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State Hospital Price Caps Modern Healthcare has a good article on various state initiatives to regulate hospital prices. Proposals range from hard caps to looser standards. Coincidentally, I had a blog on Thursday covering many of the same states and initiatives. Check it out here: https://www.healthcarelabyrinth.com/states-attack-healthcare-costs-and-hospital-prices/ In related news, healthcare policy group KFF issued a briefer on hospital competition in the U.S. The analysis examines the competitiveness of markets for hospital care based on RAND Hospital Data and American Hospital Association (AHA) survey data.  It found that one or two health systems controlled the entire market for inpatient hospital care in nearly half (47%) of metropolitan areas in 2024. In more than four of five metropolitan areas (83%), one or two health systems controlled more than 75% of the market. Nearly all (97% of) metropolitan areas had highly concentrated markets for inpatient hospital care. KFF also says that most hospital

GOP May Run Another Reconciliation Bill Republicans may run another budget reconciliation bill to advance a number of President Donald Trump’s stalled priorities, including funding for the war, a voting bill, and to fund the Department of Homeland Security. Within the bill likely will be more healthcare cuts to meet spending rule and deficit mandates. Not all of the initiatives would pass the Byrd rule, which limits what can be in such a bill. Among the healthcare cuts that could be included are: (Article may require a subscription.) #congress #trump #reconciliation #exchange #coverage https://www.modernhealthcare.com/politics-regulation/mh-gop-budget-reconciliation-bill-medicaid-aca Medicare Physician Payments Under-Funded A good Health Affairs Forefront Blog on the historic under-funding of physicians in Medicare. This is despite numerous reimbursement strategies and alternative payment models for primary care. The authors do a great job of covering the real decline in physician pay over time. Primary care physician spending per traditional Medicare beneficiary averaged

Senate Deal On Private Coverage Insulin Costs Sens. Jeanne Shaheen, D-NH, Susan Collins, R-ME, Raphael Warnock, D-GA, and John Kennedy, R-LA, reached a deal to limit out-of-pocket costs for people with diabetes by waiving any deductibles and limiting cost sharing to the lesser of $35 or 25 percent of the list price per month. This could lead to the passage of the legislation in the upper chamber. The bill would also require pharmacy benefit managers (PBMs) to pass through 100% of insulin rebates and other compensation to insurers. A pilot program in 10 states would also be set up to identify uninsured people with diabetes and providing them with $35 monthly insulin. #drugpricing #insulin #diabetes https://thehill.com/policy/healthcare/5800233-insulin-cost-cap-legislation MA Marketing Lawsuit To Proceed A civil whistleblower lawsuit against CVS Health subsidiary Aetna, Elevance Health and Humana alleging kickbacks to online brokerages for Medicare Advantage (MA) enrollments will proceed. The Justice Department has

CVS Health To Settle PBM Lawsuit With FTC CVS Health’s Caremark has become the second of the Big 3 pharmacy benefit managers (PBMs) to reach a settlement with the Federal Trade Commission (FTC) over insulin pricing. A court document filed Monday indicates the parties have requested that the matter be withdrawn “for the purpose of considering a proposed consent agreement.” No details on the settlement were made public, but the concessions likely mirror the far-reaching elements agreed to earlier by Cigna’s Express Scripts PBM. United’s OptumRx PBM will undoubtedly have to settle too. Additional articles: https://www.fiercehealthcare.com/payers/cvs-caremark-ftc-reach-settlement-insulin-pricing-case and https://www.healthcaredive.com/news/cvs-caremark-ftc-proposed-settlement-insulin-lawsuit/815581/ (Some articles may require a subscription.) #ftc #cvshealth #pbms #insulin #drugpricing https://www.modernhealthcare.com/politics-regulation/mh-cvs-health-ftc-insulin-rebate-lawsuit/ Trump Administration Launches ASPIRE Model The Centers for Medicare and Medicaid Services (CMS) announced a new model called ASPIRE. It will promote wraparound services for high-risk Medicaid and Children’s Health Insurance Plan enrollees through a payment demonstration. CMS will provide

Two Major Medicare Advantage Developments Two major Medicare Advantage (MA) developments today. Modern Healthcare reports that MA plans are pushing the Centers for Medicare and Medicaid Services (CMS) to change the $40 per member per month total beneficiary cost threshold that has been in place since 2024. Plans say this is needed so as to allow scaling back benefits more to respond to rising costs and paltry rate hikes. The 2027 proposed hike is roughly flat due to several changes in how risk adjustment will be applied. It could increase some (say to between 2% and 3%) but the final hike will not be near the cost growth in the program (that was as much as 9% coming into the year) or the over 5% hike last year. Plans have been reducing geographic footprints, shuttering expensive Preferred Provider Organization (PPO) products, and reducing benefits the past few years. But benefit

