How payers, drugmakers can collaborate to drive more outcomes-based contracts

By Paige Minemyer – As drug costs and spending continue to rise, the demand for solutions opens the door to closer collaboration between payers and manufacturers. Brian Evanko, president and chief operating officer for the Cigna Group, and Miguel Fernández Alcalde, president of EMD Serono, spoke at a keynote session at AHIP 2026 earlier this month, discussing the delicate balance between promoting innovation and ensuring affordability. Read Full Article...

HVBA Article Summary

1. Fertility Partnership as a Model for Collaboration: Cigna Group and EMD Serono highlighted their joint work on fertility treatments as an example of payer-manufacturer alignment. Through collaboration that included engagement with the Trump administration, they supported a cash-pay option for certain treatments priced between $1,000 and $1,500 per course, depending on dosage. Executives described the effort as moving beyond transactional relationships toward patient-centered problem-solving. The partnership illustrates how shared goals around affordability can lead to concrete pricing initiatives.

2. Innovation and Affordability Remain in Tension: Speakers emphasized the longstanding imbalance in the U.S. market, where rapid access to new drugs often outweighs cost considerations. While a large majority of prescriptions are filled with generics, a relatively small share of branded drugs accounts for most spending. Compared to other countries that are more selective about which new therapies reach the market, the U.S. prioritizes speed and breadth of availability. Industry leaders argued that failing to address this trade-off could threaten the sustainability of future innovation.

3. Expanding Outcomes-Based Contracts Requires Broader Engagement: Value- or outcomes-based pricing was described as an underused tool, particularly for high-cost treatments such as gene therapies that can cost millions of dollars. These arrangements tie payment to patient results and may help employers and health plans manage financial risk for breakthrough therapies. However, successful implementation requires coordination among payers, manufacturers, providers, patients and potentially government entities. Panelists also suggested that value-based frameworks should sometimes be developed during a drug’s research and development phase rather than after launch.

Employers demand changes to No Surprises Act arbitration

By Allison Bell – Federal regulators should stop health care providers from using the No Surprises Act arbitration system to weaken health plan provider networks, employer groups told Trump administration officials. "Employers cannot continue to absorb the financial burden of a broken process that rewards gaming over fairness," the benefits groups wrote in a public letter. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Employer groups allege misuse of arbitration system: A coalition of employer and purchaser organizations sent a public letter arguing that some providers are exploiting the independent dispute resolution (IDR) process under the No Surprises Act. They contend the system is being used in ways that undermine health plan networks and shift higher costs onto employers. The groups warn that without reform, the process could exacerbate existing health care cost pressures. They are urging federal officials to introduce safeguards to prevent what they describe as strategic overuse of arbitration.

2. Concentration of filings among private equity-backed providers: Citing Centers for Medicare and Medicaid Services data, the employer groups noted that 47% of the 610,000 arbitration cases filed in the first half of the year were submitted by four private equity-backed organizations: Team Health, SCP Health, Radiology Partners and Envision. The concentration of filings has raised concerns about whether certain large provider groups are driving a disproportionate share of disputes. Employers argue this pattern suggests systemic gaming of the process rather than isolated disagreements. Providers, however, maintain that the system enables more balanced negotiations with insurers.

3. Calls for stricter oversight and transparency: The coalition is asking regulators to penalize providers who repeatedly submit claims that are not eligible for the IDR process. They also want arbitrators to provide explanations when awarding payments significantly above median in-network reimbursement levels. According to the groups, clearer standards and enforcement mechanisms would help ensure the arbitration system does not become a default pricing tool. The letter was addressed to senior officials at the Treasury, Labor, and Health and Human Services departments.

20 largest healthcare data breaches reported in 2026 so far

By Naomi Diaz – At least 20 healthcare organizations have reported data breaches affecting 100,000 or more individuals to federal regulators so far in 2026, according to the HHS Office for Civil Rights breach portal. Read Full Article...

