Court Rejects Anthem’s Attempt to Relitigate Arbitration Losses Under No Surprises Act

By Wendell Potter – Last month, I wrote about an industrywide litigation campaign — a coordinated series of federal lawsuits by Anthem/Elevance, UnitedHealthcare, and Blue Cross Blue Shield affiliates targeting the providers, hospitals, and billing companies that have used the No Surprises Act’s Independent Dispute Resolution process to seek appropriate payment for care already delivered. The lawsuits deployed nearly identical legal arguments — RICO violations, ERISA claims and fraud allegations. So far, that strategy doesn’t seem to be working for Big Insurance. Read Full Article...

HVBA Article Summary

1. Federal Court Limits Insurer Challenges to Arbitration Outcomes: Judge Karen Scott dismissed Anthem's federal claims against HaloMD, emphasizing that the No Surprises Act restricts judicial review of arbitration decisions to only very specific circumstances such as corruption or undisclosed bias. This ruling reinforces that insurers cannot use broader federal statutes like RICO or ERISA to bypass the law’s intended dispute resolution process. The decision sets a precedent that could limit similar legal strategies by insurers in the future.

2. Insurers’ Arguments Addressed Within Existing Arbitration Framework: The court found that the Independent Dispute Resolution (IDR) process already allows insurers to challenge the eligibility of disputes directly with arbitrators. Judge Scott noted that Anthem’s request for federal court intervention was unnecessary because the remedy they sought was already available within the system established by Congress. Allowing federal courts to review every disputed eligibility determination would undermine the efficiency and purpose of the IDR process.

3. Broader Legal and Industry Implications Remain Unresolved: While the federal claims in this case were dismissed, Anthem may still pursue state law claims in California court, and similar lawsuits by other insurers are ongoing in different jurisdictions. Additionally, a separate case before the Fifth Circuit could impact how payment benchmarks are calculated, potentially affecting patient costs for out-of-network care. The outcome of these cases could have significant implications for both insurers and healthcare providers nationwide.

Affordability, transparency: A look at large employers' top healthcare concerns

By Paige Minemyer – The Purchaser Business Group on Health has released new data that highlights some of the key healthcare priorities of its jumbo employer members, with—perhaps unsurprisingly—the escalating affordability crisis as the biggest challenge. Rounding out the top three priorities are data analytics and transparency, as well as an interest in advanced primary care. PBGH based the findings of a survey of more than two dozens of its members, which represent some of the largest employers in the United States. Read Full Article...

HVBA Article Summary

1. Affordability Remains the Top Concern: Large employers are increasingly worried about the rising costs of healthcare, which impact both their financial stability and their employees' paychecks. The survey by the Purchaser Business Group on Health (PBGH) shows that affordability is the most pressing issue, prompting employers to seek new strategies and solutions. This concern is driving a shift toward more proactive measures to manage expenses and improve value.

2. Demand for Greater Transparency and Data Access: Employers are placing a stronger emphasis on transparency and the ability to analyze healthcare spending data. Historically, many have struggled to access comprehensive information about their costs and the value they receive from health plans. Enhanced fiduciary responsibilities and regulatory scrutiny are making data transparency even more critical for employers to fulfill their obligations and optimize spending.

3. Focus Expands to Pharmacy, Mental Health, and High-Cost Claims: Beyond general cost concerns, employers are also prioritizing issues like pharmacy benefit management, mental and behavioral health, weight management, and cancer care. High-cost claims are rising in dollar amount, not necessarily due to changes in patient populations but because of ongoing price increases. These trends are leading employers to reevaluate their relationships with vendors and engage more actively with policymakers and regulators.

