Prior Auth Is Costing Billions and Delaying Care. A New Report Says Ban It.

By Wendell Potter – A new report out this month, Ban Prior Authorization: Ending Big Medicine’s Strategy to Boost Profits by Denying Medically Necessary Care, argues that prior authorization has evolved from a limited cost-control measure into what authors Hannah Garden-Monheit and Emma Freer at the American Economic Liberties Project call a “corporate care veto” — one that allows health insurance conglomerates to override doctors while benefiting financially when care is denied. Read Full Article...

HVBA Article Summary

1. Administrative burden on clinicians is a central claim of the report: The piece says the AELP report characterizes prior authorization as more than a utilization-management tool, arguing it has become a mechanism that can overrule physicians’ decisions. It highlights estimates that the process consumes large amounts of clinician and staff time and is tied to significant systemwide costs. The author frames this burden as contributing not only to delays but also to downstream clinical and operational strain for medical practices.

2. The article disputes that more prior authorization automatically yields lower spending: It contrasts the volume of prior authorization determinations in Medicare Advantage with traditional Medicare and points to cited figures suggesting Medicare Advantage still costs taxpayers more per patient. The implication presented is that heavy reliance on prior authorization does not necessarily translate into lower overall program costs. This comparison is used to question the effectiveness of prior authorization as a cost-control strategy at scale.

3. The post connects prior authorization to patient harm and proposes narrower, independent oversight: It reports that physicians describe prior authorization as delaying necessary care and that some doctors associate it with serious adverse events. It also notes the report’s policy approach would still allow pre-approval in limited cases tied to documented issues like fraud or overprescribing. However, it says those decisions should be made by an independent third party without financial incentive to deny care, and that AI should not be used to issue denials.

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

By Jake Velie – Jake’s article draws on two important sources: the New England Journal of Medicine piece by Dr. Suhas Gondi and Dr. Zirui Song on self-insured employers as a sleeping giant in health care affordability, and Stacey Richter’s Relentless Health Value podcast conversation with Dr. Gondi about why employers and clinicians so often miss each other in practice. Together, they highlight the same underlying problem: when cost-containment decisions are not clearly translated to the point of care, patients end up carrying the burden. Read Full Article...

HVBA Article Summary

1. A communication gap between employers and clinicians creates avoidable problems: The article argues that many physicians do not realize a self-insured employer is often the real decision-maker behind coverage strategy. Employers may put cost-containment measures in place for legitimate reasons, but if those decisions do not reach clinicians clearly and early, they show up at the point of care as confusion, denials, and frustration.

2. The GLP-1 example shows how a reasonable benefit strategy can still fail the patient: In the article’s example, the doctor and patient do everything right, but the prescription is still rejected because the plan requires a different access pathway. The problem is not simply whether the drug is covered. The problem is that the physician was never told how the plan’s process actually works, so the patient ends up paying the price for a coordination failure.

3. Site-of-care programs only work when they come with navigation and provider communication: The article explains that some denials are not really denials of treatment, but attempts to redirect care to a lower-cost setting. Still, if that redirection happens without advance communication and support, it feels like a barrier instead of a strategy. The takeaway is that cost containment only works when the employer’s intent, the clinician’s workflow, and the patient’s path to care are all connected.

Health care's new back door: AI vendors become the largest data risk

By Deborah Ault – Most people can name their doctor, their hospital, and their insurance carrier. But ask the average employee whether they have ever heard of Xsolis, Cedar, Innovaccer, Cohere, or any of the growing number of technology companies quietly embedded inside today's health care ecosystem, and most would have no idea who they are. That is not necessarily a problem. It is simply the reality of modern health care. Read Full Article...

HVBA Article Summary

1. Invisible vendors are becoming central to health care operations: The article argues that patients increasingly move through a network of third-party organizations they may never directly encounter, including navigation, analytics, utilization management, and AI firms. This expanding ecosystem means more entities touch sensitive health information even when patients don’t recognize their names. The author frames this as a structural shift in how care is delivered, not simply a branding or awareness issue.

2. A major breach highlights growing exposure outside traditional institutions: The piece points to a breach involving AI utilization management company Xsolis that reportedly affected nearly 1.4 million individuals and was traced to a phishing attack. Published reports cited in the article say exposed data may have included Social Security numbers, insurance details, and medical records. The author’s broader point is that cybersecurity risk is increasingly concentrated in behind-the-scenes technology vendors, not only hospitals and insurers.

3. Employers and plan sponsors are urged to strengthen vendor oversight as AI adoption grows: While acknowledging AI’s potential to improve access, coordination, and administrative efficiency, the author emphasizes that trust is harder to maintain when decision-making and data handling are opaque to employees. The article suggests employees assume someone has vetted vendors’ safeguards and security protocols—but that this isn’t always true in practice. The takeaway is that employers, advisors, and health care leaders should proactively evaluate and govern these vendors to ensure “the back door remains locked,” especially as AI becomes a more prominent entry point into care.

