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GLP-1 BALANCE Model On Hold The Trump administration’s effort to bring GLP-1 drugs for the obese to Medicare, BALANCE, is on hold. The Centers for Medicare and Medicaid Services (CMS) planned to negotiate lower GLP-1 prices for Medicaid and Medicare Part D coverage and have health plans and pharmacy benefits managers (PBMs) agree to offer the drugs in the programs. But too few applicants applied to participate, likely due to costs and risk. Critical mass in Part D, covering 80% of Part D enrollment, was not met. The Medicaid portion of the pilot will still move forward. In Medicare, to gather necessary data, CMS now plans on funding coverage through the end of 2027 before proceeding with the model. At the same time, UnitedHealthcare said it was hoping to participate in both the BRIDGE program in 2026 and in BALANCE. Additional articles: https://www.beckershospitalreview.com/glp-1s/cms-pauses-weight-loss-balance-model-indefinitely-for-medicare/ and https://www.beckerspayer.com/payer/medicare-advantage/unitedhealthcare-eyes-cms-balance-glp-1-model/ (Some articles may require a

United To End Most PAs On Rural Hospitals Responding to the rural health crisis and its own bad PR, UnitedHealthcare says it will exempt rural hospitals from most prior authorizations. This will apply across all lines of business. United will also accelerate payments by up to 50% for about 1,500 rural hospitals and all critical access hospitals across the country. Additional article: https://www.beckerspayer.com/payer/unitedhealthcare-pares-back-prior-authorizations-speeds-up-payments-for-rural-providers/ #unitedhealthcare #priorauthoriztaion #ruralhealthcare https://www.fiercehealthcare.com/payers/unitedhealthcare-unveils-pilot-accelerate-payments-rural-hospitals United Financial Storms Subsiding? United Health Group reports today on its latest financial results and recovery. It is expected to be good news overall. United is making progress. An interesting article, though, outlining the Medicare Advantage (MA) rate challenges and how both United and investors were slow to see the impact on the insurer as well as its services unit, Optum. The article details some of the huge financial misses by United’s former leaders even with clear signals back three years ago. Investors,

PCP Stability In Doubt Elation Health finds that over 80% of primary care physicians (PCPs) are concerned about financial stability over the next several years. The company surveyed 280 PCPs from Jan. 31 to Feb. Fifty-two percent of respondents were fully independent and 48% have some affiliation.  About 64% cite government and commercial payer reimbursement as their top concern. Staffing costs, workforce challenges, technology and IT costs and rising operational costs are also challenges. Despite all this, 93% of respondents report remaining committed to primary care. Only 2% report planning to leave the practice.  #providers #physicians #margins https://www.fiercehealthcare.com/providers/over-80-pcps-concerned-about-financial-stability-over-next-several-years-elation-health Employer Affordability Challenges Purchaser Business Group on Health finds that more and more employers are considering switching insurance or pharmacy benefits managers (PBMs) as a result of rising costs. About 37% of members have issued request for proposals (RFP) for medical benefits, meaning they’re shopping between insurance providers. About 23% are conducting

Trump Getting Serious On Affordability There was a clear sign today that the Trump administration is worried about the impact of the lack of healthcare affordability. The Trump administration created a top-level healthcare position that will be a de facto affordability czar. Health and Human Services Secretary Robert F. Kennedy, Jr. has named Casey Mulligan as chief economist and chief regulatory officer of the agency. He’ll advise Kennedy and other agency leaders on affordability issues. Mulligan was on the Council of Economic Advisers during the first Trump administration and was most recently the U.S. Small Business Administration’s chief counsel for advocacy. Meanwhile, healthcare policy group KFF issued a briefer on Americans’ views of healthcare. Just under half of U.S. adults say it is difficult to afford healthcare costs, and about three in ten say they or a family member in their household had problems paying for healthcare in the past

Chronic Care Cost-Sharing Targeted A new bill would eliminate Medicare cost-sharing on care coordination services. Supporters argue the cost-sharing on the services creates financial barriers to deploying such services for many. They also argue charging seniors for the behind-the-scenes services is confusing. Further, the services have documented savings, but utilization is low due to the cost-sharing impediment. About 40 healthcare and patient groups have endorsed the measure. #chroniccare #medicare https://www.fiercehealthcare.com/providers/providers-back-new-bipartisan-bill-eliminating-medicare-chronic-care-management-cost Wegovy Gets Boost GoodRx is making available the new higher 7.2 mg dose of Wegovy for weight loss at $399 per month. This is a boost to embattled drug maker Novo Nordisk, which has lost major market share in the weight-loss drug market to Eli Lilly. #weightlossdrugs #drugpricing https://www.fiercehealthcare.com/telehealth/goodrx-launches-72-mg-wegovy-dose-self-pay-patients-399-month Most Physician Pay Up Average physician pay rose about 3% between 2024 and 2025, from $374,000 to $386,000. #providers #healthcare https://www.fiercehealthcare.com/providers/physician-compensation-3-2025-not-all-specialties-saw-raises-medscape Wakely: Exchange Enrollment Could Fall Further Wakely Consulting examined latest enrollment

