physicianshortage

Paragon Proposes Reforms The influential Paragon Health Institute released a new report calling for federal funding cuts or tax reforms impacting all health plan lines of business and coverage areas. People pay attention to what Paragon says given its influence and impact on government regulations since 2025 as well as in the One Big Beautiful Bill Act (OBBBA). In summary, Paragon wants to see the following changes: #medicare #medicaid #exchanges #employercoverage #healthcarereform #healthcare #coverage https://paragoninstitute.org/medicare/restoring-fiscal-sustainability-to-federal-health-programs-reforming-the-incentives-that-drive-health-care-spending/ Balkanization of Star Ratings We are quickly seeing the balkanization of Star calculations for SY 2026. Elevance Health filed a suit against CMS today arguing that it should have used the Clover’s judge’s measures for recalculation rather than one created by the agency. Elevance says it lost out on $115 million in bonus payments as a result. Elevance has a point. How can one contract get the judge’s ruling while others receive the “better of”

MA Star Bonus To Exceed $13B Healthcare policy group KFF reports that federal spending on Medicare Advantage (MA) quality bonuses will reach at least $13.4 billion in 2026, compared with $12.7 billion in 2025. This is more than four times higher than in 2015. More than two-thirds of Medicare Advantage enrollees (68%) are in plans that qualify for the quality bonus in 2026, down from 75% in 2025. This is the lowest since 2018. The increase ties to more enrollment not better ratings. In another briefer, KFF updates on MA coding intensity. Additional article: https://www.kff.org/medicare/decoding-medicare-advantage-coding-intensity/ #medicareadvantage #radv #riskadjustment #stars #quality #cms https://www.kff.org/medicare/medicare-will-spend-more-than-13-billion-on-the-medicare-advantage-quality-bonus-program-in-2026/ Home Health Hike For 2027 The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that would increase Medicare payments to home health providers by 2.4% in 2027. In addition, the rule would make it easier to bar providers and suppliers from Medicare over fraud. In

House Wants To Rein In Private Equity A bipartisan House bill would require extensive reporting on private equity firms’ healthcare holdings and ownership structures. The reporting is aimed at identifying financial arrangements that may impact the financial health of the healthcare entity as well as impacts on healthcare delivery. The bill is similar to state laws on transparency in private equity. Other states have gone deeper and ruled out certain financial arrangements by private equity for acquired healthcare entities. (Article may require a subscription.) #healthcare #congress #privateequity https://www.modernhealthcare.com/politics-regulation/mh-private-equity-healthcare-congress-transparency Providers Direct Contract With Employers There is a growing trend in providers direct contracting with employers. Local networks are leveraged and providers avoid prior authorization and other administrative burdens. Both employers and providers are cutting out the insurance middleman. (Article may require a subscription.) #healthplans #employercoverage #providers https://www.modernhealthcare.com/providers/mh-northwell-commonspirit-direct-contracting-employers Providers May Get Changes For Quality Reporting A new bipartisan House bill would allow

States Sue on Work Requirements Democratic governors and attorneys general from 25 states and Washington, D.C. are suing the Trump administration over the proposed Medicaid work requirements regulation. States argue the rule narrows exemptions for medically frail Medicaid beneficiaries and creates administrative barriers that could cause eligible people to lose coverage. The plaintiffs say the rule goes well beyond the statute by requiring people with serious health conditions to prove their condition significantly impairs their ability to meet work requirements. Additional: https://www.beckershospitalreview.com/legal-regulatory-issues/25-states-sue-trump-admin-over-medicaid-work-requirements-7-things-to-know/ and https://www.modernhealthcare.com/politics-regulation/mh-medicaid-work-requirement-lawsuit-democrats-bonta/ (Some articles may require a subscription.) #medicaid #workrequirements #states https://thehill.com/policy/healthcare/5946392-lawsuit-trump-medicaid-exemptions/ GLP-1 Bridge Population Healthcare policy group KFF finds that 3.8 million Medicare beneficiaries meet the criteria to be eligible for the new Medicare GLP-1 Bridge. The group looked at claims data from 2023. The proposed BALANCE program failed to attract enough plan participation. Instead, the Trump administration will run Bridge from July 2026 to Dec 2027.