HVBA Article Summary

1. Large-Scale Breaches Continue in 2026: Federal data shows that at least 20 healthcare organizations have each reported breaches impacting 100,000 or more individuals this year. The cumulative effect of the 10 largest incidents in 2026 has already reached nearly 16 million people. With more than half the year remaining at the time of reporting, the totals suggest 2026 could rival or surpass prior years. The data reflects continued cybersecurity pressures across the healthcare sector.

2. Top Incidents Involve Millions of Individuals: The largest reported breach so far involves TriZetto Provider Solutions in Missouri, affecting more than 3.4 million people, followed closely by QualDerm Partners in Tennessee at over 3.1 million. Nacogdoches Memorial Hospital in Texas and Navia Benefit Solutions in Washington each reported breaches affecting more than 2 million individuals. These figures indicate that both provider organizations and healthcare service vendors are experiencing high-impact events.

3. Comparison With 2025 Highlights Ongoing Risk: The 10 largest healthcare data breaches reported in 2025 affected more than 25 million people combined. By comparison, the top 10 incidents reported so far in 2026 have already impacted nearly 16 million individuals. This trajectory underscores the persistent scale of cybersecurity threats facing healthcare organizations. The data from the HHS Office for Civil Rights breach portal provides a running tally of these significant incidents.

How sticking with ICHRAs minimizes disruption, part 2

By Bruce Shutan – Benefit professionals who are willing to make a longer-term commitment to individual coverage health reimbursement arrangements known as ICHRAs with meaningful guardrails in place will notice dramatic results. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Long-term commitment enhances ICHRA outcomes: Experts cited in the article argue that employers who remain patient with ICHRAs over multiple renewal cycles tend to see stronger financial results. Over time, employees build up balances in HRAs and HSAs, which can make higher-deductible plans feel less risky. This accumulated cushion helps stabilize costs and can reduce anxiety about out-of-pocket exposure. The strategy depends on thoughtful guardrails, adequate allowances and consistent communication.

2. Flexibility can reduce, not raise, employer costs: Contrary to common assumptions, expanding ICHRA flexibility beyond premium-only reimbursements may actually lower overall spending. When employees can use monthly allocations for both premiums and medical expenses, they may opt for lower-cost bronze plans and retain unused funds. In examples shared, workers who chose less expensive coverage were able to accumulate hundreds of dollars per month in remaining allowances. Employers may ultimately retain unspent funds, improving cost efficiency while maintaining employee choice.

3. Broker education and adoption remain uneven: Some benefits consultants are still hesitant to recommend ICHRAs, often dismissing them before fully understanding the model. However, industry leaders interviewed suggest growing client interest could accelerate broader adoption. As brokers become more familiar with plan design mechanics and guardrails, they may better position ICHRAs as a viable alternative to traditional group plans. The article suggests that increased familiarity and successful case examples will likely drive continued expansion.

High costs of coverage, LTC crisis continue to shape health care ecosystem

By Susan Rupe – The U.S. health ecosystem is "very expensive and increasingly so and very fragmented and increasingly so, said Katherine Hempstead, senior policy officer at the Robert Wood Johnson Foundation. "We spend a lot more and have a lot less to show for it," she said. Hempstead's comments were part of a live podcast on health issues during the National Association of Benefits and Insurance Professionals Annual Convention in Atlantic City, N.J. Read Full Article...

HVBA Article Summary

1. Rising Costs and Fragmentation in U.S. Health Care: Katherine Hempstead described the U.S. health system as both increasingly expensive and fragmented, emphasizing that higher spending has not translated into better outcomes. She noted that more Americans now view health care expenses as their household’s biggest financial burden. Contributing factors include an aging population that requires more hospital-based services and the introduction of high-priced pharmaceutical treatments. Together, these trends are intensifying affordability concerns for families and policymakers alike.

2. Shrinking Plan Options and Higher Out-of-Pocket Exposure: Brokers were advised to prepare for changes in the individual insurance market that may push consumers into plans with greater out-of-pocket costs. Hempstead warned that some insurers are exiting certain markets, which could leave consumers with fewer coverage choices by 2027. This environment increases the importance of carefully evaluating plan levels and clearly explaining potential cost-sharing obligations. The instability of the under-65 ACA marketplace was also cited as a pressing concern.

