The prior authorization fight guidebook: 'Gold carding,' time limits and more

By Allison Bell - A team at the National Association of Insurance Commissioners is trying to come up with a way to update the state rules governing health plans' prior authorization procedures. Health insurers say they need some way to control torrents of high-cost claims. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Stakeholder Disputes Over Processes: Insurers, such as Elevance, assert that certain providers and their representatives are misusing the No Surprises Act arbitration process for out-of-network claims, resulting in a surge of excessively high bills. On the other hand, physicians maintain that prior authorization reviews are often handled by individuals without the necessary training or medical expertise, leading to unnecessary delays and repeated phone or video meetings over treatments, devices, or prescriptions they believe are clearly appropriate.

2. Draft Framework for Prior Authorization: The NAIC’s Regulatory Framework Task Force has produced a draft paper for state insurance regulators that explains the definition and common procedures of prior authorization. It details the differing viewpoints of providers, insurers, and consumers while notably omitting a specific section on employers’ perspectives. The draft also references the American Medical Association’s model bill, which defines “utilization review entities” broadly to include those working for both insurers and self-insured employer plans.

3. Proposed State-Level Responses: The draft outlines several potential state policy approaches aimed at streamlining prior authorization. These include “gold carding” programs that exempt consistently compliant providers from routine reviews, requirements that prior authorizations remain valid for at least one year or for the full course of approved treatment, and rules that set strict timelines for insurers to issue decisions on prior authorization requests. These measures reflect ongoing efforts to balance administrative oversight with timely patient care.

Drug price negotiation program sidesteps latest legal obstacle

By Noah Tong - The drug price negotiation program has withstood another procedural effort in striking down one of the Inflation Reduction Act’s most significant provisions. In the U.S. Court of Appeals for the 6th Circuit, a panel of judges upheld (PDF) a lower court’s decision to dismiss the lawsuit. Read Full Article…

HVBA Article Summary

1. Court Dismissal and Potential Appeal: A judge dismissed a lawsuit challenging the Medicare drug price negotiation program, ruling that most plaintiffs did not have legal standing to sue. The U.S. Chamber of Commerce, one of the remaining parties, refiled the case and now has the option to appeal the decision to the U.S. Supreme Court, potentially extending the legal battle.

2. Ongoing Legal and Political Dispute: The program, which aims to negotiate lower prices for certain high-cost prescription drugs, has been supported by both the Biden and Trump administrations at different times. However, it has faced strong opposition from drugmakers and some Republican lawmakers, who claim it violates the Constitution and may discourage pharmaceutical innovation. Supporters argue it will make critical medications more affordable for millions of Medicare patients.

3. Multiple Lawsuits from Pharmaceutical Companies: Several large pharmaceutical companies, including Teva, Eli Lilly, Johnson & Johnson, Pfizer, and Sanofi, have filed or backed lawsuits against the Centers for Medicare & Medicaid Services. These cases challenge aspects of the agency’s guidance and dispute the criteria used to determine which drugs are subject to negotiation under the program.

Cancer Is on the Rise in Younger Adults: What Is the Healthcare Industry Doing About It?

By Katie Adams - Cancer cases are becoming increasingly common among younger adults in the U.S. — a troubling trend that stakeholders all over the healthcare industry are working to reverse. Colorectal cancer in particular is appearing in increasingly younger patients, with the rate of diagnoses for this disease having risen by 15% in people ages 18 to 50 since 2004. The country’s overall five-year survival rate for colorectal cancer is slightly over half. Read Full Article…

HVBA Article Summary

1. Rising Cancer Rates Among Younger Americans: Data shows cancers are appearing earlier, with nearly 10% of new colorectal cancer cases worldwide occurring in people under 50. In the U.S., cervical cancer incidence among women ages 30–34 grew by 2.5% annually from 2012 to 2019. Many younger adults miss screenings — only 33.7% of Americans ages 45–49 were up to date on colorectal cancer screening in 2023, up from 19.7% in 2021 — leading to later-stage diagnoses, where the five-year survival rate for stage IV colorectal cancer is just 12%, compared to 92% for stage I.

2. Expanding Access to Early Detection: Experts recommend lowering screening ages and offering a broader range of options, such as DNA-based stool tests, at-home cervical cancer tests like the FDA-approved Teal Wand, and multi-cancer detection methods like SpotitEarly’s breath-based system. These options aim to address barriers like cost, time, invasiveness, and anxiety, which often result in single-digit screening uptake for some cancers.

3. Removing Financial and Logistical Barriers: Insurers such as UnitedHealthcare are eliminating out-of-pocket costs for members’ first diagnostic imaging or colorectal cancer diagnostic test starting in 2025, regardless of age. Nearly half of colonoscopies identify polyps — shifting classification from preventive to diagnostic — and about 11% of mammograms require additional diagnostic imaging. Removing these costs aims to boost early detection, which is linked to faster recovery, fewer side effects, and higher survival rates.

ACA premiums could spike by up to 18% in 2026, analysis shows

By Alan Goforth - People who purchase health insurance through the Affordable Care Act Marketplace may see a premium increase of as much as 18% in 2026, according to analysis of preliminary rate proposals by the Peterson KFF Health System Tracker. This hike would be about 11 percentage points higher than last year. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Rising Health Care Costs Drive Proposed ACA Premium Increases: Insurers in all 50 states and the District of Columbia are seeking the steepest Affordable Care Act rate hikes since 2018, based on a review of filings from 312 insurers. They attribute the increases to persistent growth in health care prices, greater use of costly prescription drugs, rising hospital and physician care expenses, as well as inflation and higher labor costs across the medical sector.