Exchange Enrollment Falls Dramatically A number of analyses have predicted that Exchange enrollment nationally will fall in 2026 after dropping from 24.3M in 2025 to 23.1 in January 2026. The analyses said that enrollment would drop to as low as 17.5M as people would not be able to afford their premiums throughout the year. Sure enough, the predictions seem to have come true, and the news may be being buried. Today, a Health and Human Services (HHS) website posted an analysis on fraudulent and phantom enrollments and deep in the release were latest enrollment figures. HHS says around 19.2 million people are enrolled in the Exchanges as of now, a drop of about 4M since January. HHS says millions are inappropriately receiving subsidies, including individuals misstating their income to gain access to free plans and phantom enrollees (those who are unknowingly enrolled in free plans by unscrupulous brokers or are

Cassidy Wants 340B Reform Sen. Bill Cassidy, R-LA, unveiled a draft for 340B reform today and challenged the public to offer comments for the possible passage of legislation later in the year. This would be the first time any statutory changes to 340B would be made in 15 years. There are numerous reforms aimed at controlling costs, reining in inappropriate use of the program, reducing duplicative discounts, and ensuring savings are actually passed through to needy consumers. The hospital lobby and others oppose any changes. Numerous studies show that 340B hospitals tend to have higher prices than non-340B ones. Changes would include the ability of drug makers to offer upfront discounts or retrospective rebates, claims submission, and mandatory pass-through of the rebates. There would also be a set number of contract pharmacies within each geographic region that a qualifying provider could have. Additional article: https://www.fiercehealthcare.com/providers/cassidys-new-plan-reform-340b-rebates-contract-pharmacy-limits-and-more (Some articles may require a

CMS Actuary: $9T Healthcare In Our Future The Centers for Medicare and Medicaid Services (CMS) Actuary released annual outyear growth projections for healthcare. The actuary says U.S. healthcare spending will hit just short of $9 trillion by 2034. That will be 20.6% of gross domestic product (GDP). While final numbers for 2025 will be tallied by December, the actuary also said healthcare spending was about $5.7 trillion in 2025, up 7.3% from about $5.3 trillion in 2024. That was about 18% of GDP. This is the third straight year of over 7% growth. The average growth over the decade will be about 5.4%, which is lower than previous projections. But healthcare spending will continue to grow faster than the rest of the economy during the decade period projected. Utilization increases have been one of the major culprits for aggressive trends the past few years. This will continue in 2026 and

Less Than 50% Are Healthcare Cost Secure A new West Health-Gallup Affordability Index survey classifies just 49% of American adults as “Cost Secure” down two percentage points from 2024 and down 12 percentage points from 2022. Forty-one percent of adults in 2025 are considered “Cost Insecure” and 10% of adults are considered “Cost Desperate.” Affordability, and specifically healthcare affordability, is a top election-year issue. #affordability #healthcare #coverage https://www.fiercehealthcare.com/payers/gallup-poll-claims-less-50-american-adults-can-afford-healthcare Exchange Rates To Jump Again Health insurance companies say premiums will spike again in 2027 after a huge surge in 2026. Rate filings are underway. Hikes discussed by plans generally are between 11 and 26%, with one request as high as 52%. Enhanced subsidies’ expiration saw enrollment decline and risk increase. Those trends are continuing along with utilization and cost hikes. In other news, Elevance Health confirmed it will exit Ohio’s small group insurance market by year’s end. Additional article: https://www.modernhealthcare.com/insurance/mh-elevance-health-ohio-small-group-aca/ (Articles

States Worried Rural Funding Could Be Clawed Back After announcing the Rural Health Transformation with much fanfare, the Centers for Medicare and Medicaid Services (CMS) is now threatening clawbacks of funding or reductions of future allocations if states do not meet policy goals and requirements set out by the agency. CMS is rejecting and reshaping state plans under the $50 billion program. States are struggling not only with the policy goals but also the speed by which the program must be implemented and dollars spent. While many of the Trump administration policy goals are noble, states and rural providers are focused more on efforts to balance budgets and keeping the doors open. (Article may require a subscription.) #cms #healthcare #ruralhealthcare #obbba https://www.modernhealthcare.com/politics-regulation/mh-cms-rural-health-fund-clawbacks — Marc S. Ryan

More Clover Stars Fallout More news on the fallout from the Clover Health lawsuit it won on its Star Year 2026 ratings. As noted earlier this week, the Centers for Medicare and Medicaid Services (CMS) have recalculated Star ratings, giving contracts the “better of” the original rating or one that includes only measures that are consistent (sort of as CMS took some liberties) with the judge’s decision on Clover. There are more losers than winners. About 5% of contracts and 10% of enrollment benefited, while about 37% of contracts and membership would have dropped if not for the hold harmless. The rest would have had no change. As I have said, CMS really had no choice but to do what it did despite a $1 billion plus price tag. I think this will be fixed over time. Yours truly is quoted in the article saying that plans likely will be