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GLOBE Model Finalized The Centers for Medicare and Medicaid Services (CMS) finalized GLOBE, a mandatory five-year model linking Medicare Part B drug prices to cost benchmarks in 19 developed countries. The program starts in January and lasts for five years. The model targets drugs in oncology, rheumatology, immunology, ophthalmology and endocrinology. The parallel Part D program is not yet finalized. The models build on various initiatives undertaken by the Trump administration. Two problems here: GLOBE will reduce fee-for-service costs and effectively reduce Medicare Advantage payments without giving plans any lower costs. This could further reduce benefits in the program over time. As well, the final rule exempts from the model drug manufacturers in the parallel GENEROUS model for Medicaid. Drug makers struck price deals in Medicaid with the president. While I support Trump’s overall efforts, I think that is a mistake. Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-cms-globe-medicare-part-b-drug-model/ and https://www.beckershospitalreview.com/pharmacy/cms-finalizes-new-drug-pricing-model-7-notes/ #drugpricing #partb #partd #medicare

More On MA Retrenchment More details on the Medicare Advantage (MA) landscape files and the depth of retrenchment for 2027. In total, the number of MA plans to be offered will only drop from 5,553 in 2026 to 5,532 in 2027. But that hides the impacts of adds and cuts. The number of impacted enrollees looks much bigger than anticipated. A Modern Healthcare analysis finds that the number of individual MA with Part D prescription drug coverage (MA-PD) products will decline 8% in 2027. Further, it says that there will be 181 counties with no plans next year, up from 67 this year. And at least 3.8 million people will be forced to select new coverage after their insurers terminate a plan. Various analyses peg 2026 impacts at between 2.9 million and 4.6 million. I think the 2027 impact will be closer to 3M — still a shock for me.

Medicare Advantage Will See Huge Changes Again in 2027 The Trump administration is putting the best spin possible on a continuing retrenchment in the Medicare Advantage (MA) industry. The Centers for Medicare & Medicaid Services (CMS) announced that weighted average MA premiums are projected to fall more than 16% from 2026 to 2027, with MA prescription drug (MA-PD) premiums set to decrease by 38% year-over-year. Additionally, CMS said average premium for standalone Part D prescription drug plans is projected to rise by less than $1 per month in 2027. The industry certainly has a different narrative. While it is true that MA remains broadly available, there is little doubt that benefits are being further diminished and that more plan terminations are occurring. This is evident in the landscape file release. A Becker’s Payer article gives an overview of the retrenchment still occurring. MA choice will go down in 29 of

Trump Admin Strikes Deal With 42 States On Improving Medicaid Quality The Trump administration has announced that 42 states will partners with the Centers for Medicare & Medicaid Services to rethink how quality is measured in Medicaid and the children’s health program (CHIP). CMS said the partnership will put health outcomes “at the center of how success is defined” and streamline hundreds of reporting requirements. The initial state participants have about 56 million Medicaid and CHIP beneficiaries and account for roughly $701 billion in fiscal 2024 Medicaid spending. At the center will be streamlining quality measure inventories, adopting digital quality measurement with near-real-time data when possible, and aligning financial accountability with outcomes measures. The program lines up incredibly well with efforts to boost lagging Medicaid outcome performance, interoperability, as well as migrate all government programs to a universal foundation of measures. Additional articles: https://www.fiercehealthcare.com/regulatory/37-states-partner-cms-initiative-rethink-medicaid-quality-measures and https://www.cms.gov/newsroom/press-releases/cms-refocuses-medicaid-quality-health-outcomes-launches-innovative-partnership-37-states #quality #medicaid #cms https://www.beckershospitalreview.com/legal-regulatory-issues/cms-launches-medicaid-quality-pledge-with-37-states/

