egwps

CVS Caremark Loses Whistleblower Suit CVS Caremark, the pharmacy benefits manager (PBM) of CVS Health, has been ordered to pay more than $289 million in damages stemming from a 2014 false claims lawsuit. The court originally set damages at $95 million after finding in favor of the whistleblower and finding CVS Caremark pushed insurers to overbill the Medicare Part D program. The judge has now tripled the settlement because the company’s actions were financially motivated and eroded public trust. CVS Health said it would challenge the decision. Additional articles: https://www.modernhealthcare.com/legal/mh-cvs-caremark-medicare-overbilling-lawsuit-2/ and https://www.beckershospitalreview.com/pharmacy/cvs-caremark-ordered-to-pay-290m-in-false-claims-suit/ (Some articles may require a subscription.) #cvshealth #fwa #partd #aetna https://www.fiercehealthcare.com/payers/pennsylvania-judge-hits-cvs-289m-fine-whistleblower-suit Health Plans Turn To Variable Copay Plans To Lower Costs More health plans are turning to variable copay plans to reduce costs and offer lower cost alternatives to employers and avoid passing on more premium and deductible costs on employees. MN-based HealthPartners said it will offer a

Employer Healthcare Costs To Soar After multiple years of high spending hikes for employer coverage, employers are facing perhaps a near-term record trend in 2026. The Business Group on Health released its annual survey and found that business firms are bracing for median cost increases of 9% in 2026. In the past two years, costs exceeded forecasts. And employers expect an 11% to 12% increase in pharmacy costs heading into 2026. Ongoing demand for GLP-1s and other medications for weight loss is a significant cost driver. About 72% said that GLP-1s are impacting their 2025 healthcare costs to either a “great” or “very great” extent, up from 56% who said the same a year ago. The survey indicates that the number of employers covering these medications for weight loss may “stagnate” in an effort to control costs. Employers will also put on more guardrails like prior authorization. Some may end

Healthcare Lawsuits Galore A good article from Modern Healthcare on various Medicare Advantage (MA) and Affordable Care Act (ACA) lawsuits. Aetna, Elevance Health, and Humana are being sued by the federal government ove alleged kickback schemes to marketing organizations to steer beneficiaries to their plans. Democratic-controlled states are suing the Trump administration over a new Exchange rule that tightens enrollment processes in the Exchanges. There is an ongoing suit over the dispute resolution process under the No Surprises Act. The suit in part involves how the median in-network rate is calculated. The Supreme Court largely sided with the government on the legality of free preventive services under the ACA but returned some issues to a lower court. (Article may require a subscription.) #aca #obamacare #medicareadvantage #exchanges #prevention #preventiveservices #nsa #nosurprisesact #marketing #fwa https://www.modernhealthcare.com/politics-regulation/mh-medicare-advantage-aca-lawsuits-regulation BCBSMA Reports Q2 Loss Blue Cross and Blue Shield of Massachusetts reported a net loss of $129.7 million on revenue

Medicare Beneficiaries To See Part D Premium Hikes Medicare enrollees in standalone Part D plans (PDPs) will see premium hikes in 2026. Premium hikes could be up to $50, although most will see something less. Increases might also hit those who enroll in a Medicare Advantage (MA) Part D. The premium hikes occurred in 2025 and to a lesser degree in 2024. Spikes will be higher in 2026. The reason for the premium hikes include: The Trump administration was in a tough spot, inheriting a mess from the Biden CMS. The move to continue the stabilization program but at lower levels is not unreasonable despite the impact on enrollees. #medicare #medicareadvantage #partd #pdp https://kffhealthnews.org/news/article/medicare-part-d-premiums-rising-reasons/ On Drug Tariffs And Onshoring Eli Lilly is speaking out against proposed tariffs on pharmaceuticals, saying they could increase drug costs and restrict patient access. I would agree this is the case on generic drugs for sure.

Humana And DrFirst Team Up On Care Gaps Humana and healthcare technology company DrFirst announced an expansion of their relationship aimed at closing care gaps. Humana suffered a huge loss of Star power in 2025. The focus initially will be boosting the use of statins among eligible members who are diabetics or have cardiovascular disease. DrFirst embeds in a physician’s electronic medical record system. Additional article: https://www.fiercehealthcare.com/payers/humana-taps-drfirst-new-program-aimed-gaps-care-patients-chronic-needs #medicareadvantage #quality #stars #humana https://www.beckerspayer.com/payer/humana-drfirst-partner-on-program-targeting-chronic-conditions Interoperability And Digital Health Goals Complicated The Trump administration wants to modernize healthcare through the use of interoperability and digital health, but it faces a number of policy issues and challenges. Experts applaud the commitment but say that a clear set of priorities are needed. The proposals are far-reaching, and prioritization is key to making progress. It also must settle some simmering unanswered challenges with clear policies, such as patient privacy, security, information blocking, and more. #interoperability #healthcare

Recap Of Q2 Health Plan Financials A good recap in Modern Healthcare on Q2 financial results of big health plans and strategies they are employing to get back to margin. The secret in Medicare Advantage (MA) will be to prioritize margin over enrollment and growth. United and Aetna have already sent word they will pare back offerings. The secret in Medicaid will be strong lobbying efforts in each state for rates and to offset program reductions. Premium increases will dominate the Exchanges. I especially liked Elevance Health’s promise to continue legal challenges against providers on the No Surprises Act independent dispute resolution process. Bravo. It is abused by a small group of providers. In general, the provider-friendly process will drive up prices throughout the system. (Article may require a subscription.) #healthplans #margins #medicareadvantage #medicaid #exchanges https://www.modernhealthcare.com/insurance/mh-aetna-cigna-unitedhealth-centene-q2-earnings Optum Acquires More Docs Optum has acquired Kingsport, Tenn.-based Holston Medical Group. The 200-provider

Exchange Enrollment Fraud Examined Conservatives in and out of government made a case that there was major fraud in Exchange enrollments, especially after subsidies became more generous. The Paragon Health Institute and other conservative healthcare policy outfits did a great deal of research and it does seem credible. The GOP Congress was convinced and made some major changes to eligibility and enrollment in the Exchanges in the budget reconciliation bill. Congress also did not act to extend more generous premium subsidies set to expire at the end of the year. Now, the Centers for Medicare and Medicaid Services (CMS) has published data that continues to fuel the narrative of rampant broker fraud. Plans were sent data by CMS that found that 35% of enrollees did not have a claim in 2024. Before the pandemic, the data showed about 22% to 24% of enrollees did not have a claim. The phenomenon

Providers Readying Opposition To 340B Pilot Providers say they are in store for significant cash flow and operational problems if a 340B pilot proposed by the Health Resources and Services Administration (HRSA) goes into effect. Given interest in reform, HRSA proposed a voluntary pilot to allow brand drug makers to convert to a rebate on a small subset of drugs as opposed to an upfront discount in the drug discount program. The program is meant to help ensure availability of drugs to lower income populations. The 340B program pricing is 25%-50% less. Providers fear the pilot will eventually become how the entire program is run. Brand drug makers support the change as they feel the program is not living up to the original intent. Indeed, studies show that eligible providers, often hospitals, are not extending the discounts to low-income populations and instead are pocketing the discount. Indeed, some studies suggest