How Trump's OBBBA will impact open enrollment

By Paola Peralta - Open enrollment is only a few months away, and benefit leaders may face new and unprecedented challenges — and it's all to do with President Trump's new act. In July, the Trump administration signed into law the One Big Beautiful Bill Act (OBBBA), which focuses primarily on tax cuts and spending reform and affected funding to many public services such as Medicaid, Medicare, the Supplemental Nutrition Assistance Program and the Children's Health Insurance Program. These changes will have sweeping repercussions for employees everywhere, and will be reflected in the way they enroll in their benefits this year. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Anticipated Increase in Enrollment and Costs: With eligibility tightening for public programs like Medicaid and Medicare, a significant number of employees and their dependents are expected to shift to employer-sponsored health plans. This surge in enrollment will expand the overall risk pool, which could drive up plan costs and result in higher premiums, increased deductibles, or reduced coverage options. In response to rising costs, many employees may choose high-deductible plans and rely more heavily on tools like HSAs and FSAs to save money and manage their healthcare expenses.

2. Shift Toward Voluntary and Comprehensive Benefits: As public services such as certain financial wellness programs, telehealth offerings, or student loan assistance become less accessible, employees may increasingly turn to voluntary benefits to fill those gaps. This could include traditional offerings like accident insurance, hospital indemnity, and legal aid, as well as emerging options like menopause care, caregiving support, and other specialized wellness initiatives. These changes reflect a growing need for employers to provide diverse, comprehensive support that aligns with evolving employee circumstances and expectations.

3. Critical Role of Clear, Proactive Communication: In an environment of uncertainty and potential confusion, benefit leaders must prioritize open, transparent, and thorough communication. This means clearly explaining who will be affected by changes, what specific changes are occurring, and how employees can adapt. Preparing FAQs, educational materials, and ensuring HR teams are highly accessible before open enrollment begins will help employees feel supported. The way leaders handle this period could significantly influence employee trust, retention, and recruitment in the long term.

Insurers vow to speed up prior authorizations with AI, new data standards

By Allison Bell - Employers have been asking health insurers for years to speed up and simplify efforts to screen workers' requests for coverage for CAT scans, specialty drugs and stomach operations. Insurers told state insurance regulators Tuesday that, this time around, they think they really can make prior authorization processes work better. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Projected Efficiency Gains Through Standards and AI: Insurers aim to raise real-time approvals for complete prior authorization files from about 20% today to 80% by 2027. This improvement is expected to come from broader adoption of the Fast Healthcare Interoperability Resources (FHIR) data standard across all plan types—not just Medicare and Medicaid—and the strategic use of artificial intelligence to speed up processing. AI will be used to facilitate faster approvals, with safeguards to ensure that any denial based on medical necessity still receives a clinician’s review, preserving human oversight in decision-making.

2. Operational and Process Changes: America’s Health Insurance Plans (AHIP) and the BlueCross BlueShield Association recommend further reducing the number of procedures that require prior authorization and maintaining physician involvement for denials. They also stress the need to increase electronic submission rates, since nearly half of prescription and medical service prior authorization requests are still sent by phone, mail, or fax. These outdated methods, combined with a high percentage of incomplete submissions, slow down processing and contribute to the current approval rates—about 10% for prescription drugs and 97% for medical services.

3. Differing Stakeholder Perspectives: The National Health Law Program (NHELP), a patient advocacy group, questions whether the insurers’ promises represent meaningful change, noting that the commitments largely mirror existing obligations and appear to lack significant consumer or provider group input. Insurers dispute this skepticism, pointing to reductions in the scope of prior authorization requirements—now affecting fewer than 4% of commercial prescription drug claims and fewer than 7% of commercial medical claims—as evidence of substantial progress in streamlining the process.

