AI speeds up prior auth, coding while driving higher costs for health systems: PHTI report

By Cailey Gleeson – While artificial intelligence solutions can reduce administrative burden in prior authorizations and billing, organizations are reporting increased transaction volumes and higher costs, according to a new report. The Peterson Health Technology Institute took insights from a January 2026 workshop featuring senior leaders from a spectrum of organizations, ranging from health systems to federal agencies. Leaders discussed ways in which technology and policy can enable AI to reduce administrative costs, accelerate payment cycles and promote high-value care. Read Full Article...

HVBA Article Summary

1. AI Reduces Administrative Burden but Raises Costs: While AI tools streamline processes like prior authorizations and billing, the report finds that these efficiencies are accompanied by increased transaction volumes and overall higher costs for health systems. The anticipated savings from automation are not being fully realized because the cost of implementing and maintaining AI solutions offsets the administrative reductions. This suggests that the financial benefits of AI in healthcare administration are more complex than initially expected.

2. Implementation Barriers and Unintended Consequences: The report highlights that widespread adoption of AI faces significant obstacles, such as reliance on electronic health record (EHR) vendors and inconsistent policy standards. Additionally, increased system activity, including so-called "bot wars," and limited effectiveness in complex cases present new challenges. These factors may lead to unintended operational issues and limit the scalability of AI-driven solutions in healthcare.

3. Impact on Billing Intensity and Policy Implications: AI deployment, particularly through tools like AI scribes, is contributing to higher billing intensity and increased medical spending, which could strain affordability for payers and patients. Health plans are responding with reimbursement reductions, but the effects of these measures are not yet clear and may disadvantage providers who have not adopted AI. The report calls for coordinated policy action to address AI-driven medical inflation and recommends redesigning deployment processes to truly reduce administrative waste.

Life insurance applications for ages 70-plus skyrocket 46% in Q1

By Allison Bell – U.S. consumers ages 70 and older rushed to apply for life insurance in the first quarter of 2026: They submitted 46% more applications than in the first quarter of 2025. Overall application activity was 14% higher than in the year-earlier quarter, according to new application activity data from MIB Group. The oldest insurance shoppers were especially interested in universal life and in policies with a face amount of $100,000 to $250,000. The shoppers' application activity for those types of policies was more than twice as high in the latest quarter as it was in the year-earlier quarter, MIB reported. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Significant Increase in Older Applicants: The first quarter of 2026 saw a notable rise in life insurance applications from individuals aged 70 and above, outpacing the growth seen in younger age groups. This surge may reflect changing demographics, such as people having children or purchasing homes later in life, which can increase the need for financial protection at older ages. The trend suggests that insurers may need to adjust their offerings and underwriting practices to accommodate the evolving needs of older clients.

2. Preference for Specific Policy Types: Older applicants showed a marked preference for universal life insurance and policies with face amounts between $100,000 and $250,000. Application activity for these products more than doubled compared to the previous year, indicating a shift in the types of coverage sought by this demographic. This could be driven by long-term care planning or the desire for flexible, cash-value policies that can address a range of financial needs.

3. Changes in Data Reporting and Age Bands: The MIB Group updated its data collection methods and redefined its age bands, with the oldest category now starting at age 70 instead of 71. As a result, current application figures cannot be directly compared to those from previous years. These methodological changes are important for interpreting trends and ensuring that year-over-year comparisons are accurate and meaningful.

CMS Proposes Deadlines for Prior Authorization Requests in Medicare Advantage

By Joyce Frieden – Medicare Advantage plans would have to respond to urgent prior authorization requests for medications within 24 hours, and standard requests within 72 hours, under a proposed rule from the Centers for Medicare & Medicaid Services (CMS). Issued Friday, the proposed rule also would require full disclosure of claims denials and appeals outcomes, according to a CMS press release. Although CMS issued a final rule on prior authorization deadlines for medical tests and procedures in February 2024 under the Biden administration, drugs were not included in it. Read Full Article...

