first100days

Providers React To Medicaid Cuts Protests broke out at the Capitol and providers and advocates reacted to Medicaid reductions in a draft framework of the budget reconciliation bill. Provider taxes are especially getting attention. The bill proposes to freeze all new provider taxes, while a proposed administration rule would rein in what the administration calls provider-tax waivers that violate the spirit of the law. Limits on state directed payments, often funded by provider taxes, would occur as well in the reconciliation bill. In other news, the Trump administration says it plans on revisiting the mental health parity rule. In addition, doctors appear to be on the verge of some relief in terms of a Medicare physician rate fix. While no relief will be granted in 2025, in 2026 rates would increase by about 2.25% and future increases would be linked to the Medicare Economic Index, which generally rises faster than

Trump Backs MFN Drug Pricing President Donald Trump expanded his drug reform proposals today by announcing an executive order that seeks to implement the strictest form of international reference pricing (IRP) known as most favored nation (MFN) status pricing. Americans would receive the lowest price for a drug offered anywhere in the world. It appears that the proposal would be for all Americans – across Medicaid, Medicare, and commercial products. Trump said in a social media post that savings would be 30% to 80%. Another report narrowed the number to 59%. Trump said that the most expensive drugs would perhaps be attacked first. His MFN proposal builds on a rule he attempted to implement for Medicare Part B medical drugs back in Trump 45. It was eventually rescinded by the Biden administration after being struck in court. While the idea was good, it did have many implementation challenges. At the

Medicare and Medicaid Cover GLP-1s For Disease States Other Than Obesity The Hill has a good article explaining what the coverage of GLP-1s is in Medicare and Medicaid. Generally, GLP-1s are covered for disease states such as diabetes and cardiovascular diseases, but not for obesity alone. In the commercial world, some employers cover the drugs for obesity alone. In addition, drugmakers Eli Lilly and Novo Nordisk market their GLP-1 drugs under different names. Here is the skinny so to speak. The brand drug makers are looking to expand these drugs to other disease states. Novo Nordisk: Ozempic – for treatment of diabetes Wegovy – for weight loss and cardiovascular disease Eli Lilly: Mounjaro – for treatment of diabetes Zepbound – for weight loss and certain sleep apnea. #branddrugmakers #drugpricing #glp1s #weightlossdrugs https://thehill.com/policy/healthcare/5290997-medicare-medicaid-coverage-weight-loss-drugs CVS Being Sued Over Alleged Fraud Four state attorneys general are suing CVS Health and its pharmacies for

Drugs: Trump May Propose MFN; PBMs Using Various Ways To Control GLP-1 Costs Politico reports exclusively that Donald Trump is on the verge of proposing most-favored nation (MFN) pricing, the strictest form of international reference pricing, to lower drug costs. The executive order would cover the Medicare program for now, but recently the president urged MFN for Medicaid as well. The move would be a major confrontation with the brand drug industry. I have argued Trump’s populism would win out here and he would propose something like this. My blog on the topic: https://www.healthcarelabyrinth.com/expect-big-things-from-donald-trump-on-drug-prices/ . In other news, pharmacy benefits managers (PBMs) are using various and disparate ways to reduce GLP-1 weight-loss drug trends. CVS has dropped Zepbound in favor of Wegovy in the commercial world. It is also using NovoCare, Novo Nordisk’s direct-to-consumer platform for GLP-1s. Humana will also use NovoCare. In 2024, Cigna launched EncircleRx, a program that controls

Trump Says Drug Tariffs Coming President Donald Trump announced that he plans to impose tariffs on pharmaceutical products within the next two weeks. In addition, he issued an executive order directing the Food and Drug Administration (FDA), the Environmental Protection Agency (EPA), and other agencies to facilitate domestic pharmaceutical production and to raise fees for inspecting foreign drug plants. Health plans and pharmacy benefits managers (PBMs) have had a mixed reaction to the imposition of tariffs. CVS Health and Centene see impact that they are studying now, while United Healthcare said it has less concern. Over time, prices will be passed through the supply chain and ultimately to health plans, which will have to pass on costs to employer groups. Government programs would over time recognize cost hikes as well. At the same time, tariffs costs could end up in diminished formularies and higher cost-sharing. The Pharmaceutical Research and Manufacturers

