Insurers Are Rejecting More Prescriptions Than Ever, New Study Finds

By Wendell Potter – A new study published in JAMA puts hard numbers behind something patients and doctors have been telling me for years: getting a prescription filled increasingly means running an obstacle course of denials, prior authorization forms, and step therapy requirements — and a lot of people never make it through. Read Full Article...

HVBA Article Summary

1. Large claims-data analysis across major insurance markets: The researchers examined pharmacy claims tied to more than 2 million first-time attempts to fill certain brand-name prescriptions with no generic alternative. The dataset spanned commercial insurance, Medicare, Medicare Advantage, Medicaid, and ACA marketplace plans, allowing comparisons across coverage types. The study period ran from January 2018 through September 2024, capturing changes over multiple years rather than a single snapshot.

2. Denials are frequently linked to insurer coverage mechanisms: The article describes rejections connected to whether a drug is excluded from a plan’s formulary or is subject to utilization-management tools such as prior authorization and step therapy. It frames these policies as a key reason patients face additional steps before they can obtain the medication their clinician prescribed. The piece also notes the industry’s stated rationale—cost control and steering patients toward lower-cost or evidence-supported options—while emphasizing that the same mechanisms can function as practical hurdles to access.

3. Patient impact includes treatment disruption and policy pushback: The article highlights that rejected prescriptions can translate into delayed or foregone treatment, not merely administrative inconvenience. It situates the findings amid ongoing efforts by federal regulators and state lawmakers to standardize and speed prior-authorization decisions, and in some cases to limit how insurers apply these rules. The piece also notes insurers’ argument that market changes—such as more brand-name drug introductions—may contribute to rising rejection levels, while maintaining that access obstacles are increasing across coverage types.

Fifth Circuit orders overhaul of No Surprises Act payment rules

By Kristen Smithberg – A federal appeals court has invalidated two components of the methodology health plans and insurers use to calculate payment benchmarks under the No Surprises Act, potentially requiring the recalculation of qualifying payment amounts. In an Aug. 11 ruling, the full U.S. Court of Appeals for the Fifth Circuit largely sided with the Texas Medical Association and other healthcare providers challenging regulations issued by the Departments of Health and Human Services, Labor and Treasury. Read Full Article...

HVBA Article Summary

1. Two QPA calculation practices were rejected by the Fifth Circuit: The court said insurers may not use contracted amounts for services a provider does not actually perform when computing the qualifying payment amount (QPA). It also found insurers cannot automatically leave out certain bonuses, incentives, or similar adjustments when those payments are tied to a particular item or service. The net effect is that the benchmark used in parts of the No Surprises Act payment framework may need to be recalculated using a different methodology.

2. The ruling focuses on how “ghost rates” and incentives can skew benchmarks: The article describes how provider contracts can contain default fee schedules for services that are not expected to be performed, creating very low negotiated amounts that can pull down the benchmark. It gives an example involving an OB-GYN contract that includes rates for obstetrical services even when the physician does not deliver babies, and notes prior guidance excluded $0 placeholders but allowed other nonzero low values. The court also concluded excluding relevant bonus and incentive payments conflicted with the statute’s instruction that the QPA reflect the “total maximum payment” for the service.

3. Implementation impacts and partial wins for the government remain: The decision follows years of litigation over No Surprises Act implementation, including a 2023 district-court decision, a 2024 panel reversal, and then rehearing by the full court. The court did not accept all provider challenges; it upheld excluding one-off, single-case agreements from QPA calculations in response to a challenge raised by air ambulance companies. Federal officials warned recalculations could be extensive, and the court indicated agencies could allow continued use of existing QPAs temporarily while new amounts are calculated, with the case sent back to the district court for further proceedings.

Drugmakers, health insurers battle over coupons for high-cost medicine

By The Washington Times – If you ask New Jersey state Sen. Jon Bramnick which industry exerts the most influence in Trenton, the answer is a no-brainer: health insurers. So Mr. Bramnick felt like he notched a big win when then-Gov. Phil Murphy in January signed his bill prohibiting “copay accumulator” programs, a policy in which insurers do not count drugmaker-provided coupons toward a patient’s annual deductible and out-of-pocket maximum. Read Full Article...

