election2026

Other PBMs May Settle With FTC On Insulin Suits The Federal Trade Commission (FTC) may be close to settlement in its insulin suits with CVS Caremark and OptumRx, two of the remaining big 3 pharmacy benefits managers (PBMs). Express Scripts has already settled and any future settlements are expected to be as far-reaching in terms of impacting existing business practices. The FTC said in a court filing that it is making “significant progress” in talks with the two PBMs, Additional article: https://www.fiercehealthcare.com/payers/ftc-seeing-progress-discussions-optum-caremark-insulin-case #pbms #drugpricing #ftc https://www.healthcaredive.com/news/optumrx-caremark-progress-ftc-settlement-insulin-case/813834 Eli Lilly Launches DTC Platform Eli Lilly has officially launched Employer Connect, its direct-to-employer platform for its obesity medications. The program is aimed at supporting employer choice with multiple models. It will launch with more than 15 independent program administrators as partners. Lilly will offer Zepbound KwikPen to network pharmacies at a discounted $449 price. #glp1s #drugpricing #weightlossdrugs #employercoverage https://www.fiercehealthcare.com/payers/eli-lilly-launches-its-direct-employer-platform-obesity-drugs Hospitals Ask For Halt

Study Finds Multiply Comorbid Drive Inpatient Admissions A new report by Vizient finds that 11% of the U.S. population has multiple chronic conditions but these patients account for 52% of inpatient admissions, 35% of emergency department visits, and 32% of office visits. Patients with at least one chronic condition make up nearly 8 in 10 inpatient admissions.  Among Medicare beneficiaries, more than half of those aged 65 to 74 have at least one chronic condition, and the same is true among nearly two-thirds of those 75 and older. This creates huge cost challenges in Medicare as America ages. Controlling chronic disease states is key. #aging #medicare #hospitals #chronicconditions https://www.beckershospitalreview.com/quality/patient-safety-outcomes/11-of-us-population-accounts-for-52-of-admissions-vizient/ Employers Seeking Alternatives For Drug Price Relief With drug spending and health costs surging for employers, more and more are looking for alternatives to traditional pharmacy benefit manager (PBM) arrangements. Drug pricing platform GoodRx announced its entry into the crowded field with

Plans Oppose Flat 2027 MA Rates In comments on the proposed 2027 Advance Notice of rates, Medicare Advantage (MA) plans say a flat rate will mean reduced benefits and services and increased out-of-pocket costs for seniors. UnitedHealth Group estimates the proposed rate increase would lead insurers to reduce benefits by more than $600 a year. AHIP says its actuary Wakely determined no-premium plans could face a 50% cut to supplemental benefits and increased out-of-pocket costs by $1,000. Premiums could increase $23 per month, resulting in a jump of more than $550 for a couple each year. The plans also argue rising utilization and costs are being ignored. In addition, Humana, insurer trade group AHIP, and the Blue Cross Blue Shield Association want the proposed changes to risk adjustment regarding chart reviews not linked to encounters to be delayed until 2028. UnitedHealth Group and the Better Medicare Alliance recommend that CMS implement

Regional MA Plans Surged In Open Enrollment Becker’s Payer interviewed several executives at regional plans that grew tremendously during the Medicare Advantage (MA) open enrollment season as most big national plans contracted and shed lives. Medicare Advantage enrollment grew less than 1% for open enrollment, but regional plans grew by 443K while national plans dropped by 328K. Seniors benefited from the continued commitment of the regional plans. Health Alliance Plan in Michigan added more than 37,000 new enrollees in open enrollment, a 58% increase. Priority Health added more than 35,000 new members in open enrollment. SCAN Group added 127,000 new members during open enrollment. The growth pushed SCAN into the top 10 nationally among MA plans. Alignment Healthcare grew 31% year over year in 2025 to roughly 276,000 total members. Network Health grew 37% during open enrollment to 126,000 total MA members. #medicareadvantage #enrollment https://www.beckerspayer.com/payer/medicare-advantage/were-running-in-when-others-are-running-out-stability-drives-record-growth-for-regional-medicare-advantage-plans/ Elevance Health Frozen Over Risk

Independent Physicians Embrace PE A good article discussing the plight of independent physician practices. With about half of physicians now owned by health systems and many of the remainder owned by public equity and health plans, standalone practices are suffering. Medicare rates have increased just 10% since 2001, yet costs are up for practices by 63% in that time. Medicare rates drive commercial rates. Independent practices are getting creative to survive, including teaming up with public equity firms that own medical service organizations and tapping into their services and capital, while remaining free-standing. (Article may require a subscription.) #physicians #independentpractices https://www.modernhealthcare.com/providers/mh-independent-physicians-private-equity-partnerships/ Centene Wants More Flexibility To Combat Fraud Centene is asking the Centers for Medicare and Medicaid Services (CMS) to empower insurers to tackle fraud. It wants the agency to ease a “complex web of regulations.” In part Centene wants to be able to suspend payments to providers without waiting