Will Vertical Integration Be A Focus? An interesting Becker’s Payer article indicating vertical integration will become a strong focus. Recently, late-night TV host John Oliver tore into the inner workings of huge vertically integrated company UnitedHealth Group. The article notes that UnitedHealth is now the fourth-largest company in the world by revenue, taking in $447 billion last year, up 11.8% year over year. It reported ten significant subsidiaries down from a reported 2,700 a short time ago. Vertical integration is not unique to United. While health plan execs have defended vertical integration it is increasingly being looked at by Congress and federal agencies. Sens. Elizabeth Warren, D-Mass., and Josh Hawley, R-Mo., introduced the Break Up Big Medicine Act, which would prevent companies from simultaneously owning a health insurer or pharmacy benefit manager and a provider or management services organization. #verticalintegration #healthplans #unitedhealthcare https://www.beckerspayer.com/payer/as-vertical-integration-scrutiny-grows-unitedhealth-takes-center-stage/ Oz Says AI Will Cost More In

MedPAC Chair Defends MA Analysis Dr. Amol Navathe, the new chair of congressional Medicare policy arm MedPAC, defended the work and Medicare Advantage over-reimbursement estimates of his organization. He doubled down on MedPAC’s view that MA is reimbursed 14% more than what is spent in traditional fee-for-service (FFS). Critics of MedPAC, including me, stand by our assessment that MedPAC is relying on old data that does not recognize risk adjustment reforms and updates. In addition, MedPAC has picked up some spurious academic analyses on so-called favorable selection and has essentially adopted them as fact. The chairman himself is an academic and his defense of this process is expected. Republicans in Congress are challenging MedPAC’s way of thinking, considering a bill to force MedPAC to broaden its viewpoints, including definitively setting aside the favorable selection argument. As MedPAC always does, it says it will open the doors and encourage engagement, but

Trump Admin To Disenroll 760K From Exchange The Centers for Medicare and Medicaid Services (CMS) canceled 315,000 health insurance Exchange enrollments covering more than 760,000 people. CMS says these enrollments were unlawful and that the rescissions are part of its anti-fraud campaign. The agency said the government will save $2.2 billion in premium subsidies.  In addition, CMS said it will terminate more than 200 agents and brokers that have failed to comply with enrollment standards. Additional articles: https://www.fiercehealthcare.com/regulatory/cms-cancel-aca-coverage-760k-crack-down-brokers-latest-anti-fraud-push and https://www.modernhealthcare.com/politics-regulation/mh-cms-aca-enrollment-fraud/ and https://www.modernhealthcare.com/politics-regulation/mh-aca-broker-enrollment-freeze/ and https://thehill.com/policy/healthcare/6104381-vance-oz-aca-obamacare-crackdown/ #exchanges #healthcare #coverage #enrollment https://www.beckershospitalreview.com/finance/cms-cancels-aca-policies-for-760000-people-freezes-broker-registrations/ Appeals Court Sides With Plans In NSA Suit A federal appeals court ruled that a plastic surgery practice cannot sue Cigna to collect more than $3 million it won through the No Surprises Act’s (NSA) arbitration process. The court says the No Surprises Act gives providers a right to be paid but leaves enforcement to the Labor Department, the Treasury Department,

ICHRAs Slated To Grow Demonstrably Federal officials have rebranded individual coverage health reimbursement arrangements (ICHRAs) as CHOICE arrangements. While the name change is recent, new news that ICHRAs are slated to grow demonstrably. Oscar Health CEO Mark Bertolini projected during the company’s investor day that the ICHRA market will reach 2.5 million members by 2029, a 400% increase. It stands now at about 500,000. States are passing laws to encourage the provision of healthcare. Three states are offering tax credits to employers providing ICHRA funds to workers, while other states are considering different methods to drive adoption. #ichras #healthcare #coverage https://www.modernhealthcare.com/insurance/mh-ichra-choice-mehmet-oz-indiana-georgia/ NSA Arbitration Crippling Employer Groups A new study from the ERISA Industry Committee finds that self-funded employers are facing the brunt of costs from the poorly designed and very provider-friendly No Surprises Act (NSA) arbitration process. Almost 90% of decisions are made in favor of providers and awards are