Fourth Court Rejects Insurers' No Surprises Act Litigation Campaign

By Wendell Potter – A federal judge in Georgia has handed Elevance Health another defeat in its campaign to use the courts — rather than the arbitration process Congress built — to fight the No Surprises Act. U.S. District Judge Thomas Thrash Jr. has dismissed a lawsuit that Blue Cross Blue Shield Healthcare Plan of Georgia (an Elevance company) had filed against medical billing company HaloMD and two physician groups. The insurer’s theory was familiar by now: racketeering, ERISA violations, state deceptive-trade-practices claims, all alleging that the defendants had defrauded it through the No Surprises Act’s independent dispute resolution (IDR) process. The complaint claimed HaloMD had initiated tens of thousands of disputes in just the back half of 2024, netting close to $6 million in what Elevance called improper arbitration awards. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Federal Courts Are Rejecting Insurers’ Litigation Strategy: The Georgia ruling marks the fourth time a federal court has dismissed similar lawsuits brought by insurers seeking to challenge No Surprises Act arbitration outcomes. Judges in California, Texas and Florida have also concluded that insurers cannot sidestep the statute’s limits on judicial review by reframing payment disputes as fraud or racketeering claims. In each instance, courts have emphasized that Congress designed the independent dispute resolution process to keep these conflicts out of federal court. The repeated dismissals suggest a consistent judicial interpretation of the law’s jurisdictional boundaries.

2. Dispute Over Arbitration Outcomes and Win Rates: Providers represented by HaloMD argue that insurers’ frequent losses in arbitration reflect low initial payment offers rather than systemic abuse. Company representatives contend that insurers default in roughly a quarter of disputes and that provider success rates—often cited at around 85%—do not prove the system is rigged. Insurer trade group AHIP, by contrast, says nearly 40% of disputes were flagged as ineligible in 2024, though arbiters agreed with only 17% of those challenges. The disagreement centers on whether these figures indicate flawed incentives or simply the expected functioning of the IDR framework.

3. Broader Industry and Policy Implications: Insurers and their trade associations continue to press lawmakers and regulators for changes, arguing that the arbitration system encourages inflated charges and disadvantages employers and consumers. Provider-side advocates respond that the courts have consistently rejected claims that the IDR process itself is unlawful or fraudulent. One pending case in Ohio may test whether insurers can extend liability claims to individual executives behind billing firms, potentially expanding the legal stakes. For now, however, courts have maintained that payment disputes under the No Surprises Act belong in arbitration, not federal litigation.

The rise and consequences of PBM vertical integration

By Cassie McGrath – Pharmacy benefit managers (PBMs) have come under a lot of pressure lately. They’re accused of raising drug costs and pushing independent pharmacies toward closure. But how did they get so much power? Read Full Article...

HVBA Article Summary

1. Vertical integration has concentrated control among a few healthcare conglomerates: The largest PBMs are now owned by major health insurers, embedding pharmacy benefit management within broader healthcare corporations. According to the FTC, four of the largest conglomerates—UnitedHealth Group, CVS Health, Cigna Group, and Humana—control 22% of all US health expenditures. This structure allows a single company to influence prescribing, price negotiation, and pharmacy dispensing. Critics argue that such consolidation reduces transparency and makes it difficult to track how profits are generated across the supply chain.

2. Market consolidation has significantly reduced competition: In 1995, more than 40 PBMs operated in the US, but today the market is dominated by a small group. The FTC estimates that the three largest PBMs manage 79% of prescription drug claims for 270 million people, while the six largest control 94% of claims nationwide. This dominance gives PBMs substantial leverage over formularies, reimbursement rates, and pharmacy access. Analysts say this level of concentration limits competitive checks on pricing and contracting practices.