MA Plans Object To Flat 2027 Rates The Medicare Advantage (MA) community was shocked by the near-flat rates that the Centers for Medicare and Medicaid Services (CMS) proposed for 2027. MA plans are now laying out the potential impacts in comments on the proposed regulation. The rate hike was computed at just 0.09% due to two new risk adjustment reforms – one embedded in the new v28 model and another that bars risk scoring unless diagnoses also appear on submitted provider encounters. The changes wiped out the economic growth increase. Various MA plan trade groups were unanimous in saying that the rate as is could undermine the program yet again. Major health plan trade group AHIP said in comments to the proposed rule that the flat rate “risks undermining CMS’ goal of providing beneficiaries with stable, affordable choices during the annual enrollment period.” It noted sharply rising medical costs and

SOTU Has Little On Healthcare President Trump touted his accomplishments in his State of the Union address Tuesday but spent little time on affordability in healthcare. In the speech he did hit two main topics, but just for a total of five minutes of the marathon speech. I was not impressed with the vagueness of his health insurance coverage proposal but have given Trump a great deal of credit on moving the drug price needle. No one has been able to really do the latter before. #trump #healthcare #coverage #drugpricing https://www.healthcaredive.com/news/trump-state-of-the-union-healthcare-2026/812962 GoodRx Launches Employer Direct Program GoodRx announced it will launch Employer Direct, a new program that will allow employers to offer workers lower costs on branded products. Through the program, firms can select branded drugs and subsidize the cost for the cash-pay price available through GoodRx. The idea is that employers can lower employee costs by leveraging GoodRx existing

CBO: Medicare Part A Trust Fund Bust in 2040 The Congressional Budget Office (CBO) has updated its estimates around the solvency of the Medicare Part A Trust Fund and now expects the fund to go bust in 2040. The balance will grow each year through 2031, but then spending will begin to overtake revenue until it eventually runs out in 2040. This is 12 years less than the last estimate. The culprits are: The CBO’s projection is better than the Medicare’s trustees’ last projection, which said the fund would be depleted by 2033. Additional article: https://www.fiercehealthcare.com/regulatory/cbo-estimates-medicare-trust-fund-will-run-out-2040 #medicare #spending #insolvency https://www.healthcaredive.com/news/medicare-trust-fund-expire-2040-cbo-gop-obbb/812937 UnitedHealthcare Expands Referral Requirements Starting May 1, enrollees in UnitedHealthcare health maintenance organization (HMO) Medicare Advantage (MA) products will need a referral from a primary care provider to go to many specialists. This brings back an old-school managed care lever to reduce costs. The prerequisite has already been in place

Exchange Enrollment Expected To Drop While actual enrollment during the open enrollment season in the Exchanges did not drop a great deal, the cost of not extended enhanced subsidies is now appearing to take hold. State Exchanges as well as health plans are reporting cancellations as well as lack of premium payments, which could send rolls dropping dramatically throughout the year. As one example, the biggest Exchange plan nationwide, Centene, says it expects its rolls to drop over one-third this quarter. Cigna, Elevance Health, Molina Healthcare, and UnitedHealthcare anticipate collectively losing approximately 3.4 million exchange members by the end of 2026.  (Article may require a subscription.) #exchanges #enrollment #healthplans #coverage https://www.modernhealthcare.com/insurance/mh-aca-exchanges-membership-premium-payments No Suprises Battles A Modern Healthcare article covers the ongoing battle between insurers and providers regarding the No Surprises Act arbitration process. Physician groups, hospitals, and air ambulance companies have filed millions of claims seeking higher reimbursement from insurers

Congress Inches Toward Site Neutral Payments Congress didn’t pass site neutral payments in Medicare but did make some incremental progress toward the reform in the FFY 2026 appropriations bill that was recently passed. This could lead to cuts to the tune of billions of dollars in hospital reimbursements in the future. The bill requires health systems to obtain unique National Provider Identifiers, or NPIs, for their outpatient departments by 2028. This will have the effect of giving the government detailed information about outpatient care provided at hospital-owned facilities — and its cost — to support broader site-neutral policies. The Trump administration did implement site neutral payments for drug administration via regulation this year. That follows some other modest reforms several years ago. Site neutrality pays the same rate to provider regardless of the site the service is performed at – physician office, ambulatory surgery center, off-campus hospital outpatient department, or