Two Sleeping Giants Keep Missing Each Other, and Patients Pay the Price

By Jake Velie – The New England Journal of Medicine just published an article calling self-insured employers “A Sleeping Giant of Health Care Affordability.”¹ The authors, Dr. Suhas Gondi and Dr. Zirui Song, wrote it because most physicians do not know that a self-insured employer sits behind that carrier card their patient walks in with. That is not a minor knowledge gap. That is the root cause of a dysfunction that costs plans millions and leaves patients stuck in the middle. Read Full Article...

HVBA Article Summary

1. Employers and clinicians act as separate decision-makers, creating avoidable friction for patients: The piece argues that both self-insured employers and clinicians have meaningful influence over cost and outcomes, but they rarely coordinate. Because clinicians often don’t know an employer is effectively the payer behind an insurance card, they may make treatment decisions without understanding plan-specific constraints. The result is that patients experience denials, delays, or unexpected costs even when everyone believes they are following the rules. The author frames this as a coordination and communication gap rather than a purely technical problem.

2. GLP-1 benefit designs can backfire when plan rules aren’t communicated to prescribers: In the GLP-1 example, a physician completes the clinical and administrative steps (including prior authorization), yet the patient still faces a denial at the pharmacy counter. The article attributes this to employer coverage being routed through a designated third-party vendor model rather than any issue with the clinical decision itself. Without a feedback mechanism to inform the prescriber promptly, the physician may not learn about the true requirement until a later follow-up visit. The patient and clinician bear the immediate frustration, while the employer’s intended cost and care-management approach is not understood at the point of care.

3. Site-of-care programs can resemble coverage denials without navigation and provider outreach: The author describes scenarios where a drug is effectively covered, but only when administered in a lower-cost setting, and clinicians may not know this prior to ordering treatment. When prior authorization results in a denial tied to the administration site, patients and providers can interpret it as the employer refusing necessary therapy. The article emphasizes that effective steering requires advance communication, member navigation, and clinical coordination—otherwise it becomes administrative friction. It also argues that common health IT systems are not designed to surface employer-specific coverage pathways to clinicians, leaving the burden on plan sponsors and vendors to close the loop.

CMS tightens ACA broker access rules before open enrollment

By Mark Rosanes – Federal regulators are changing how brokers access and submit Affordable Care Act (ACA) applications before this fall's open enrollment. Agents who have not tightened their documentation practices face rejected applications, flagged accounts, and scrutiny of their National Producer Numbers (NPN). The rule changes follow a sharp drop in ACA enrollment and a federal push to remove fraudulently enrolled policyholders. Enrollment fell nearly three million to about 19.2 million this year, according to an HHS report released in June 2026 and reviewed by KFF Health News. Read Full Article...

HVBA Article Summary

1. CMS is adding new pre–open enrollment guardrails for broker access: CMS plans to require additional identity-proofing for brokers enrolling consumers ahead of the fall open enrollment period. The agency also intends to restrict broker access to consumer accounts until the broker has been authorized by the consumer to act for them. These changes shift more responsibility onto brokers to verify authorization and identity before they can complete submissions.

2. Applications missing key identifiers may be blocked and trigger downstream verification: CMS is set to block broker-submitted ACA applications that do not include an enrollee Social Security number. Flagged accounts are described as having patterns such as use of a sales broker, a zero premium, and missing Social Security or immigration documentation numbers. Insurers are directed to reach out to enrollees to confirm the sign-up, and unverified policies must be reported for cancellation after a 60-day window.

3. Oversight and enforcement pressures create spillover risk for compliant agents: The article describes fraud patterns tied to commission-seeking agents allegedly enrolling consumers without their knowledge, including signals like zero-claim enrollment and movement into zero-premium plans. It also notes enforcement actions and criminal charges connected to ACA-related conduct, illustrating the scale of scrutiny around this area. At the same time, it highlights that legitimate brokers can still face review if their National Producer Numbers are linked to flagged accounts, increasing the importance of maintaining strong consent and verification documentation.

Stop-loss issuers see less competition

By Allison Bell – Executives at the insurance companies that are still selling stop-loss insurance to employers with self-insured health plans sound happy about the market. Many have talked about their stop-loss operations during the public conference calls companies have been holding to discuss results for the second quarter of the year with securities analysts. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Stop-Loss Market Tightens as Insurers Pull Back: Unum is running off its stop-loss business, while Cigna continues efforts to restore margins and SiriusPoint reports that employer stop-loss pricing is firming. Reduced competition is contributing to a more favorable pricing environment for insurers that remain active in the market. These conditions could lead to another round of significant stop-loss premium increases for employers in 2027.

2. Rising Medical Claims Drive Higher Stop-Loss Costs: Stop-loss insurers have faced increasing claims costs since mid-2024 as healthcare utilization and underlying medical expenses have risen following the pandemic. Insurers have also reported more costly claims involving patients diagnosed with advanced conditions, including metastatic cancer, after delaying routine screenings or care. Tokio Marine HCC reported that claims increased more than expected in 2025, adding pressure on carriers to raise employer rates.

