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Medicare Advantage Plans Want Fewer Members Modern Healthcare covers a real oddity – Medicare Advantage (MA) plans want fewer members. Given upside down financials right now and the need to get back to investor margins, MA plans are trying all things to ensure they do not get members into plans that are underwater or even less profitable. The past few years and into 2026, the plans are eliminating commissions on a number of their plans and products. In addition, marketing budgets overall appear to be being reduced dramatically. The lack of commissions, reduced marketing, and overall contraction of offerings has led the Centers for Medicare and Medicaid Services (CMS) to predict an actual contraction of 900,000 enrollees in 2026 compared with 2025. I see why they see a sea change, but I still have my doubts that we will see an actual contraction. Clearly growth will come down from a

Hospitals Hate Price Reform: CHA Sues State Over Price Caps The oblivious-to-the-true-healthcare-crisis hospitals are once again trying to cripple reforms to price in the system. The California Hospital Association (CHA) has filed a lawsuit against the state’s Office of Health Care Affordability, arguing the agency’s price caps on hospitals are unlawful and will threaten critical access to patients in need. Chicken Little is back! The arguments are old news from the hospital lobby playbook. The main goal is to continue to safeguard bloated price masters and bureaucracies at the expense of the American people. The state agency is imposing a 3.5% statewide spending growth target for 2025, declining to 3% by 2029, as well as lower targets for existing price outlier hospitals. The CHA hides behind the fact that premiums are increasing by 10%, arguing the efforts have not worked. Yet, much of that is utilization increases as well as

Oz Still Demanding Greater Medicare Advantage Accountability At a Better Medicare Alliance event Wednesday, Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz declared his support for Medicare Advantage (MA) but argued the plans could improve in several areas. Specifically cited were improper payments and prior authorization. Oz previously announced a voluntary plan agreement to streamline and limit prior authorizations as well as a new CMS program to conduct risk adjustment audits on 100% of MA contracts every payment year. The latter initiative was hit with a major roadblock when a federal judge struck the rule governing how the agency would carry out such audits. CMS did not respond to a request for comment on whether it plans to repromulgate the audit rule and Oz stayed mum during the event but has implied he wants to continue the robust audit efforts. Oz specifically called out the use of

Lown Finds Overuse Of Unnecessary Back Surgeries The respected Lown Institute, a healthcare researcher and policy group, has found that hospitals performed over 200,000 unnecessary back surgeries on older adults over a three-year period in Medicare. The hospitals billed a total of more than $1.9 billion for what Lown says are low-value services. Lown also found that 60% of total overuse for spinal fusion/laminectomies came from the 10% of worst offender physicians. It notes that these unnecessary procedures cause a rise in serious complications. One example: spinal fusion complications occur in up to 18% of patients and can lead to stroke, pneumonia, or death. Lown looked at Medicare fee-for-service (FFS) claims from 2021 to 2023 and Medicare Advantage (MA) claims from 2020 to 2022 for rates of spinal fusions/laminectomies and vertebroplasties that met the researchers’ criteria of a low-value procedure based on the patient’s clinical presentation at the time of

More Star Rating News Modern Healthcare has done a follow-up Star rating article. It notes that several provider-owned insurers saw big drops in the percentage of Medicare Advantage (MA) members in plans rated at least four Stars. Some Blue Cross and Blue Shield companies also reported declines. Startup insurers also had mixed reviews. Among the plans getting hit: Big Blue winners included: (Article may require a subscription.) #cms #medicareadvantage #stars #quality https://www.modernhealthcare.com/insurance/mh-medicare-advantage-ratings-2026-bcba-clover-health Government Shutdown Politics As the government shutdown continues, there is both public jockeying as well as quiet deliberation on the issue of Exchange healthcare subsidy extensions. Vice President JD Vance said that the enhanced subsidies fuel waste and fraud in the insurance industry. Sen. Mark Kelly, D-AZ, said a hypothetical commitment from Republicans to hold a vote by the end of the year on extending the  subsidies would not be sufficient to secure Democratic support for reopening government.

Trump Strikes Drug Price Deal With AstraZeneca A second brand drug maker has struck a deal with President Donald Trump on lowering drug prices. AstaZeneca agreed to terms similar to Pfizer with a few additions. The agreement provides that all drugs in Medicaid are subject to most-favored-nation pricing. As well, AstraZeneca will offer medicines at a deep discount off the list price when selling directly to American patients. The drugs will appear like Pfizer’s on the new TrumpRx website. Three items are not seen in the Pfizer deal. AstraZeneca agrees that MFN will apply to future innovator drugs introduced. AstraZeneca will repatriate increased foreign revenue on existing products that AstraZeneca realizes. And the company will invest $50 billion in U.S. manufacturing and research and development. The deal will exempt AstraZeneca from the 100% tariffs the Trump administration wants to impose on brand drugs. In a blog this week, I questioned

Star Ratings Stable For SY 2026 Despite the government shutdown, the Star Year 2026 Ratings data tables are out. The three-year downturn in Star ratings appears to have ended, but SY 2026 was relatively flat to SY 2025. The average Star rating moved from 3.65 in SY 2025 to 3.66 in SY 2026. Of the 481 MA contracts rated in both SY 2025 and SY 2026, about 29% (140) of contracts saw ratings drop a half a Star or more, 26% (125) of contracts saw ratings increase a half a Star or more, and about 45% (216) stayed the same. The number of contracts at 4 and greater is about the same at just over 200. I suspect enrollment in these plans is about the same too, which was about 64% in 2025. But about a quarter of contracts at 4 or greater are different. As in the past there