‘Ultimately it’s going to be a great financial decision’: UHS CEO speaks on Talkspace bet

By Rebecca Pifer Parduhn – Universal Health Services is the largest behavioral health provider in the U.S., when it comes to brick-and-mortar facilities. But the King of Prussia, Pennsylvania-based health system’s virtual services took a major leap forward on Monday when it closed its acquisition of Talkspace, a major player in the booming online therapy market. With the $835 million deal, UHS says it’s now able to serve patients at any stage of their mental health journey, whether they’re looking for a one-off therapy session or 24/7 inpatient care. It’s a major bet on continued demand for behavioral healthcare, which has surged as conditions like anxiety and depression become more prevalent and stigmas around seeking care erode. Read Full Article...

HVBA Article Summary

1. Rationale centers on unmet demand and broader access points: UHS CEO Marc Miller said the system sees persistent unmet demand for behavioral health services across multiple states, driven in part by mismatches between services available locally and what patients need. He also cited reimbursement and coverage as barriers that can prevent demand from being fully met. The Talkspace acquisition is positioned as a way to better align UHS’ offerings across its footprint and reach patients who might not connect with in-person services.

2. Strategy aims to create an end-to-end “menu” across care settings, including telehealth: Miller described UHS as expanding tele-services from a smaller base and integrating them alongside intensive outpatient, partial hospitalization, and inpatient programs. He said the combined organization expects to route patients to the most appropriate level of care, rather than relying on a single setting. The company also expects cross-referrals between Talkspace users and UHS’ existing patient base, including patients who have not previously used tele-services.

3. Future dealmaking and investor messaging emphasize outpatient growth and operational differentiation:Miller said UHS is open to additional acquisitions, particularly as add-ons that make its behavioral health continuum more robust, but noted the company does not plan to be aggressively acquisitive. He highlighted outpatient as a current focus area, while noting ongoing additions of inpatient beds where needed. In discussing investor concerns amid industry headwinds and UHS-specific performance challenges, he framed the Talkspace deal as both patient-oriented and a long-term financial decision for the company.

Employers face a new GLP-1 question: Are the drugs worth it?

By Jimmy Nesbitt – Employers have spent years arguing over how much GLP-1 coverage should cost. A harder question is starting to take over: Is it paying off? Bank of America's recent disclosure that it spends more than $250 million a year on the drugs — out of a roughly $2 billion healthcare budget — has sharpened that question across the industry, where 8 in 10 employers already say GLP-1s are driving up costs. Ali Diab, CEO of Collective Health, said most employers still can't answer it. Pharmacy claims and medical claims typically live with separate vendors, so few companies can see whether a member's drug costs are being offset by better outcomes elsewhere. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Data fragmentation limits ROI measurement: The interview argues that many employers are set up to view pharmacy spending and medical outcomes in separate systems managed by different vendors. That separation makes it difficult to tie GLP-1 prescription costs to changes in the same individual’s utilization or clinical outcomes over time. As a result, employers may manage GLP-1s as a pharmacy budget problem rather than a total-cost-of-care question.

2. Member-level, longer-term tracking is emphasized: The recommended approach is to evaluate what happens to a person’s broader healthcare use and markers (such as ER visits and A1C) across a multi-year window rather than focusing on short-term drug spend. The article notes self-insured employers may have more ability to connect pharmacy and medical claims for the same member, but often do not operationalize that advantage. The implication is that better integration and analytic support could change coverage decisions by clarifying where costs are being avoided (or not).

3. Adherence and support programs affect financial outcomes: The interview highlights persistence on therapy and discontinuation/weight regain as major factors that can swing any return-on-investment model. It also argues that GLP-1 prescriptions paired with nutrition support or coaching can be a different “bet” than prescribing the drug alone, even if both look the same on a pharmacy invoice. For leaders considering eligibility restrictions during open enrollment, the guidance is to first understand who is using the drug, who stays on it, and how their total utilization changes before tightening access.

NABIP makes recommendations for prescription drug affordability

By Susan Rupe –The National Association of Benefits and Insurance Professionals said it is ready to work with lawmakers to advance reforms that increase prescription drug affordability while strengthening Medicare’s long-term sustainability. NABIP sent a letter to Senate Finance Committee ranking member Ron Wyden, R-Ore., on Aug. 17 in response to the committee’s request for information on policy options to lower prescription drug prices and improve affordability for patients. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Focus on Part D Stability and Beneficiary Choice: NABIP urged Congress to develop a long-term strategy to stabilize premiums and preserve access to stand-alone Medicare Part D plans, noting that these plans lack the Medicare Advantage rebate dollars available to MA-PDs. The association raised concerns about rising premiums, fewer stand-alone plan options, narrower formularies, and the end of CMS’s Part D Premium Stabilization Demonstration. NABIP argued that beneficiaries should continue to have a practical choice between traditional Medicare with stand-alone drug coverage and Medicare Advantage.