3. Sun Life Reports Strong Growth Amid Hardening Market: Sun Life reported an 86% increase in stop-loss sales from the second quarter of 2025 to the latest quarter, reaching $225 million. The company attributed its performance to disciplined pricing, underwriting and success in securing attractive business as stop-loss pricing strengthened. Sun Life and Skyward Specialty executives also highlighted growing employer interest in analytics and medical cost-management tools as organizations seek to address rising healthcare and stop-loss expenses.

More employers are dropping the largest PBMs

By Tina Reed – More corporations are cutting ties with the three biggest pharmacy benefit managers and striking deals with smaller rivals to help manage their drug costs, a new survey from the National Alliance of Healthcare Purchaser Coalitions found. Read Full Article...

HVBA Article Summary

1. Large PBMs face increasing competition from smaller rivals: The survey indicates a continuing move by employers away from the three largest PBMs (CVS Caremark, Optum Rx, and Express Scripts) toward other vendors. It also suggests the shift is not limited to employers that have already changed vendors, since many still using the largest PBMs report they are evaluating alternatives. The trend reflects employers treating PBM selection as a more active, revisited purchasing decision rather than a long-term default relationship.

2. Transparency and pricing practices are central to employers’ PBM decisions: Beyond overall cost, employers are seeking operational changes such as greater access to claims data and stronger commitments around pricing methods. The article highlights “spread pricing” as a specific practice employers are scrutinizing when comparing PBMs. These factors suggest that plan sponsors are weighing governance and visibility into drug benefit management alongside headline pricing.

3. Policy pressure and employer purchasing strategies are evolving in parallel: The article notes that major PBMs have adjusted by adopting cost-plus pricing approaches and returning manufacturer rebates to plan sponsors. It also points to new congressional transparency requirements that change how PBMs are compensated, reinforcing the broader push for clearer financial flows. Additionally, the survey findings connect fuller claims-data access with greater use of high-value purchasing strategies, implying that data availability may influence how effectively employers manage pharmacy benefits.

Cedar launches Kora Platform to build out agentic AI for medical billing

By Cailey Gleeson – Cedar, a patient financial platform for healthcare providers, launched an agentic artificial intelligence platform Thursday aimed at patient medical billing. Kora Platform is a suite of purpose-built AI agents that integrates with healthcare organizations’ existing electronic health records (EHRs), telephony and call center systems. Some of the capabilities included within the suite include autonomous inbound voice, autonomous outbound voice, two-way text and advanced reporting. “We really want Kora Platform to be this agentic advocate that's sitting in the pocket of every patient,” Cedar Chief Strategy Officer Dugan Winkie told Fierce Healthcare. Read Full Article...

HVBA Article Summary

1. What Cedar says Kora is designed to do: Cedar is positioning Kora Platform as a set of AI agents meant to help patients navigate medical billing tasks. The company says the suite integrates with provider systems like EHRs as well as telephony and call center tools. It is described as supporting multiple channels, including inbound and outbound voice, two-way text, and reporting. Cedar’s executive framing emphasizes an “advocate” experience intended to reduce the burden on patients to figure out billing steps on their own.

2. Personalization and continuity across patient interactions: Cedar says Kora can adapt in real time to anticipate what a patient needs and to trigger the “next financial action.” The platform is also described as retaining memory of prior conversations with patients. Cedar argues that carrying context across touchpoints prevents patients from needing to restart explanations when they call again. This approach is presented as a way to make billing support more continuous and less repetitive for patients.

3. Operational performance metrics and deployment plans: Cedar reports it has processed 1.5 billion payments across 50 million “unique financial journeys,” which it says informs its personalization capabilities. Executives also cite call-related results, including more than 600,000 patient conversations handled through automated inbound calling and a 40% inbound call containment rate. For outbound calling, Cedar reports a 20% pickup rate and characterizes that as four times the industry average, along with a 21% relative payment rate within seven days of outreach. The company says it is actively deploying new agentic workflows and plans to develop additional workflows collaboratively with customers and innovation partners.

Eli Lilly files first lawsuits over retatrutide 'black market'

By Shelby Livingston – Eli Lilly has sued six US companies for selling what it claims is the pharma giant’s investigational diabetes and weight loss drug retatrutide, which is still undergoing clinical trials. The litigation is Lilly’s first involving retatrutide. Lilly has waged another legal battle against companies that are offering compounded versions of its FDA-approved diabetes and weight loss drug tirzepatide, marketed as Mounjaro and Zepbound. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Lilly Takes Legal Action Against Retatrutide Sellers: Eli Lilly filed lawsuits against six compounding pharmacies, medical spas and online sellers in California and Texas that it alleges are illegally marketing and selling retatrutide. The drug remains in Phase 3 clinical trials and has not been approved by the FDA, with Lilly planning to seek approval in the first quarter of 2027. Lilly is asking the courts to prohibit the companies from marketing and selling products containing the investigational drug.