HVBA Article Summary

1. CMS Proposes Digital Prior Authorization Rule: The Centers for Medicare & Medicaid Services (CMS) has proposed a rule to modernize prior authorization by transitioning to real-time electronic systems, with compliance expected to begin in 2027. The initiative builds on prior agreements across much of the insurance industry to reduce authorization requirements for common services. The goal is to minimize delays and improve timely access to prescribed medications and care.

2. Expanded Scope and Transparency Requirements: The proposed rule would apply to Medicare Advantage, Medicaid, CHIP, and Affordable Care Act marketplace plans. Insurers would be required to publicly report metrics such as approval and denial rates, decision timelines, and appeal outcomes. These reporting requirements are intended to increase accountability and provide clearer insight into how efficiently prior authorization processes are managed.

3. Focus on Digital Infrastructure and Stakeholder Alignment: CMS is proposing enhanced use of electronic prior authorization tools, including APIs and real-time formulary and coverage checks for pharmacy benefits. The agency is also seeking input on related improvements such as cybersecurity, step therapy processes, and authorization for medical equipment and lab services. While progress has been acknowledged, officials noted ongoing challenges in achieving full collaboration between providers and payers to streamline administrative workflows.

Strategies for delivering smarter pharmacy benefits

By Ben Conner – Pharmacy benefit managers (PBMs) have been acting as a middleman in the prescription drug supply chain since the late 1960s. For decades, their role has been seen as essential to insurance plans, but behind the scenes, they have the ability to influence which drugs are covered, how much they cost and who can get them. This lack of transparency in the industry can put patients at risk, according to the American Medical Association. "As PBMs increasingly act in their own self-interest without transparency or accountability, drug prices rise and patients face health risks from cost-prohibitive drug treatments," noted AMA President Bobby Mukkamala, M.D. By adding unnecessary complexity and cost, PBMs often stand between patients and the medications they need. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. PBMs' Influence and Lack of Transparency: Pharmacy benefit managers have long played a central role in determining drug coverage and pricing, but their operations often lack transparency. This opacity can result in higher drug prices and create barriers for patients seeking affordable medications. The American Medical Association and other stakeholders have raised concerns that PBMs' self-interested practices may negatively impact patient health outcomes.

2. Emergence of Consumer-Focused Alternatives: The pharmacy benefits landscape is evolving with the introduction of technology and direct-to-consumer programs. Tools like GoodRx and platforms such as ScriptCo and Mark Cuban's Cost Plus Drugs allow consumers to compare prices and access medications outside traditional PBM channels. These alternatives highlight the potential for cost savings and increased price transparency, though they may not always integrate seamlessly with insurance benefits.

3. Need for Greater Transparency and Broker Leadership: The article emphasizes the importance of full disclosure regarding administrative fees, rebates, and spread pricing to align PBM incentives with the interests of employers and patients. Brokers and advisers are encouraged to advocate for solutions that balance cost savings with coverage protections for plan members. Moving forward, the industry is challenged to create pharmacy benefit strategies that prioritize clarity, value, and improved patient outcomes.

CMS taps 150 digital health companies, providers for ACCESS Model

By Heather Landi – The Centers for Medicare and Medicaid Services picked 150 digital health companies and healthcare providers to participate in the launch of its tech-enabled chronic care model. The Center for Medicare and Medicaid Innovation (CMMI) announced in December the Advancing Chronic Care with Effective Scalable Solutions (ACCESS) Model as a 10-year payment program to encourage the use of technology to treat chronic diseases. CMS aims for the ACCESS Model to provide stable, recurring payments for technology used to treat diabetes, hypertension, chronic kidney disease, obesity, depression and anxiety. The model will help pay for telehealth software, wearables and wellness apps that address the conditions. Read Full Article...

HVBA Article Summary

1. Broad Participation and Scope: CMS selected 150 organizations, many of which are new to serving Medicare beneficiaries, to participate in the ACCESS Model. These participants include a diverse mix of digital health startups, established healthcare providers, and technology companies focused on chronic disease management. The initiative aims to expand technology-supported care options for conditions such as diabetes, hypertension, chronic pain, and depression.