HVBA Article Summary

1. How copay accumulator programs affect patients: Patients who use manufacturer coupons for expensive medications can later discover that the assistance did not count toward their deductible or out-of-pocket maximum. When the coupon support ends, they may face unexpectedly higher costs before insurance coverage meaningfully applies. Supporters of restrictions argue this structure can disrupt treatment adherence for people managing serious conditions that rely on high-cost drugs. Critics dispute the fairness of the setup, but the patient impact often centers on surprise bills and timing of cost exposure.

2. State policy is uneven and limited in reach: The article describes a patchwork approach, with 26 states plus Washington, D.C., and Puerto Rico taking steps to restrict accumulators via laws or insurance regulation. These policies differ, ranging from broad prohibitions to narrower rules tied to whether a lower-cost generic alternative exists. However, state restrictions generally apply only to state-regulated insurance plans. Many employer-sponsored self-funded (ERISA) plans are outside state authority, leaving a substantial portion of covered people unaffected by state bans.

3. Federal status remains contested and industry arguments diverge: A federal court action in 2023 invalidated earlier HHS rules that would have permitted accumulators in certain situations, but the article says the federal landscape remains unsettled in practice. Some lawmakers are pursuing the HELP Copays Act to require insurers to count third-party assistance toward deductibles and out-of-pocket limits, including for ERISA plans, though the bill has not advanced out of committee. PBM and insurer-aligned groups argue coupons function as a marketing tool that steers patients to higher-priced drugs, while drugmaker groups say accumulators allow insurers and PBMs to capture assistance and leave patients with unexpected costs. The piece portrays the dispute as part of a broader fight over who bears responsibility for high prescription drug prices and how cost-sharing should be structured.

A look at where Aetna is seeing value-based care success in Medicare Advantage

By Paige Minemyer – Aetna is seeing its value-based care efforts pay off in both preventive care metrics and cost savings, according to a new analysis from the company. The insurer compared (PDF) outcomes across 20 different measures for individuals in its Medicare Advantage plans between value-based models and fee-for-service, and found that the value-based arrangements supported better results across 17 of the included measures. Read Full Article...

HVBA Article Summary

1. Aetna reports broad performance advantages for MA value-based care: Aetna’s analysis evaluated 20 measures and found value-based arrangements performed better on 17 of them compared with fee-for-service. The article frames the results as evidence that these models can deliver both prevention-related improvements and lower costs. It positions the findings as part of an ongoing debate about whether the effort required to run value-based programs is justified.

2. Two-sided risk partnerships stand out in Aetna’s findings: Ali Khan, M.D., Aetna’s chief medical officer for Medicare, said stronger results appear when providers take on greater financial risk and therefore have more incentive to manage outcomes and spending. The report highlighted that providers in two-sided risk models showed the strongest performance across multiple measures, including functional status assessments and certain chronic disease and screening metrics. The article also notes that getting more providers to accept risk remains a significant obstacle for expanding value-based care.

3. Aetna emphasizes a multi-year strategy and operational support for total cost of care: Khan argued that value-based care should be approached as a longer-term, iterative effort rather than something judged too quickly. He said the focus needs to shift toward managing total cost of care instead of narrower goals that shaped earlier phases of value-based care. The article describes how payer partners can enable this by investing in interoperability and care management tools, and it cites Aetna’s Clinical Collaboration Program, which places nurses on-site in hospitals to help with care transitions.

Knowing what to cut matters more than what to add

By Tom Murphy – Spend enough time in rooms with CHROs and benefits leaders and a pattern emerges that no one quite wants to say out loud: the companies winning on benefits right now aren't winning by offering more. They're winning by being honest about what isn't working. That admission is quiet, uncomfortable and increasingly unavoidable. And it's reshaping the industry, including benefits advising. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Flat Benefits Budgets Are Driving Greater Scrutiny: With 79% of employers expecting benefits budgets to remain flat or increase only slightly, organizations are placing more pressure on existing programs to demonstrate value. Legacy offerings with low utilization or limited relevance are increasingly competing with benefits that may better address workforce needs. This shift is moving benefits strategies away from adding more programs and toward evaluating which offerings deliver meaningful employee value.

2. Personalization and Workforce Fit Are Increasingly Important: Although 73% of employees say more benefits would increase loyalty, fewer than half believe their current benefits meet their needs, while more than half say health and wellbeing offerings feel irrelevant. At the same time, 80% say personalized options would increase engagement, and tailored wellbeing programs have been associated with a 5.5% reduction in turnover. These findings suggest employers may benefit from aligning offerings more closely with employee demographics and needs, including health, financial wellbeing, mental health and caregiving support.