Budget Reconciliation Could Slip Into The Summer A prominent GOP lawmaker told hospital stakeholders today that action on budget reconciliation spending cuts could slip into the summer. Rep. Buddy Carter, R-GA, who chairs a key health subcommittee, indicated the possible slowdown. In addition, hospital leaders exhorted lawmakers to avoid sweeping cuts, which could include work requirements, reduced state matches for the expansion population, fraud reduction, and a per capita cap funding mechanism. They also want the Exchange enhanced subsidies to continue. Insiders say Medicaid per-capita caps and other major structural reforms to the program were being put on the back burner due to moderates’ concerns, but budget hawk conservatives revolted. The committee was readying about $621 billion in Medicaid cuts over ten years. The package included numerous eligibility reforms and restrictions, a reduction in Medicaid expansion match, work requirements, and reducing provider tax allowable rates to 5%. Medicaid spread pricing

International Reference Pricing Bill To Lower Drug Prices Unveiled Two senators, conservative Josh Hawley, R-MO, and progressive Peter Welch, D-VT, have introduced legislation to lower prescription drug prices. The bill would prohibit pharmaceutical companies from selling drugs in the U.S. at prices higher than the international average. This is a form of international reference pricing (IRP). Trump proposed IRP for Medicare Part B drugs under Trump 45 and said he wanted to do so in Medicare Part D as well. The proposal was later pulled back by the Biden administration. Trump has now called for most-favored nation (MFN) pricing for Medicaid. MFN is a form of IRP.  Trump also unveiled a master executive order to reduce drug prices in America. This bill is an important development as it includes a conservative senator. It appears that populism is winning over the GOP, which is usually very friendly to Big Pharma. I

Cigna Reports Good Financial News The Cigna Group reported $1.3 billion in profit for the first quarter of 2025, bucking the trends that have hurt other companies in the insurance industry. Its earnings surpassed Wall Street’s expectations. The company posted a $277 million loss in the prior year quarter. Cigna reported $65.5 billion. That’s up from $57.3 billion for Q1 2024. Cigna faced less pressure around medical costs, reporting a medical loss ratio of 82.2% – up from 79.9% a year ago. Cigna just sold its Medicare assets to Health Care Service Corporation (HCSC). It also announced two new GLP-1 programs. In other news, insurtech Alignment Healthcare exceeded its high-end guidance for the first quarter. The company posted $926.9 million in revenue, up 47.5% year over year. Adjusted gross profit came in at $107.2 million. Alignment still posted a net loss for the quarter at $9.4 million. Additional articles: https://www.fiercehealthcare.com/payers/cigna-bucks-medical-cost-trend-posts-13b-q1-profit

Trump Meets House Leaders On Medicaid Cuts President Donald Trump met with House GOP leaders to discuss Medicaid reductions. Trump said he opposes Medicaid coverage cuts but would support efforts to rein in fraud, waste, and abuse. But Trump has given little word about what would violate his pledge to protect Medicaid. Conservatives want deep cuts and have sent a letter to colleagues saying they want “meaningful reforms” in budget reconciliation. They singled out reducing the Medicaid expansion enhanced reimbursement. Moderates are lining up against reductions, with moderate Don Bacon saying he is leaning against reductions in federal matching funds or provider tax changes. Bacon did say he would support up to $500 million in cuts over the ten-year window. He would support work requirements, more frequent eligibility, and bars on the undocumented. In other news, a poll from healthcare policy group KFF finds that large majorities of Americans, including

Humana Stuns With Great Numbers In Recovery Humana stunned investors with great Q1 recovery numbers, well above what investors had expected. The company beat earnings expectations for the first quarter and reaffirmed its 2025 guidance. Medical costs for the Medicare Advantage (MA)-dominant insurer came in as predicted. Humana had a profit of $1.2 billion, up 68% compared to the first quarter last year. Humana has shed unprofitable MA lives in an effort to get back to a 3% margin by 2027. As important, Humana is seeking to undo a huge concentration of its MA lives in one very large master contract. This will take several years. When Humana’s Star performance was industry-leading, the concentration helped. But that contract dropped dramatically in Star Year 2025, causing a huge loss of quality bonus and rate rebate revenue. Humana still expects a medical loss ratio (MLR) for the full year of between 90.1%