Read My Lips — No New Faxes: CMS Finalizes Electronic Exchange Rule The Centers for Medicare & Medicaid Services (CMS) finalized a new healthcare and electronic processes rule that is aimed at slashing wasteful spending and antiquated paperwork. The rule establishes national standards for the electronic exchange of clinical documentation used to support healthcare claims. CMS says the initiative will help end faxing and mailing in favor of electronic transactions. The agency hails the change as a way to reduce providers’ administrative burden. CMS says the rule will reduce costs, save time, ensure faster care delivery, and enhance security and efficiency. CMS says the “Administrative Simplification; Adoption of Standards for Health Care Claims Attachments Transactions and Electronic Signatures Final Rule” is projected to save the healthcare industry $781 million annually. The standards adopted apply to any Health Insurance Portability and Accountability Act (HIPAA)-covered entities, including health plans, healthcare clearinghouses, and

Senate Dems Unveil Healthcare Agenda If They Take Over Twelve Democratic senators signed a letter detailing their plan for health insurance reforms they will pursue if they take back the Senate. They want to focus on affordability, reduce barriers to insurance, and hold insurance companies accountable. The Democrats said Republicans were responsible for recent healthcare cuts, including the expiration of enhanced subsidies in the Exchanges and Medicaid and Exchange cuts. They would undo the reductions. Democratics want more affordable coverage, smoother enrollment — through “a one-stop shop” — and wider offerings for lower-income people. They would extend coverage to those in states that did not expand Medicaid and want a “Medicare-type” public option for all Americans. They also want to turn back recent changes on skimpier policies and standardize plans. In addition, they would focus on price transparency, prior authorization, and medical loss ratio gaming reforms. Vertical integration reform of

Praise For And Panning Of Trump Proposals Insurers and hospitals are largely together in criticizing the Trump administration’s proposed rule to allow non-network benefit plans to become qualified health plans under the Affordable Care Act (ACA) and in the Exchanges. The groups say individuals won’t be able to grasp the differences between network and non-network plans and this would expose them to higher-than-expected out-of-pocket costs. Trump officials argue premiums have gone up so much over the years that alternatives must be tested. At the same time, in an unlikely event, billionaire entrepreneur Mark Cuban praised the federal government’s TrumpRx drug platform, saying the initiative is saving Americans money. “Everyone wants me to rip on TrumpRx,” Cuban wrote on X. “Reality is, it’s saving patients money on IVF and a few other drugs. A lot of money. IMO, anything that saves patients money is a win.” Cuban is right. While TrumpRx

Moody’s Keeps Insurers On Negative Outlook Credit agency Moody’s Ratings has affirmed the negative credit outlook for the health insurance industry. Moody’s says medical costs continue to rise and plans will have limited prospects for profitable growth. It expects plan redesigns, benefit cuts, and exits from low-performing markets to continue. Moody’s notes that cost inflation has impacted every business line and will continue through the coming months. It says reimbursement rates have generally lagged these inflation rates. #healthplans #margins https://www.fiercehealthcare.com/payers/moodys-insurers-2026-outlook-negative-cost-pressures-continue-batter-industry Healthcare Entities Struggle With Interoperability Mandate The Workgroup for Electronic Data Interchange (WEDI) says a share of payers and providers have yet to start working toward the application programming interface (API) requirements for the interoperability and prior authorization final rule. WEDI advises the Department of Health and Human Services (HHS) on health information technology. Payers and providers must complete API requirements by Jan. 1, 2027.  As of February, 10% of

CMS Quality Conference Opens The Centers for Medicare and Medicaid Services (CMS) Quality Conference began today with some major addresses by CMS Administrator Dr. Mehmet Oz and other top officials. I will have a blog on the major addresses soon. In the meantime, some key points that were addressed: At the HIMSS conference in Las Vegas last week, Oz went all in on the use of AI, agentic AI, and digital health. Opening the CMS conference, Oz raised some of the same themes, saying CMS is devoted to a tech-first transformation, interoperability, and patients engaging digitally. He said technology was a solution to controlling disease exacerbation, rural health access, and driving annual wellness visits. Oz also noted the following: In related news, announced grant applications for the ELEVATE Model in Medicare. The model will offer Medicare coverage to functional and lifestyle medicine providers. Interested participants seeking grants under the model