exchanges

Is American healthcare headed for a huge transformation? PwC things so. NOTE: This blog is published in collaboration with Lilac Software. Learn more at https://lilacsoftware.com . Financial and management consultant PwC came out with a blockbuster report that predicts major changes in how healthcare will be delivered over the next decade. While I believe healthcare reform is critical to save our system, it is fair to say that the technological changes too will critically remake how care is delivered. The report is titled: “From breaking point to breakthrough: the $1 trillion opportunity to reinvent healthcare.” PwC says healthcare is in the process of a monumental shift. Artificial-intelligence-driven, consumer-centric healthcare services will emerge. This will simplify care models, lower costs, and increase quality. PwC’s main prediction is that $1 trillion of national healthcare spending could go to digital-first, personalized medical care by 2035. The Centers for Medicare and Medicaid Services’ Office

Program audits will get tougher and tougher for Special Needs Plans In my last blog on 9/25/2025 here ( https://www.healthcarelabyrinth.com/the-meteoric-growth-of-special-needs-plans-snps/ ) I discussed the meteoric rise in Special Needs Plan (SNP) growth, why plans are investing here, and why executives have to be watching out for pitfalls.  One of them clearly is the growing compliance, regulatory, and program audit environment. I promised an overview of the maturing SNP program audit regulatory environment. A few quick points: Emerging trends: Back some time ago, CMS concentrated on whether a health risk assessment (HRA) was complete and a care plan issued. These two tests were very much the focus of CMS’ regulatory and audit tests. But CMS has now gone far beyond these simple tests. That is not to say these are not important – they are. A plan can miserably fail and audit without them. But these have now become table stakes

Plans are investing in SNPs and executives need to prepare for scrutiny Notwithstanding the huge meltdown in health insurance generally and Medicare Advantage (MA) specifically, MA plans are busy making new investments in the program, prognosticating that investments in Special Needs Plans (SNPs) will pay huge dividends. Back in March of this year, I wrote a detailed blog on everything SNP – from what they are, the types, history, growth, regulation, and more. Go here to read the details, which are still very relevant: https://www.healthcarelabyrinth.com/special-needs-plans-snp-growth-a-relative-bright-spot-for-medicare-advantage-ma/ . In this blog, I am updating some recent growth trends and I will further elaborate about why plans are investing here and some of the rising risks to consider. On Monday, I plan to do a deep dive into current audit and regulatory trends in SNPs to help plans and executives prepare for program audits. A growth update Plans have been investing heavily in

MA continues plugging along despite financial woes A quick blog to tell you about enrollment growth in Medicare Advantage (MA) from August 2025 to September 2025. MA growth slowed down from 2024 to 2025 because of the financial woes of the MA industry. But the rolls are still growing due to aging and the popularity and value of MA compared with the archaic traditional Medicare (fee-for-service) program. What do the latest statistics show? Growth from January 2024 to February 2025 was 4.39% or 1.468 million. (I used February 2025 because of issues with the January 2025 statistics). Enrollment in MA reached 34.941M in February 2025. In September 2025, it reached 35.579M. MA enrollment grew about 51K from August to September and about 637K from February to September. Growth in September was down from 91K in August. How did Big MA do? From January 2024 to February 2025, Big Plan MA

MA plans may cheer the delay on supplemental benefits notifications, but it could work against them over time The Centers for Medicare & Medicare Services (CMS) announced in a short notice published in the Health Plan Management System (HPMS) that it is delaying enforcement of Medicare Advantage (MA) supplemental benefits notification requirements. It says it will reconsider the regulatory requirements. Background on recent reforms In light of the ongoing controversy over the surge of rebates in the rate-setting program and the inability to determine how much of the extra dollars are truly spent on added benefits, CMS instituted two key reforms. First, it clarified ambiguity about whether supplemental benefits must be submitted as encounter data. It now requires all benefit utilization to be submitted as such. This has led to a very complicated directive from CMS to MA plans on how to submit such data. Many supplemental benefits are not

Price disparity with other countries underscores need for reform A quick blog on a recent Peterson-KFF Health System Tracker Chart Collection comparing U.S. healthcare prices and utilization against those in other developed nations. I like these periodic looks at prices and utilization throughout the developed world because it reveals at least one of the biggest reasons our healthcare system is in crisis or at least tumbling toward it. In my book, The Healthcare Labyrinth, I make the case that three key reforms are needed to the healthcare system – price reform, affordable universal access, and a pivot to primary care and care management. In many ways, the three go together. As an example, price reform is needed to ensure affordable universal access. And only with affordable universal access can we really get back to the rebuilding of primary care, wellness, and prevention. Wellness and prevention mean care at lower cost

A new risk adjustment study could lead to momentum to pass reforms I have written about Medicare Advantage (MA) risk adjustment (RA) overpayments before, but a new study has me thinking again whether the time really has come for RA reform. Many studies paint MA overpayments with a broad brush, saying the entire system is over-reimbursed. But a new study backs up something I have said for a long time – that a small number of larger MA plans receive a disproportionate benefit from these RA overpayment schemes by using aggressive or even fraudulent coding. The study by the Alliance of Community Health Plans (ACHP), a group that represents local and regional nonprofit payers, finds something similar to a few other studies that have zeroed in on the real culprits giving all of MA a bad name. ACHP’s study finds that UnitedHealthcare, the biggest MA insurer, collected up to $785

I am beginning a Medicare Advantage contraction counter as we move toward open enrollment and 2026 Given the ongoing financial challenges for insurers in general but specifically in Medicare Advantage (MA), we have already seen announcements of many high-profile contractions for 2026. In my August 14 blog here ( https://www.healthcarelabyrinth.com/what-is-in-store-for- medicare-advantage-in-2026/ ), I tell you all about the challenges and my prediction that contraction will be heavy but not what it was in 2025. I am already thinking my prediction could be wrong here given the recent announcements. We could in fact see contraction that comes close, rivals, or even exceeds what we saw in 2025. Thus, periodically I will write a quick blog – here is installment 1 – tracking the announced MA contractions for 2026. 2025 contraction overall To refresh your memory on what happened in 2025, here are some important statistics for an alarming downsizing by plans:

The GOP is not wrong about the need to bring accountability to government programs I have taken the position that most of the reductions to healthcare in the One Big Beautiful Bill Act (OBBBA) were simply bad policy, but a number of you have asked me about my comments throughout the budget saga that some changes were reasonable. Others have asked why I have been mentioning the conservative Paragon Health Institute quite a bit. Paragon’s cadre of staff and fellows have populated key healthcare positions in the White House and healthcare agencies under Trump 45 and 47. Many of the reductions in the OBBBA came from Paragon positions. Let me answer the second question first. While I may not agree with everything Paragon trumpets, the think tank has rigorous policy discipline, and you have to respect that. They, too, are an influential player and I would be foolish not to

While the No Surprises Act is helping Americans avoid surprise bills, it is fundamentally flawed and driving costs Since the No Surprises Act (NSA) was passed in late 2020 and went into effect beginning January 1, 2022, I have argued that the baseball-style arbitration process in the law is heavily stacked against health plans and favors providers. While the bill certainly stops Americans from receiving surprise bills, there is little question to me that the bill itself has and will continue to increase costs in the healthcare marketplace. A few new studies show the pros and cons of the bipartisan legislation. Let’s take a look at them. The pros As I note, the NSA has saved so many from exorbitant out-of-network (OON) bills. That is a good thing. While not every surprise bill has been stopped (e.g., ground ambulances), OON abusive billing for all emergency care and most surgery or procedures