2. Outcome-Based Payment Structure: The ACCESS Model introduces a payment system where providers receive recurring payments for technology use only if patients achieve clinically significant health outcomes. This approach is designed to incentivize measurable improvements in chronic disease management, such as reduced blood pressure or improved mental health. Commercial insurers covering 165 million members have also pledged to align their payment models with this outcome-based framework.

3. Financial Challenges and Industry Response: Despite the program's ambitions, the announced payment rates for participating providers are lower than many in the industry expected and may not cover the costs for high-touch, clinician-driven care. This has raised concerns about negative profit margins for some digital health companies, although larger, scaled organizations may benefit from increased patient volume and performance-based bonuses. The model's financial structure could influence which types of companies and care models are sustainable under ACCESS.

The strategic reframing of women's benefits

By Beth Rush – In 2026, employee benefits strategy will look materially different than what came before. Cost pressures are intensifying, workforce demographics are shifting and employers are being held to higher standards of accountability around health outcomes. In this environment, benefits advisors in 2026 are no longer positioned as plan interpreters. They're architects of sustainable, future-ready benefits ecosystems. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Women's Health as a Strategic Priority: Women's health benefits are shifting from being viewed as supplemental to becoming a central component of workforce performance and retention strategies. Employers are increasingly tying decisions around fertility care, maternal health, menopause support, and HRT coverage to measurable business outcomes. This reframing positions women's health as a proactive investment in organizational resilience rather than a compliance obligation.

2. Integration and Life-Stage Approach: Traditional benefits often fragmented women's health services and focused narrowly on reproductive years, neglecting broader health needs across life stages. In 2026, employers are moving toward integrated, life-stage-informed benefits design, recognizing that health needs evolve predictably over time. This approach aims to improve care continuity, reduce administrative burdens, and allocate resources more efficiently for better outcomes.

3. Advisor Roles and Evidence-Based Design: The role of benefits advisors is evolving from interpreting plans to designing strategic, clinically aligned benefits ecosystems. Advisors are now expected to provide data-driven recommendations, scrutinize vendor claims, and ensure that offerings support access, equity, and practical utilization. Their expertise is critical in helping employers navigate complex choices and implement benefits that address both cost management and employee wellbeing.

Can Genes Affect GLP-1 Side Effects and Treatment Outcomes?

By Marilynn Larkin – Two genetic variants could help explain differences in side effects and weight loss in patients taking GLP-1 drugs, a new study suggested. To investigate a potential genetic basis for inter-person variability in weight-loss efficacy and the incidence of side effects in people taking the drugs, researchers conducted genome-wide association studies using self-reported 23andMe data from 27,885 individuals (median age, 52 years; 82.4% female). They found that the GLP-1 receptor variant rs10305420 was associated with a slightly greater decrease in BMI (0.641% loss), corresponding to about 0.76 kg of extra weight lost per allele in individuals who carried this variant compared with those who did not. Read Full Article...

HVBA Article Summary

1. Genetic Variants Influence GLP-1 Drug Responses: The study identified two genetic variants that contribute to differences in weight loss and side effects among people taking GLP-1 medications. One variant in the GLP-1 receptor gene was linked to slightly greater weight loss, while another in the gastric inhibitory polypeptide receptor gene was associated with increased risk of nausea and vomiting. These findings suggest that genetics play a modest but measurable role in individual responses to these drugs.

2. Non-Genetic Factors Remain Important Predictors: Researchers found that factors such as sex, age, type of medication, dose, and duration of treatment were also strongly associated with treatment outcomes. The combined effect of genetic and non-genetic factors explained about 25% of the variation in weight-loss responses. This indicates that while genetics are relevant, other demographic and clinical characteristics are equally or more significant in predicting outcomes.

3. Study Limitations Affect Generalizability: Experts highlighted several limitations, including reliance on self-reported data, which may introduce measurement errors and reporting bias. The study population was predominantly female and of European ancestry, and the median treatment duration was relatively short, limiting the applicability of the results to broader populations and longer-term outcomes. As a result, the evidence is not yet sufficient to support using genetic information alone to guide routine clinical decisions for GLP-1-based therapies.