3. Financial incentives and regulatory scrutiny are intensifying: The FTC reported that the three largest PBMs generated $1.6 billion in excess revenue on two cancer drugs between 2020 and part of 2022, raising concerns about formulary design and rebate structures. Independent pharmacies say vertically integrated PBMs can steer patients to affiliated pharmacies, contributing to closures; one study found that 1 in 3 retail pharmacies shut down between 2010 and 2021. Federal lawmakers have introduced bipartisan bills aimed at curbing PBM influence, and some states, including Tennessee and Arkansas, have passed laws restricting common ownership of PBMs and pharmacies. These efforts have prompted lawsuits and ongoing debate about how to balance oversight with industry operations.

ICHRA Interest Is Not a Predictor of Adoption

By Emily Boyle – As employers face mounting pressure from healthcare costs, individual coverage health reimbursement arrangements may offer a route to more predictable healthcare costs while giving employees greater choice in their insurance selection. However, a joint study from the Employee Benefits Research Institute and Morgan Health, a division of JPMorganChase & Co., cautioned that employer interest should not be interpreted as a guarantee of rapid adoption. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. High Interest, Especially Among Larger Employers: The survey found that 69% of employers with at least 100 employees that offer health plans said they were at least somewhat likely to adopt an ICHRA within two years. More than one-third of all surveyed employers were actively planning or evaluating the option, including 62% of large employers offering health plans. Interest was also notable among smaller firms, though at lower levels. These figures indicate meaningful curiosity about the model, particularly among employers already providing coverage.

2. Knowledge Gaps and Awareness Challenges Persist: While nearly 60% of employers reported being somewhat familiar with ICHRAs, understanding varied widely by employer size and current benefit offerings. Among small employers not offering health benefits, 55% were unaware that ICHRAs were even an option, and only between 56% and 69% correctly understood that the arrangement involves fixed employer contributions for individually purchased coverage. A significant share mistakenly believed employers select and purchase plans under an ICHRA. These misunderstandings suggest that education and outreach could play a critical role in future adoption.

3. Concerns About Cost, Quality and Policy Shape Adoption Decisions: Employers expressed strong interest in features that would mirror traditional group plans, with 85% saying guaranteed network quality and choice would increase their willingness to adopt ICHRAs. Payroll integration and the ability to add point solutions were each cited by 79% as important enhancements. Affordability concerns were widespread, with 85% of large employers offering health plans citing worries about individual market premiums and 84% concerned about out-of-pocket costs. Additionally, many respondents said tax credits and greater stability in marketplace rates would make the model more attractive.

HHS Is Reviving Its 340B Rebate Push — And Providers Are None Too Pleased

By Katie Adams – HHS unveiled a plan to reintroduce a rebate program for 340B drug discounts last week. The department, through the Health Resources and Services Administration (HRSA), is seeking to replace upfront discounts with rebates for a subset of 340B drugs. Read Full Article...

HVBA Article Summary

1. Revised Rebate Pilot After Legal Setback: HRSA is attempting to relaunch a rebate-based model for certain 340B drugs after its earlier effort was blocked in court over procedural and legal concerns. The new pilot would shift discounts from the point of sale to a rebate system, requiring hospitals to pay upfront and seek reimbursement later. This change places new tracking and verification responsibilities on providers. The revised program is expected to begin next year, setting the stage for potential renewed legal challenges.

2. Limited Scope Focused on IRA-Linked Drugs: The pilot applies to 25 drugs that are subject to Medicare’s negotiated “maximum fair price” under the Inflation Reduction Act, including Ozempic, Eliquis, Otezla and Calquence. However, these medications are not the primary drivers of 340B spending, which is heavily concentrated in high-cost specialty drugs. HRSA data show that specialty drugs accounted for 62% of total 340B spending last year despite representing only 38% of purchased units. Overall, the drugs included in the pilot make up less than 5.5% of total 340B sales, underscoring the program’s relatively narrow initial reach.

