pace

Outgoing Biden FTC Fires Another Shot At PBMs CVS Caremark, Express Scripts and OptumRx – the Big 3 pharmacy benefits managers (PBMs) — dramatically mark up specialty generic drugs to affiliated pharmacies, according to a new report from the Federal Trade Commission (FTC). This is the second of two scathing reports. The FTC analyzed 51 specialty generic drugs from 2017 to 2022 and found that the PBMs’ affiliated pharmacies acquired $7.3 billion in excess revenue when compared to the National Average Drug Acquisition Cost (NADAC), an estimate of what it costs a pharmacy to acquire a drug. Further, the report says the conclusion could be an underestimation. PBMs generally defended themselves by saying that the report is misleading because it is based on a subset of drugs, that clients not PBMs choose networks, and they bring many savings to the system. But the report does show that PBM-affiliated pharmacy dispensing

MA Pay Hike Inadequate; Physicians Upset Health plans stocks did well on the news that Medicare Advantage (MA) rate hikes would improve in 2026, but many are still calling the increase inadequate and hope the incoming Trump administration will offer more relief. Advocates for MA are saying individual plan offerings will still have to decrease in 2026 after a major contraction in 2025. See my blog today digesting the announcement: https://www.healthcarelabyrinth.com/calling-all-plans-advance-notice-released-for-2026-ma-and-part-d-rates-and-other-policies/ . In related news, physicians are very upset that health plans will see an increase while they will see a fifth year of reductions. Docs feel plans are getting preferential treatment. I see the docs’ point. In other news, the Centers for Medicare and Medicaid Services (CMS) want to continue a premium stabilization program for standalone Part D (PDP) plans. A spike in premiums would have occurred without the program. Republicans think the program could be extra-legal (as I

2026 MA Proposed Rate Announced The outgoing Biden administration has released its Advance Notice for 2026 rates and other policy changes. I quickly reviewed the 180-page Advance Notice, the CMS Fact Sheet, and CMS Press Release. Here are some highlights and Healthcare Labyrinth will have more information on rates and Star changes next week. My summary: The announcement is progress for MA plans and will be a bit of a relief for insurers and investors. But this still is a very skimpy increase given all the MA world is facing. It could mean a third year in MA benefit cuts. Details: — CMS says MA rates go up by 4.33%. But plans will take issue with including a risk score trend of 2.1% in the calculation. Plans will say they will get closer to a 2.23% because plans do not count the coding increase as a real revenue increase. They

Musk Calls Out Goals For DOGE Tesla CEO Elon Musk, who is co-leader of Donald Trump’s proposed Department of Government Efficiency (DOGE) commission, said that the best-case scenario would be to put together $2 trillion in cuts to federal spending. He said that then DOGE would have a good shot at executing $1 trillion in reductions. Whether the goal is a real $1 trillion or $2 trillion, it is clear that healthcare program cuts will play a big role in spending reductions. #doge #government #spending #trump #congress #healthcare https://thehill.com/homenews/administration/5076095-elon-musk-doge-2t-spending-cut-goal/?tbref=hp Generic Drug Lobby Worried About Tariffs The U.S. generic drug lobby is worried about the imposition of tariffs and wants to convince the incoming Trump administration such tariffs would hurt efforts to lower drug prices. The Lobby is also pushing for so-called “skinny” labeling, biosimilar automatic interchangeability, and patent reform. (Article may require a subscription.) #drugpricing #generics #tariffs #trump #biosimilars #patents

Exchange Enrollment Hits Record With about a week left of enrollment, the Centers for Medicare and Medicaid Services (CMS) said that the Exchanges have reached yet another record enrollment number after mostly lagging during the enrollment season. More than 23 million people have selected coverage. There are 3.2 million new enrollees. Of the people who have signed up so far, 16.7 million found coverage on the federal Exchange, with 6.9 million on the state Exchanges. This is the fourth consecutive year of enrollment records. Enhanced premium subsidies expire at the end of 2025, which could dramatically impact enrollment. Today congressional Republicans declined to say they would simply let the subsidies expire. Instead, they expect the issue to emerge during talks to extend the Trump tax cuts and the reconciliation process. I still see this as a long shot, but it is bolstered by Sen. Lisa Murkowski’s advocacy for continuation of the enhancements.