Most expensive drugs in the US in 2025

By Zoey Becker, Kevin Dunleavy, Eric Sagonowsky, Angus Liu, Fraiser Kansteiner - With more and more expensive gene therapies hitting the market, one-dose, curative treatments are continuously shuffling the list of the U.S.’ highest-priced drugs. In just two years, half of Fierce Pharma’s 2023 list of the most expensive drugs has been replaced with a fresh crop of newer, pricier treatments. Each of the drugs on this year’s list are one-dose therapies, prompting goodbyes to pharmacy-dispensed drugs like Myalept, a leptin deficiency med that for years was one of the world’s most expensive with its $1.26 million yearly cost. Read Full Article…

HVBA Article Summary

1. High-cost gene therapies face slow adoption despite record prices: Kyowa Kirin’s Lenmeldy became the world’s most expensive drug at $4.25M per dose, overtaking CSL’s Hemgenix ($3.5M), yet uptake in the U.S. has been minimal, with only one patient treated so far due to late diagnoses, limited newborn screening programs, and narrow patient eligibility. Similar challenges are seen across other ultra-expensive treatments like Roctavian and Zynteglo, where even approved and available therapies struggle to gain momentum despite high expectations.

2. Market exits and strategic shifts highlight commercialization challenges: Pfizer withdrew its $3.5M Beqvez less than a year after approval due to low demand and limited physician and patient interest, marking its full exit from the gene therapy field. BioMarin considered selling off Roctavian after minimal uptake, while bluebird bio, despite securing multiple high-profile FDA approvals, sold itself to private equity after years of weak commercial performance, reflecting the broader difficulty of sustaining viable gene therapy businesses.

3. Pricing debates persist amid questions of value and accessibility: While drugmakers argue that multi-million-dollar price tags are justified by the potential for lifetime healthcare savings, reduced treatment burden, and the rarity of targeted diseases, cost watchdogs like ICER frequently recommend lower price benchmarks. These groups highlight concerns about the durability of benefits, long-term safety risks, and the strength of clinical evidence—especially for therapies with mixed trial results or limited real-world patient outcomes—fueling ongoing debate over affordability and equitable access.

How Decentralized Care Models Will Reshape Healthcare

By Asher Perzigian - The hospital as we know it is on the brink of becoming unrecognizable. It’s no longer the central hub of healthcare and is rapidly becoming the most expensive and least convenient option. By 2030, up to 30% of hospital revenue could be lost to decentralized care models that are faster, more affordable and increasingly global. This shift is not just a trend; it’s a fundamental change in how healthcare is delivered and accessed, and it requires building resilience to adapt to new challenges and opportunities. The road ushers in a messy reality paved with potential payment reform, regulatory hurdles, and clinical burnout. Read Full Article…

HVBA Article Summary

1. Shift from centralized to decentralized care delivery: The healthcare industry is transitioning away from hospital-centric models toward a more flexible, patient-centered approach that delivers services virtually, at home, and within local communities. This shift is supported by innovations such as telemedicine, wearable health devices, remote monitoring, and AI-powered care tools, while traditional hospitals are expected to focus primarily on specialized treatments, acute care, and emergency services.

2. Technology integration and workforce adaptation: Advances in AI, immersive virtual reality training, telepresence robotics, and data-driven platforms are transforming how clinicians and support staff deliver care. These changes require significant investment in digital infrastructure, redesigned care pathways, and continuous training for healthcare professionals, all while addressing barriers such as the digital divide that can limit access for vulnerable populations like seniors, rural residents, and the chronically ill.

3. Strategic transformation for competitiveness: To maintain relevance and resilience in a rapidly evolving healthcare market, organizations must rethink the role of physical facilities, expand and integrate digital care solutions, and develop more adaptable workforce models. This includes building operational efficiency, ensuring seamless patient experiences across settings, and fostering a culture of continuous innovation that prioritizes both accessibility and high-quality care.

Hospitals reject $2.8B BCBS settlement, claiming anticompetitive practices persist

By Alan Goforth - More than 6,400 providers chose to opt out of a $2.8 billion antitrust settlement with the Blue Cross Blue Shield Association by the July 29 deadline. They include hospitals owned by some of the nation’s most prominent health systems, such as the Mayo Clinic, University of Michigan Health and AdventHealth. Read Full Article… ^{_{(Subscription required)}} 

HVBA Article Summary

1. Settlement and Operational Changes: In 2023, Blue Cross Blue Shield (BCBS) companies and their association agreed to a $2.8 billion settlement to resolve a 2012 lawsuit alleging they conspired to divide markets, reduce competition, and drive up costs. While denying wrongdoing, BCBS committed to operational changes in claims processing, provider communications, contracting, and payments, including adjustments to its BlueCard program to streamline prior authorization and payment procedures.