3. Providers Warn of Financial and Administrative Strain: Hospital groups and trade associations argue that the rebate model would create significant operational burdens, especially for financially strained and rural providers. The American Hospital Association estimates the policy could impose hundreds of millions of dollars in compliance costs and disrupt hospital cash flow. Critics also contend that HRSA may again face legal scrutiny if the revised approach is viewed as inconsistent with administrative law. HRSA, meanwhile, maintains that the rebate system is necessary to improve oversight, transparency and long-term sustainability of the growing 340B program.

Lilly beats forecasts again as tirzepatide makes up nearly two-thirds of revenue

By Kyle LaHucik – Eli Lilly posted $23 billion in second-quarter revenues, coming in about $3 billion above analysts’ estimates. Lilly also once again raised its full-year revenue guidance to between $85 billion and $87 billion, which is $5 billion above the low end of the range it predicted headed into the year. This is another guidance bump for the company, as it had already ramped up expectations during its first-quarter earnings with a $2 billion increase to both ends of its prior range. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Tirzepatide Continues to Drive Lilly’s Financial Performance: Lilly reported that Mounjaro revenue increased 91% year over year to $9.9 billion, while Zepbound revenue grew 44% to $4.9 billion, bringing combined tirzepatide sales to $14.8 billion. These products represented 64% of Lilly’s second-quarter revenue, underscoring the significant role of its GLP-1 portfolio in the company’s overall business. With patent protection expected to extend for about another decade, tirzepatide remains a key long-term growth driver for Lilly.

2. Lilly Expands Pipeline While Investing in Future Obesity Therapies: Alongside its commercial success, Lilly has completed approximately 12 biotech acquisitions this year to strengthen existing therapeutic areas and expand into new fields such as psychedelics and in vivo cell therapy. The company also highlighted continued investment in its obesity pipeline, including retatrutide and eloralintide, with management describing the latter as the largest R&D investment in Lilly’s history. At the same time, Lilly disclosed the discontinuation of a Phase 2 gene therapy program for Gaucher disease type 1 as part of ongoing portfolio management.

3. Competitive GLP-1 Market Remains Focused on Lilly and Novo Nordisk: Lilly and Novo Nordisk continue to dominate the obesity drug market, while competitors remain several quarters or years away from launching comparable products. Both companies are advancing oral GLP-1 therapies, with Novo maintaining an early lead in that segment while Lilly continues to emphasize its next-generation obesity pipeline. Following their earnings reports, Lilly shares rose nearly 4% in pre-market trading, while Novo Nordisk shares declined nearly 5% after reporting mixed clinical and business updates.

Why supplemental health isn't 'supplemental' anymore

By Diana Steinhoff – For years, employers have been told that if they offer a solid medical plan and a menu of voluntary "extras", such as accident, critical illness, and hospital indemnity, they've done their job. In a high‐deductible world, that playbook is no longer working. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. High deductibles are reshaping what "coverage" means: The article argues that rising deductibles and out-of-pocket maximums have outpaced wage growth, leaving many insured employees unable to comfortably afford care. A cited national survey found that 31% of employees without supplemental products would be willing to pay the full cost themselves, signaling strong unmet demand. This shift suggests that traditional employer medical plans alone are no longer sufficient to ensure practical access to care. As a result, financial protection is becoming a central component of benefits strategy rather than an optional add-on.

2. Modern supplemental designs focus on everyday diagnoses, not rare events: Traditional products were typically tied to narrow triggers such as specific accidents or critical illnesses, which limited their usefulness. Newer models instead align benefits with diagnosis codes and recognize more than 13,000 conditions across varying levels of severity. By matching how care is coded and billed, these plans aim to address the more common medical events that generate significant costs before deductibles are met. This broader scope is intended to increase the likelihood that employees actually receive payments when they need them.