Benefits cost increase concerns soar among plan sponsors

By Michael Popke – As health care costs soar, employers are searching for new solutions — some of them unconventional. Findings of the new Lockton 2026 National Benefits Survey indicate that 46% of self-funded plan sponsors say they would consider international drug sourcing for pharmacy benefits, an approach that remains complex and may expose plan sponsors to legal and compliance risks if not properly designed and administered (although the risk is unclear based on the lack of regulatory enforcement). In fact, 7% of respondents are already using international sourcing for pharmacy benefits. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Cost Reduction Becomes Top Priority: The survey reveals that reducing costs has become the most important factor for 54% of employers when making benefits decisions, a significant increase from 38% the previous year. This marks a shift away from the traditional focus on attracting and retaining talent, which has now dropped to 19%. The data suggests that rising health care expenses are forcing employers to prioritize financial sustainability over workforce recruitment and retention.

2. Employers Explore a Range of Cost-Saving Strategies: Plan sponsors are actively evaluating spending in areas such as plan optimization, network solutions, eligibility management, and pharmacy benefits. Tactics gaining traction include offering specialized management programs, leveraging narrow or high-performing networks, and applying spousal surcharges. These approaches reflect a willingness among employers, especially those with self-funded plans, to adopt both foundational and progressive strategies to manage rising costs.

3. Balancing Cost Control with Employee Impact: Despite the strong emphasis on cost containment, 81% of employers still consider employee impact an important factor when evaluating benefits changes. This highlights the ongoing challenge of managing expenses without diminishing the perceived value or effectiveness of benefits packages. Employers are seeking sustainable solutions that maintain employee trust and access to quality care while addressing the financial pressures of increasing health care costs.

The End of Incrementalism: Why Healthcare Innovation is Finally Reshaping the Model

By Patrick Doolittle – Most of what we called healthcare innovation over the last decade was an expensive lie we told ourselves. Between 2015 and 2020, we poured billions into digitizing the status quo, making existing systems slightly more efficient, stretching legacy models to reach more people, and congratulating ourselves on it. We weren’t transforming healthcare. We were putting a fresh coat of paint on a building with a crumbling foundation and calling it a renovation. Read Full Article...

HVBA Article Summary

1. Incremental Innovation Has Failed to Transform Healthcare: The article argues that much of the investment in healthcare innovation over the past decade has focused on making minor improvements to existing systems rather than fundamentally changing them. These efforts often resulted in shifting costs rather than reducing the overall expense or improving outcomes. As a result, the healthcare system remained inefficient and expensive, with true transformation still needed.

2. Artificial Intelligence and Data Are Driving Structural Change: The current wave of innovation, powered by AI and decentralized health data, is fundamentally altering the healthcare landscape. Continuous health monitoring and agentic AI are enabling proactive, personalized care that bypasses traditional clinic visits and hospital-centric models. This shift is expected to make many routine healthcare practices, such as the annual physical, obsolete within the next decade.

3. Consumers Will Be Central to the New Healthcare Model: The article predicts that consumers, empowered by access to their own health data and AI-driven tools, will drive the adoption of new care models. As these technologies become more widespread and economically necessary, employers and healthcare providers will need to adapt or risk becoming obsolete. By 2030, continuous health monitoring is expected to become a standard employee benefit, and many primary care offices may be replaced by virtual-first, data-driven alternatives.

The hidden cost of healthcare data breaches

By Jeff Leston – As many as 150 million working Americans are covered by health plans organized under ERISA. Given the scale of health insurance data breaches, there is a high probability that millions of them — and their health plans — will be a victim of fraud and identity theft. More than 400 million health insurance identities have been breached or compromised since 2021 alone. Yet no breached entity, employer, third-party administrator (TPA) or health insurance carrier has offered any protection against identity theft and fraud against health insurance benefits. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Widespread Breaches and Limited Protection: Despite the massive number of health insurance identities compromised in recent years, affected organizations rarely provide meaningful protection against the resulting risks of identity theft and fraud. Most responses are limited to credit monitoring, which does not address the specific dangers associated with stolen health information. This gap leaves plan participants vulnerable to fraudulent claims and financial harm.