3. Brokers and Advisers Face a Shift Toward Strategic Benefits Design: As employers focus on utilization, engagement and measurable value, brokers and advisers may play a larger role in helping clients identify underused programs and prioritize benefits that better match workforce needs and organizational culture. A more focused portfolio can potentially reduce administrative complexity while improving employee participation in relevant core and voluntary benefits. The emerging approach emphasizes a smaller number of well-matched benefits rather than a broad menu of offerings that may not generate sufficient engagement.

Out-of-pocket care creates health data blind spots

By Allison Bell – One of big employers' top strategies for controlling health plan costs — new strategies for analyzing and using patient data — could collide with other strategies for controlling health plan costs. The coming data collision shows up in a new employer survey report posted by the National Alliance of Healthcare Purchaser Coalitions. The coalitions represent groups for big health plan sponsors, and most of the 408 survey participants manage plans with at least 500 participants. Almost 30 manage plans with 50,000 or more participants. Read Full Article...

HVBA Article Summary

1. Employer data access is linked to how aggressively costs are managed: The National Alliance survey suggests employers with deeper access to claims data tend to deploy a wider set of cost-control tactics. Coalition analysts report a clear gap in the average number of strategies used by employers with full claim-level visibility versus those with limited access. The implication is that information constraints can shape not just reporting but real operational choices. This frames data availability as a driver of benefit design and management intensity, not just an administrative detail.

2. Cost containment efforts may reduce the data employers rely on: The article describes a potential “collision” where some savings-oriented approaches can also push care outside plan systems. When plan coverage is reduced for certain services, patients may pay cash and the resulting clinical signals may not appear in claims feeds. That can make it harder for plan sponsors, administrators, and clinicians to spot emerging risks and intervene early. The tension is between lowering plan-paid spend and preserving the data trail that supports population health management.

3. Out-of-network telehealth and cash-paid prescriptions can create blind spots: Programs connected to companies like Amazon and Walmart are highlighted as pathways that can steer patients toward telehealth for GLP-1 prescriptions. The article notes that when prescribers are outside a plan network and patients pay cash, plan sponsors and primary care doctors may not see medication use in their usual data sources. That missing context could matter if the drug is being used in relation to suspected or known conditions such as sleep apnea. Overall, the piece suggests that fragmented purchasing channels can complicate clinical oversight and cost forecasting.

Leading benefits professionals buying into AI, with caution

By Danielle Lee – Benefit leaders are embracing — but also bracing for — AI as a key tool to improve processes and expedite employee concerns, while also cautioning employers to apply copious scrutiny and human intervention. "From an organizational perspective, AI can significantly reduce administrative workload by automating routine inquiries and allowing HR professionals to focus on more strategic, people-centered work," said Heather Newton, director of talent and training at domestic violence services provider Child & Family Center. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. AI as an HR Enhancement, Not a Replacement: Benefits leaders see AI as a tool for automating repetitive administrative work and helping HR professionals spend more time on employee support, strategy, and complex decisions. They emphasize that issues involving health, finances, careers, and families still require human empathy, judgment, and context. As hybrid and remote work continue, maintaining human connection is also becoming an important part of the employee experience.

2. More Personalized and Accessible Benefits Experiences: AI, data analytics, and digital tools could help employers move from one-size-fits-all benefits strategies toward more personalized education, communications, and support. Leaders expect benefits platforms to become easier to navigate and more comparable to consumer experiences such as online banking and shopping. However, employers will also need to consider how these technologies affect plan costs, affordability, data use, and long-term sustainability.

3. Employee Concerns Remain Despite Workforce Optimism: Forty-eight percent of employees say they are more concerned about AI than a year ago, with concerns including its impact on salary (72%), promotions due to insufficient AI knowledge (67%), and falling behind because of limited workplace usage (66%). At the same time, 32.7% of companies that conducted AI-driven layoffs have rehired 25%–50% of eliminated roles, while 36% of organizations that cut jobs for AI have brought back more than half of those positions. Separately, 60% of business leaders expect their workforces to grow rather than shrink and the same percentage expect AI to reinvent human roles.