2. Policy Uncertainty Adds Pressure: The potential expiration of enhanced premium tax credits at the end of 2025 could significantly affect affordability for ACA marketplace enrollees, with average out-of-pocket premiums projected to rise by more than 75%. Insurers warn this may prompt healthier individuals to drop coverage, which could further shift costs and impact market stability.

3. Political and Market Reactions: Some state officials, such as Arkansas Gov. Sarah Huckabee Sanders, are urging regulators to reject large proposed increases, calling them excessive and harmful to consumers. At the same time, experts forecast that employer-sponsored health care costs will also climb in 2026, driven by both longstanding cost pressures and new macroeconomic factors such as tariffs, government spending reductions on Medicare and Medicaid, and possible cost-shifting to the employer market.

Drugmakers racing to launch the first weight-loss pill

By Reuters - Weight-loss drugs are expected to pull in more than $150 billion in industry-wide revenue by the early 2030s, thanks to the ever-growing popularity of Eli Lilly's (LLY.N), Zepbound and Novo Nordisk's (NOVOb.CO), Wegovy. Both the GLP-1 weight loss drugs are weekly injections, although several drugmakers are racing to develop an oral medicine or pill that might prove to be as effective as the injectables. Read Full Article…

HVBA Article Summary

1. Easier Manufacturing and Supply Advantages: Pills are simpler and faster to produce than injectables, which could help manufacturers sidestep the early supply shortages experienced with Novo Nordisk and Eli Lilly’s injectable obesity drugs. This manufacturing advantage is driving a surge of interest in oral GLP-1–based weight-loss treatments, as companies look to compete in a rapidly expanding and highly lucrative market.

2. Late-Stage Leaders and Efficacy Results: Eli Lilly’s once-daily orforglipron delivered approximately 12.4% weight loss over 72 weeks in a late-stage trial, while Novo Nordisk’s oral semaglutide achieved about 15% in similar testing. Both companies are targeting U.S. regulatory decisions by late 2025 and preparing large-scale manufacturing. Meanwhile, competitors such as Structure Therapeutics, AstraZeneca, Roche, and Viking Therapeutics are advancing earlier-stage candidates, reporting weight-loss outcomes in the 6% to 8% range, with further trials planned to confirm safety and durability.

3. Setbacks and Development Challenges: Not all programs are moving forward without obstacles—Pfizer halted its twice-daily danuglipron due to tolerability problems and later faced liver safety concerns with a once-daily extended-release version. These challenges highlight that, despite strong commercial potential and encouraging early trial results across the industry, drug development in this space remains risky, with safety, tolerability, and long-term efficacy still critical hurdles for market entry.

More than skin deep: Why it's time to invest in dermatology benefits

By Paola Peralta - Skincare is more than just a beauty trend —it's an important component of employees' health and wellness, and can cut down on employers' healthcare spend, too. Approximately one in four Americans — or 84.5 million people — are impacted by skin diseases every year, according to data from the American Academy of Dermatology Association, including eczema, acne, psoriasis and skin cancer. Read Full Article… ^{_{(Subscription required)}} 

HVBA Article Summary

1. Dermatology is undervalued yet essential: Even though skin conditions like psoriasis and eczema are chronic illnesses linked to systemic inflammation (similar to diabetes or IBS), they remain a low priority in employer healthcare strategies. This oversight leaves many employees underserved and contributes to wasteful healthcare spending on short-term fixes rather than effective, ongoing care.

2. Access barriers are high: The U.S. has only 3.7 medical dermatologists per 100,000 people, and many focus on cosmetic procedures rather than medical care. This shortage leads to long wait times and limited appointment availability, often forcing employees toward expensive prescription drugs that may not address the root cause of their condition.

3. Specialized supplemental benefits can close the gap: Adding third-party dermatology providers as a supplemental benefit can dramatically improve access, offering next-day appointments, comprehensive intake processes, and continuous communication with providers. This approach can reduce prescription reliance, lower costs, and help employees manage their conditions more effectively for better long-term health and productivity.

Prudential in $100 million US FTC settlement over unit's healthcare promises

By Jonathan Stempel - Prudential Financial (PRU.N), reached a $100 million settlement to resolve U.S. Federal Trade Commission civil charges that its Assurance IQ unit misled consumers into buying healthcare plans that did not provide the promised coverage. A settlement with Assurance, which Prudential shut down last year, was filed on Wednesday in federal court in Seattle. Read Full Article… ^{_{(Subscription required)}} 

HVBA Article Summary

1. Misleading Insurance Marketing Allegations: The FTC accused Assurance of engaging in deceptive practices—particularly targeting consumers seeking low-cost health coverage—by creating the impression that its plans provided comprehensive benefits comparable to those required under the Affordable Care Act. According to the FTC, the company failed to clearly disclose substantial coverage limitations and benefit restrictions, which in many cases left customers unexpectedly responsible for large out-of-pocket medical expenses.

2. Company Response and Settlement: Assurance chose not to admit or deny the allegations as part of the resolution. Prudential, which acquired Assurance for $2.35 billion in 2019, agreed to settle the case, emphasizing in its statement that it remains committed to strict legal and regulatory compliance. The company also noted that the settlement payout had already been recognized in its financial results, allowing it to focus on its broader core business priorities moving forward.

3. Business Decline and Closure: Prudential initially viewed Assurance’s direct-to-consumer model as a way to serve an estimated 17 million underserved customers in need of health insurance. However, after recording $2.14 billion in goodwill write-downs over three years due to underperformance, Prudential decided in early 2024 to wind down Assurance’s operations entirely, signaling a strategic retreat from that segment of the insurance market.