Bill Would Force Insurers To Count DTC Drugs Against Deductible, MOOP North Carolina Republican Rep. Greg Murphy, MD, has introduced a new bill that would compel insurers to apply the cost for drugs purchased from direct-to-consumer (DTC) platforms to deductibles and out-of-pocket maximums (MOOPs) in insurance. Using these platforms, patients can often find prices that cost far less out-of-pocket, especially for brand drugs, Murphy’s office said. #drugpricing #dtc #branddrugmakers #healthplans https://www.fiercehealthcare.com/regulatory/bill-seeks-force-payers-apply-dtc-drug-purchases-patient-deductibles Safety Net Hospitals Lag On Cost Reporting An analysis published in JAMA Network Open finds that hospitals serving more disadvantaged populations lag on complying with price transparency regulations.  #pricetransparency #hospitals https://www.fiercehealthcare.com/providers/hospitals-more-disadvantaged-patients-fall-short-price-transparency-study — Marc S. Ryan

Healthcare Costs Vary Across Regions A new report titled the Health Cost Landscape from the Health Care Cost Institute found that healthcare spending per person with employer coverage was $6,711 but the figure can vary significantly by region. Spending was 70% higher than the national average in Charleston, West Virginia, while costs were 41% below the national average in Bakersfield, California. The report looked at more than 1.3 billion medical claims submitted from 2018 to 2022, with data from 38 million people. The report also found that the price of services, utilization trends and the types of services used all contribute to the spending figures. Prices were the largest driver in variation. Most of the metropolitan areas included in the study were highly concentrated hospital markets, with 88% either highly or very highly concentrated. #healthcare #costs #employercoverage https://www.fiercehealthcare.com/finance/healthcare-spending-varies-widely-between-metropolitan-areas-hcci ACCESS Winners Announced The Centers for Medicare and Medicaid Services (CMS) announced

New Drug PA Requirements In Government Programs Notwithstanding the voluntary prior authorization reforms, the Centers for Medicare and Medicaid Services (CMS) issued a new proposed rule that extends recent non-pharmacy prior authorization requirements to retail drug requests. In the case of retail drugs, urgent requests would have to be fulfilled in government programs within 24 hours, with all others in 72 hours. The requirement is within a broader Interoperability Standards and Prior Authorization for Drugs rule. The PA requirements are effective October 1, 2027. The rule would also require insurers to publicly report certain metrics around prior authorization, including approval and denial rates, appeal outcomes, and decision timeframes. As well, CMS is proposing to require payers to support three National Council for Prescription Drug Programs (NCPDP) standards—the SCRIPT, Formulary & Benefit (F&B), and Real-Time Prescription Benefit (RTPB) standards–beginning October 1, 2027. The proposed standards allow providers to query formulary information,

Priority Health Overpayment Audit The Health and Human Services (HHS) Office of the Inspector General (OIG) says Priority Health may have collected at least $4.4 million in Medicare Advantage (MA) overpayments throughout 2018 and 2019. The targeted audit focused on ten high-risk diagnosis groups. Auditors found medical records did not back diagnosis codes across 252 of 300 sampled enrollee-years, prompting $828,010 in net MA overpayments — an 84% error rate. OIG says many codes were for a previous diagnosis that was no longer active. #medicareadvantage #radv #riskadjustment #overpayments https://www.beckerspayer.com/legal/priority-health-estimated-to-have-received-4-4m-in-overpayments-audit/ Wakely Details LEAD A great Wakely Consulting white paper detailing the ACO LEAD model, which will succeed ACO Reach and run from 2027–2036. LEAD will eliminate rebasing (locking in base years), expand capitation and specialist risk-sharing, integrate high-needs populations into a unified ACO structure, and offer more flexible alignment mechanisms. Benchmarking and value-based care incentives also evolve along while strengthening quality incentives

CMS Understood Rate Impact on MA More evidence that the Centers for Medicare and Medicaid Services (CMS) understood the potential impact of a zero-rate hike on Medicare Advantage (MA) benefits and cutbacks in 2027. The agency raised the rate hike to about 2.5% by amending its proposal for more aggressive risk adjustment and v28 model changes. This means payments will move from basically a zero increase to $13 billion, just over half of what 2026 will see. CMS clearly listened to plan complaints about the proposed model changes. Plans argued cost recognition would not be correct if the model were adopted. CMS could still adopt this in the future. And as I noted, most plans will see more than 2.5% because the unlinked chart change that was adopted hits big plans much more given their risk adjustment practices. Experts say UnitedHealthcare faces a $5 billion reduction and Humana $2 billion. Still,