2. Ongoing Antitrust Allegations: In 2024, multiple provider groups, health systems, and Texas Health Resources filed new lawsuits alleging BCBS continues anticompetitive practices such as reduced payments, horizontal market allocation, and price-fixing. Plaintiffs seek treble damages—tripling the original settlement amount—and injunctive relief to bar BCBS from continuing the alleged collusion, including restrictions on BlueCard and national accounts programs.

3. Stakeholder Claims and Impacts: Plaintiffs argue BCBS’s structure facilitates coordinated actions among its independent entities, benefiting member plans at providers’ expense by artificially lowering reimbursements since at least 2008. They claim this has caused ongoing financial harm to hospitals and health systems, while BCBS maintains that its prior settlement changes demonstrate a commitment to resolving disputes and improving provider relations.

Conservative policy shop Paragon Health previews post-OBBB health reform priorities

By Noah Tong - Fresh off a legislative victory this summer, the Paragon Health Institute is flexing its health policy chops and eyeing the next areas of reform the think tank wishes to see. During a webinar Thursday, President Brian Blase, Ph.D., was among the speakers defending President Donald Trump’s bill, highlighting the importance of eliminating waste, fraud and abuse, reducing Medicaid spend and implementing work requirements. These changes were opposed by most industry stakeholders and a cohort of advocacy groups. Read Full Article…

HVBA Article Summary

1. Nationwide Medicaid Work Requirement Implementation: The budget bill introduces the first nationwide Medicaid work requirements, marking the most significant healthcare legislation since the Affordable Care Act. States will receive $200 million in grants and a 90% federal match rate to support enforcement, with the Centers for Medicare & Medicaid Services (CMS) required to issue an interim final rule by June 2026. Paragon, a GOP- and Trump-aligned policy group, will assist states in adopting the requirements and improving administrative efficiency, leveraging technology to reduce improper payments.

2. Future Reform Priorities and Federal Funding Adjustments: Paragon plans to advocate for reduced federal funding below the current 90% for Medicaid expansion enrollees, modifications to the 340B program, and broader reforms such as site-neutral payment policies and cost-sharing subsidy changes aimed at reducing premiums and increasing competition. These measures, while discussed for a summer tax bill, were postponed, signaling possible future legislative efforts.

3. Potential Medicare Advantage and Executive Action Changes: Although the bill does not address Medicare Advantage, bipartisan dissatisfaction could drive reforms, including benchmark caps, ending quality bonus payments, and revising risk adjustment. Additionally, executive actions could promote short-term and association health plans, along with individual coverage health reimbursement arrangements, expanding insurance options outside traditional programs.

A surgeon’s case for conservative MSK care | Viewpoint

By Benedict Nwachukwu - As a practicing orthopedic surgeon, my goal is always to strive for an evidence-based approach. Not only do I perform surgeries as a way to address musculoskeletal (MSK) issues, but increasingly, I also steer patients toward a nonsurgical approach. MSK issues are a massive hindrance globally. In the U.S., MSK conditions are the leading cause of long-term disability and rank third in how common they are and how much they affect overall health. MSK conditions represent a growing health burden, responsible for an economic cost of $980 billion annually. Read Full Article…

HVBA Article Summary

1. Conservative care should be the first-line approach for MSK conditions: Strong research evidence indicates that many musculoskeletal surgeries could be delayed or completely avoided with early adoption of physical therapy and other nonoperative treatments. Despite this, these options are often bypassed due to a widespread belief in quick fixes like surgery, injections, or medication, which can lead to premature or unnecessary procedures.

2. Collaborative, preventive care can be highly effective: Experiences such as treating NBA players in the COVID-19 “bubble” showed that multidisciplinary, non-surgical strategies — involving physicians, trainers, and therapists — can deliver excellent recovery outcomes even in high-demand populations. This underscores how coordinated, preventive approaches can reduce reliance on surgery while still achieving optimal performance and health results.

3. Hybrid and personalized care pathways improve access and outcomes: Combining in-person, hands-on therapies with digital platforms for remote guidance not only expands access to specialized care but also enhances patient engagement and continuity. This approach supports individualized treatment plans, ensures that surgery is considered only after conservative care has been exhausted, and helps maintain long-term functional improvements.