3. Long-Term Care and Policy Gaps: Speakers highlighted the long-term care crisis as an unresolved weakness in the nation’s safety net. Hempstead pointed to widespread misconceptions, including the belief that Medicare covers long-term care services, and urged federal policymakers to confront looming Social Security and Medicare shortfalls. Industry leaders called for better consumer education about coverage limitations and suggested exploring mechanisms such as high-risk pools to stabilize insurance markets. Brokers, they said, must stay informed and strategic to effectively guide clients through these complex challenges.

Dementia Will Cost the United States $818 Billion in 2026, USC-Led Study Finds

By Jason Millman – A new USC-led study finds Alzheimer’s disease and related dementias will cost the United States an estimated $818 billion this year, driven largely by often-overlooked costs to persons living with dementia and family and friends providing their care. Read Full Article...

HVBA Article Summary

1. Hidden Costs Drive the Economic Burden: The study emphasizes that the largest share of dementia’s economic impact stems from reduced quality of life for people living with the condition, totaling $320 billion. Informal care partners also experience significant quality-of-life losses valued at $15 billion due to emotional and physical strain. These impacts go beyond traditional healthcare spending and reflect declines in independence, cognition and daily functioning. By incorporating these factors, the model broadens how policymakers understand dementia’s full societal toll.

2. Millions Provide Unpaid Care with Major Economic Impact: About 5.2 million Americans provide 6.8 billion hours of unpaid care to family members or friends with dementia, work valued at $237 billion. Many caregivers are in their prime working years, balancing jobs with caregiving responsibilities. In addition to unpaid labor, lost wages for people with dementia and their care partners total $23 billion annually. These figures illustrate how dementia affects household finances and workforce participation nationwide.

3. Improved Modeling Supports Policy and Treatment Planning: The 2026 estimates build on prior research by adding new components, including forgone earnings of people living with dementia and updated measures of care partners’ health-related quality of life. The model draws on nationally representative datasets such as the Health and Retirement Study and Medicare and Medicaid administrative data, using dynamic microsimulation to project future trends. Researchers say this approach allows them to assess how emerging treatments, diagnostics and care models could influence long-term costs and resource needs. The project aims to provide transparent, peer-reviewed data to guide healthcare and policy decisions as the dementia population grows.

How to stabilize your GLP-1 budget amid increasing demand, cost

By Lee Hafner – Millions of Americans now take GLP-1s, but with healthcare costs at record highs, how can employers continue to fund access? Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Rising demand and escalating costs are straining employer budgets: Commercial healthcare costs are projected by PwC to increase 9% in 2027, adding further pressure to employers already covering high-cost GLP-1 medications. KFF reports that 1 in 8 adults are taking GLP-1s, underscoring the scale of demand. Embla estimates the drugs cost employers between $7,200 and $10,800 per employee annually, which can quickly add up for self-funded plans. A Business Group on Health survey found that 10% of employers plan to drop GLP-1 coverage in 2027, reflecting the financial strain.

2. Specialty care accounts and lifestyle spending accounts offer cost controls: Alex Shubat of Espresa suggests employers consider specialty care accounts (SCAs) or lifestyle spending accounts (LSAs) to manage GLP-1 expenses. SCAs allow employers to contribute up to $2,200 in pretax funds specifically for healthcare-related services such as weight loss or hormone treatment, creating a defined cost ceiling. These accounts can operate alongside traditional medical plans, helping employers cap exposure while maintaining access. By setting fixed allowances, organizations can create more predictable budgets while giving employees flexibility in how they use funds.

3. Employers are encouraged to rethink benefit design rather than eliminate coverage: Instead of cutting GLP-1 coverage entirely, Shubat recommends restructuring existing benefits to consolidate spending into broader account-based models. He argues that many single-point solutions can be rolled into LSAs, potentially allowing companies to remain budget neutral. Pairing LSAs for preventive services with SCAs for clinical care can create a more holistic approach to employee health. This strategy aims to balance CFO concerns about rising pharmacy spend with employee demand for continued access to high-impact medications.