3. Employer-funded models can integrate with high-deductible strategies: The article highlights a large employer that fully funded a diagnosis-based supplemental plan for more than 3,000 employees in high-deductible health plans. After one year, nearly one in three covered employees received a benefit, with over 1,600 claims paid and hundreds of thousands of dollars distributed. The design relied on automatic claims processing tied to medical data, reducing paperwork and speeding payments. Proponents argue that pairing high deductibles with an integrated protection layer can help control premium costs while improving employees’ financial stability.

CVS raises guidance as it posts nearly $3B in profit, $106B in revenue for Q2

By Paige Minemyer – CVS Health is raising its guidance for the year as it blew past Wall Street analysts' expectations in the second quarter. Read Full Article...

HVBA Article Summary

1. Strong Quarter Drives Upgraded Outlook: CVS reported nearly $3 billion in second-quarter profit on $106.1 billion in revenue, exceeding analyst expectations and improving significantly from the same period last year. For the first half of 2026, the company generated $5.9 billion in profit and $206.5 billion in revenue, marking substantial year-over-year growth. On the strength of these results, CVS raised its full-year earnings per share guidance to a range of $7.90 to $8.10, up from its previous projection of $7.30 to $7.50. The updated outlook signals management’s confidence in continued operational momentum.

2. Aetna Performance and Medical Cost Trends: The Aetna insurance unit delivered 3.5% revenue growth in the quarter, reaching $37.5 billion, largely fueled by gains in government plans. Its medical loss ratio improved to 87.4% from 89.9% a year earlier, reflecting better cost performance in its government segment. Total membership stood at 26 million, roughly in line with the prior year’s 26.7 million. However, revenue growth was partially offset by the company’s exit from the Affordable Care Act exchanges.

3. Mixed Results Across Business Segments: CVS’ health services division, which includes pharmacy benefit manager Caremark, posted $51.8 billion in revenue, an 11.5% increase year over year, driven by branded drug inflation and pharmacy mix. At the same time, pricing improvements for clients moderated some of that growth. The pharmacy and consumer wellness segment remained relatively flat at $33.8 billion, with higher prescription volumes and Rite Aid asset contributions counterbalanced by regulated price cuts, new generic launches and reimbursement pressure. These dynamics illustrate varied performance trends across CVS’ diversified portfolio.

Women on GLP-1s and hormone therapy seek better clinical support

By Lee Hafner – Women are using GLP-1 and hormone therapy prescriptions to better manage their health, but when it comes to corresponding clinical support, their needs are going unfilled. Read Full Article...

HVBA Article Summary

1. Gaps in Follow-Up Care for Popular Therapies: A recent study of more than 1,500 women ages 30 to 60 and 520 healthcare providers found that 26% of women surveyed had tried GLP-1s or hormone replacement therapies. Of those women, nearly 37% reported that their post-treatment care felt limited, inconsistent or lacked follow-up altogether. The findings suggest that while access to medications is expanding, structured clinical oversight is not keeping pace. This disconnect may undermine the effectiveness and safety of these treatments.

2. Providers Report Training and Time Constraints: Clinicians acknowledged shortcomings in addressing hormonal and metabolic health, with 58% saying hormonal shifts and 48% citing metabolic changes as inadequately managed. Only 51% said they felt confident prescribing GLP-1s, and just 44% felt fully equipped to connect overlapping hormonal, metabolic and mental health symptoms. Additionally, 38% said they lack sufficient appointment time to address multiple interconnected concerns. These limitations point to systemic barriers affecting comprehensive women’s healthcare delivery.

3. Integrated, Employer-Supported Care Models Are Emerging: More than half of surveyed women said their concerns had been dismissed, and 48% reported losing trust in the healthcare system due to their experiences. In response, Maven introduced self-pay options that provide access to metabolic and hormonal specialists, virtual care across 30 specialties and structured medication management programs. Clinicians surveyed said women most need an integrated model that addresses hormonal, metabolic and mental health together. Employers that facilitate access to such models may help improve workforce health outcomes and reduce broader economic impacts tied to untreated midlife health issues.