to get deeper price reductions in the second year of negotiations (2025 for an effective date of 2027). The executive order is general. But it does commit to evaluating ways to ensure prices drop more than the average 22% seen in the 2024 negotiations, increase transparency, increase generic introduction and penetration, further importation, and reform pharmacy benefits managers (PBMs) and other middlemen. It also indicates special programs would be set up for the low income. The order will solicit information from the public and stakeholders. On the other hand, Trump also said the actions would minimize any negative impacts of the maximum fair price on pharmaceutical innovation within the United States. This likely could mean protecting certain small molecule drugs longer

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April 15, 2025

State AGs Want Healthcare Entities With PBMs Broken Up A bipartisan group of state attorneys general wants Congress to pass legislation that would break up healthcare entities that own both pharmacy benefits managers (PBMs) and pharmacies. This targets UnitedHealth Group, CVS Health, and The Cigna Group, which control somewhere between 68% and 80% of the PBM market. At issue, too, is co-manufacturing of specialty medications. More and more state regulation of PBMs is passing. There is a growing bipartisan consensus in Congress for the need to reform PBMs. Additional article: https://insidehealthpolicy.com/inside-drug-pricing-daily-news/state-ags-demand-congress-ban-pbms-owning-pharmacies (Articles may require a subscription.) #pbms #drugpricing https://www.modernhealthcare.com/politics-policy/cvs-caremark-express-scripts-arkansas-vermont Fitch Says MA Rate Hike Will Help Stabilize Recovery Fitch, a rating agency, says the increased Medicare Advantage (MA) 2026 rate hike of over 5% “will likely significantly support the recovery” of MA plans as they face rising medical costs. But the rater notes that they do not resolve all the

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April 14, 2025

Drug Imports Will Get Tariffs The Trump administration is preparing to levy tariffs on imported pharmaceuticals within the next month or two. This is after drugs got a reprieve recently. Lobbies for the generic and biosimilar industries say tariffs could deepen existing drug shortages, raise prices, and harm patient access. In addition, the Department of Commerce has launched an investigation to assess the impact of pharmaceutical imports on U.S. national security. Additional articles: https://insidehealthpolicy.com/inside-drug-pricing-daily-news/commerce-says-pharmaceutical-tariffs-coming-next-month-or-two and https://www.beckershospitalreview.com/hospital-management-administration/federal-government-launches-probe-on-drug-imports-5-notes/ #tariffs #healthcare #drugpricing https://thehill.com/policy/healthcare/5245652-trump-tariffs-pharma-drug-shortages-trade-war-hhs-kennedy UnitedHealth Antitrust Suit Goes To Arbitration The Justice Department’s antitrust lawsuit aimed at blocking UnitedHealth Group’s $3.3 billion acquisition of Amedisys will go to mediation. The government alleges that United’s purchase of Amedisys would create an anti-competitive environment in the home health industry given its existing assets. Additional article: https://www.modernhealthcare.com/legal/unitedhealth-amedisys-antitrust-lawsuit-doj-mediation (Some articles may require a subscription.) #antitrust #doj #unitedhealthcare #homecare https://www.fiercehealthcare.com/payers/unitedhealth-group-amedisys-plan-divest-facilities-bid-close-33b-merger Physician Pay Jumps Medscape’s latest physician compensation report finds

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Fetterman Is Right On GLP-1s, But Now Is Not The Time To Expand Coverage In Medicare

I was touched by a recent New York Times opinion piece that Sen. John Fetterman, D-PA, wrote. Fetterman is the much-maligned senator elected in 2022 in a contest with Dr. Mehmet Oz, now administrator of the Centers for Medicare and Medicaid Services (CMS). Fetterman had a stroke during the campaign. He had clear trouble understanding questions during the campaign and equally had a hard time responding. He used technology-based assistive devices to get through debates and other appearances during the election. After winning rather handily in the end, the senator checked himself into a hospital for clinical depression shortly after assuming office. I said he was much-maligned because during the campaign and after, Fetterman was attacked as being unfit to hold the office of senator. It actually went beyond criticism to being mocked by some for his stroke and clinical depression. Too, he has come under intense criticism for his

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