2. Safety Concerns Center on Unapproved and Untested Products: Lilly argues that products marketed as retatrutide for “research use only” are actually being sold for human use despite lacking FDA approval. The company says consumers may be injecting substances with unknown composition, purity, potency and sterility, while alleging that some sellers provide dosing and administration guidance. Five of the six companies did not respond to requests for comment, while Texas Peptides appeared to have shut down its website.

3. Lilly Expands Efforts to Address the Illicit Retatrutide Market: Beyond the lawsuits, Lilly said it has referred more than 200 individuals and entities to federal and state regulators and enforcement agencies. The company has also reported more than 14,000 websites, advertisements, social media posts and product listings across more than 100 countries to online platforms and service providers. Lilly maintains that the unauthorized market creates consumer safety risks and may also divert patients from its FDA-approved medicines.

Caregiving benefits increasingly important to 'sandwich generation'

By Alan Goforth – The United States is experiencing a major demographic transformation, often called the graying of America. More than half of adults in their 40s are part of the "sandwich generation," balancing care needs of aging parents and children while managing careers of their own. The family circumstances of sandwiched adults vary considerably by age, a Pew Research Center study found. In their 30s and 40s, most have an aging parent and at least one child younger than 18, but no adult children they have supported financially. This is the case for nearly all sandwiched adults in their 30s (95%) and 65% of those in their 40s. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Sandwich Generation Caregiving Extends Beyond Young Children: Many adults in their 50s and older are balancing support for aging parents with financial assistance to adult children, rather than caring primarily for minors. Among sandwiched adults, 59% of those in their 50s and 83% of those 60 and older have helped an adult child financially while also having an aging parent. This reflects how caregiving and financial responsibilities can continue well into later working years.

2. Caregiving Is Affecting Employee Wellbeing, Productivity and Retirement: Zety found that 22% of Gen X caregivers spend more than 16 hours per week providing care, while 37% of those caring for aging relatives also support minor or adult children. More than half report caregiving-related stress and burnout at work, and 44% say they struggle with focus and productivity. Financial pressures are also significant, with 52% saying responsibilities for others affect their retirement savings and 16% reporting that they have delayed retirement.

3. Employers Are Expanding Benefits to Address Caregiving Needs: Three in 10 caregivers report receiving little or no employer support, contributing to interest in benefits that address caregiving, workforce wellbeing and long-term financial planning. CareScout has introduced a worksite long-term care insurance solution that combines insurance protection with immediate access to care planning, navigation and caregiving resources. The approach is designed to support employees who are currently helping aging family members while also preparing for their own potential future care needs.

GLP-1 Telehealth Platforms Rated by U.S. News

By Jennifer Henderson – For the first time ever, U.S. News & World Report has released ratings of telehealth platforms offering GLP-1 weight-loss drugs. The inaugural ratings evaluated 20 online platforms that offer FDA-approved, brand-name GLP-1 medications, such as semaglutide (Wegovy), tirzepatide (Zepbound), and orforglipron (Foundayo). Overall, 11 of the platforms received top ratings, including Amazon One Medical, Noom, Ro, and WeightWatchers. Companies that only offer compounded GLP-1 medications -- which are not FDA-approved and may carry greater risks -- were not included in the ratings. Read Full Article...

HVBA Article Summary

1. What U.S. News rated and what it left out: The rankings covered 20 online platforms that provide FDA-approved, brand-name GLP-1 medications and resulted in 11 platforms receiving top ratings. Services focused only on compounded GLP-1s were excluded, reflecting concerns that compounded versions are not FDA-approved and may pose additional risk. At the same time, the article notes that some rated platforms may still provide compounded products, according to U.S. News. This suggests the ratings are primarily oriented around branded-medication access but do not necessarily eliminate compounded options across all included companies.

2. Why the ratings were introduced now: U.S. News framed the project as a response to increased consumer demand for GLP-1 medications and the complexity of choosing among telehealth vendors. The article highlights patient-facing challenges such as unclear fee structures, differences in physician oversight, and navigating insurance processes. A statement from U.S. News’ health managing editor describes the online marketplace as crowded and confusing, with potential hidden costs and variable clinical oversight. The ratings are positioned as a tool intended to help patients identify telehealth providers viewed as more trustworthy.

3. How platforms were evaluated and what users reported: U.S. News scored platforms on a 5-point scale across six areas: clinical support, health screening processes, transparency, insurance support, supplemental support, and customer satisfaction. The methodology also incorporated feedback from more than 1,200 active GLP-1 telehealth users. In those user surveys, 85% rated their experience as “very good” or “excellent,” and nearly two-thirds reported losing more than 10% of their body weight. The article also emphasizes U.S. News’ view that telehealth should support, not replace, in-person care and that patients should maintain coordination with their primary care physician.