2. Legal and Fiduciary Responsibilities: ERISA and HIPAA impose obligations on plan administrators to safeguard participants' health information and prevent unauthorized access. The legal landscape is evolving, with lawsuits increasingly targeting not just breached entities but also plan sponsors and advisers for failing to adequately protect against fraud. Employers may soon face litigation if they do not take proactive steps to secure health data and prevent misuse.

3. Need for Post-Breach Protection Doctrine: Experts argue that simply notifying individuals of a breach is insufficient; organizations should implement measures to prevent downstream misuse of compromised data. This includes asset protection, transaction controls, and monitoring for exploitation, rather than focusing solely on database security. Without such a shift in approach, individuals remain exposed to ongoing risks even after a breach is disclosed.

With health costs ballooning, workers turn to wellness and the internet, ADP finds

By Emilie Shumway – The ballooning cost of healthcare — for both employers and employees — is not a new revelation. Benefits leaders have been following the upward trajectory for years, with pharmaceutical costs, rising utilization, inflation and the consolidation of providers all playing a role. Employers have followed different paths on dealing with the spike in costs, but at least some have shifted those costs onto employees, including by raising deductibles and other cost-sharing provisions, employers told benefits consultant Mercer last summer. Read Full Article...

HVBA Article Summary

1. Rising Healthcare Costs Lead to Delayed Care: As medical expenses continue to climb, a growing number of workers are skipping necessary care or reducing medication usage due to out-of-pocket costs. This trend has increased since 2020, indicating that financial barriers are having a greater impact on employee health decisions. Such delays in care can have negative long-term consequences for both employees and employers, potentially resulting in higher costs down the line.

2. Shift Toward Wellness and Digital Resources: In response to rising costs, many employees are prioritizing wellness activities such as mindfulness, nutrition, and exercise to maintain their health. Additionally, a significant portion of workers are turning to the internet and even generative AI for medical advice, reflecting a shift toward self-managed care. While these strategies may help some individuals, they also highlight gaps in access to affordable professional healthcare.

3. Employer Strategies and Employee Financial Stress: Employers have responded to cost pressures by increasing deductibles and shifting more expenses to employees, but this has led to greater financial stress and uncertainty among workers. More employees now report feeling unprepared to handle out-of-pocket healthcare expenses, with a notable rise in those with minimal savings for medical needs. Experts suggest that simplifying plan design, improving education, and offering flexible benefits could help employees make better-informed, cost-conscious choices without sacrificing necessary care.

Behavioral health utilization is up with anxiety disorders leading demand, report finds

By Anastassia Gliadkovskaya – Behavioral health utilization increased substantially from 2018 to 2024, with anxiety disorder care fueling much of that growth, according to Trilliant Health. The health data analytics and market research firm's latest report outlines a 62.6% jump in behavioral health utilization, based on any visit associated with a behavioral health diagnosis code. Between 2008 and 2024, the prevalence of mental illness increased by almost 6 percentage points. Read Full Article...

HVBA Article Summary

1. Anxiety Disorders Drive Utilization Growth: The report highlights that anxiety disorders have become the leading cause of behavioral health visits, with the fastest growth rate among all mental health conditions. Women aged 18-44 experienced the highest utilization for anxiety disorders in 2024. This trend may be influenced by increased screening and greater awareness, but it also raises questions about potential overdiagnosis and unmet needs that are now being addressed.

2. Telehealth Expansion and Plateau: Telehealth has played a significant role in behavioral health care, with nearly two-thirds of telehealth visits in 2024 attributed to behavioral health. However, the rapid growth of telehealth seen during the early COVID-19 pandemic has begun to plateau. This suggests that while telehealth remains a crucial access point, its expansion may be stabilizing as the healthcare system adapts to new norms.

3. Workforce Shortages and Price Variability: The report projects a substantial shortfall in mental health professionals, with a national adequacy rate of only 27% in 2025 and significant state-by-state disparities. Additionally, there is considerable variation in commercial reimbursement rates for psychotherapy, with some rates differing by as much as 20 times for the same service. These findings underscore ongoing challenges in ensuring both access to care and fair, transparent pricing in behavioral health services.