2. Balance Lower Drug Costs With Overall Coverage Affordability: NABIP supports efforts to reduce prescription drug out-of-pocket costs but cautioned that policies such as drug-specific cost-sharing caps should be evaluated for their broader effects on premiums, formularies, plan participation, and pharmacy access. It also recommended protections for beneficiaries facing significant formulary changes, pharmacy-network disruptions, or repeated difficulty obtaining covered medications, including expedited appeals and narrowly defined Special Enrollment Periods. The association’s position is that lower costs at the pharmacy counter should be considered alongside the overall stability and accessibility of Medicare drug coverage.

3. Increase PBM and Supply-Chain Transparency: NABIP recommended evaluating PBM performance based on the total net effective cost of prescription drugs rather than primarily on rebate volume, incorporating fees, spreads, markups, and affiliate revenue. It also called for greater oversight of vertically integrated organizations and private-label drugs, arguing that these arrangements can make financial relationships and pricing more difficult for plan sponsors and advisors to assess. NABIP further recommended prohibiting contractual restrictions that prevent plans from accessing their own information, comparing alternatives, or pursuing lawful lower-cost arrangements.

GLP-1s are forcing a strategic reset across healthcare: Wells Fargo report

By Heather Landi – Healthcare cost pressure alone does not predict which employers take action on it. The stronger predictor is whether an employer can see their own claims data. Where that data is stored turns out to matter as much as whether they formally have access to it at all. Read Full Article...

HVBA Article Summary

1. GLP-1s Could Reshape Traditional Healthcare Service Lines: Growing use of GLP-1 obesity medications may shift healthcare from treating obesity-related complications toward earlier prevention and long-term weight management. Bariatric surgery volumes fell 34.1% from 2022 to 2024 while GLP-1 use increased more than 140%, and the SELECT trial found semaglutide reduced major cardiovascular events by 20% among overweight or obese adults without diabetes. These trends could reduce demand for some acute procedures and hospitalizations while increasing demand for obesity medicine, specialty pharmacy, medication management, adherence support and integrated cardiometabolic care.

2. Impact on Procedure Volumes and Healthcare Spending Remains Mixed: GLP-1-driven weight loss could reduce some obesity-related complications, but its effect on areas such as orthopedics is less certain because weight loss may also make more patients eligible for procedures such as joint replacement. At the same time, the drugs are creating substantial near-term costs, with 64% of large employers covering GLP-1s for weight loss reporting moderate or significant increases in prescription drug spending and Medicare Part D GLP-1 spending reaching $27.5 billion in 2024. The Congressional Budget Office estimates broader Medicare coverage of anti-obesity drugs would increase federal spending by about $35 billion from 2026 through 2034, with health-related savings taking years to materialize and not fully offsetting medication costs.

3. Investment and Pharmaceutical R&D Are Shifting Toward Obesity Care: Obesity has overtaken oncology as the largest contributor to forecast late-stage pharmaceutical pipeline value, with obesity drugs representing roughly 25% of that value compared with just 1% in 2022. As GLP-1 adoption expands, healthcare organizations may need to rebalance investments away from some service lines centered on obesity-related complications and toward preventive and longitudinal care. The ultimate financial impact will depend heavily on drug pricing, patient persistence, adoption rates and whether long-term reductions in healthcare utilization are sufficient to offset higher pharmacy spending.

Mutual of Omaha promotes long-term care distribution veteran to VP role

By Mark Rosanes – Mutual of Omaha has promoted Corri Campbell to vice president of brokerage distribution for long-term care and supplemental health. In the role, she will lead sales for the company's health product portfolio, covering long-term care, critical illness, and accidental death insurance. Campbell joined Mutual of Omaha in 2019 as sales director for long-term care, was promoted to national sales director in 2021, and has held leadership roles of increasing responsibility since. Before joining Mutual of Omaha, she spent more than 20 years at Genworth in sales, training, and regional leadership positions, giving her nearly three decades of experience in long-term care distribution and sales leadership. Read Full Article...

HVBA Article Summary

1. Expanded brokerage-distribution leadership at a major LTC writer: Mutual of Omaha elevated Corri Campbell to a VP role overseeing brokerage distribution for long-term care and supplemental health. Her remit includes leading sales across a broader health product portfolio, not only long-term care. The move places a long-tenured LTC distribution executive in a more senior position at a time when brokerage relationships can be pivotal for stand-alone LTC carriers.

2. LTC carrier count has fallen dramatically over decades: The article cites Milliman’s annual US industry LTCI claims projection (March 2025) indicating fewer than 15 carriers remain active in the individual LTC insurance market. That compares with more than 100 companies selling individual policies in the 1990s, underscoring the scale of market contraction. It also notes Mutual of Omaha’s standing among leading carriers by earned premiums in the NAIC’s 2024 experience report, alongside an external review describing it as one of the few large carriers still writing stand-alone LTC policies.

3. Genworth’s exit-and-return illustrates barriers to re-entry: Campbell’s background includes more than 20 years at Genworth, which the article says suspended new individual LTC brokerage sales in March 2019 after reserve and pricing challenges. According to the article, Genworth re-entered the market in October 2025 through a new subsidiary, CareScout Insurance Company. The need for a separate entity and the multi-year gap are presented as evidence of how difficult it can be for an LTC carrier to re-enter on sustainable terms.