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Plans Launch New Ad Campaign On NSA Disputes A new health plan ad campaign takes aim at the No Surprises Act (NSA) law and its arbitration component. It says that the dispute processes “create a ‘fox guarding the hen house’ dynamic.” Data show that providers are far more likely to win (87% of the time) and earn significantly higher payouts than payments before the law. It is driving overall healthcare costs up. Further, it is subject to abuse, with five organizations accounting for 63% of disputes in the first half of 2024: Team Health, SCP Health, Radiology Partners, AGS Health and HaloMD. Plans have sued but it will take the courage of Congress to fix his problem. #nosurprisesact #transparency https://www.fiercehealthcare.com/payers/new-payer-backed-ad-campaign-pushes-no-surprises-act-idr-reform Administration Attacks Fraud The Centers for Medicare and Medicaid Services (CMS) announced two fraud initiatives. First, CMS and the Department of Health and Human Services (HHS) issued an ultimatum to

Makary Resigns At FDA Food and Drug Administration (FDA) Marty Makary, M.D, is out at the agency, having resigned under pressure from Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. The move was approved by the White House. The last straw appeared to be Makary’s reluctance to approve fruit-flavored e-cigarettes given the potential for abuse by minors. Critics argued that Makary lacked government experience and did not lead the agency well. Others say he rightfully pushed back on certain administration initiatives he deemed wrong-headed. I won’t get into the saga, only to say that Makary was dealt a poor hand, with layoffs and huge cutbacks at a time of great political volatility for the agency. Such appointments don’t always work out for the principled person. I am a supporter of Makary, who I have been connected with for over five years now. (He endorsed my book when it

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