Trump and Vance stall congressional spending deal, leaving healthcare provisions in jeopardy

By Noah Tong and Emma Beavins - President-elect Trump and Vice President-elect JD Vance have weighed in on the continuing resolution–and it's not pretty for Mike Johnson. Given the afternoon's disarray, sources say Congress will not vote on a continuing resolution to fund the government tonight. Funding runs out Dec. 20. Read Full Article… 

HVBA Article Summary

1. Spending Bill Controversy: The proposed spending bill has sparked strong opposition, with figures like Elon Musk and Vivek Ramaswamy criticizing its size and rushed nature. Their stance reflects growing tensions over government efficiency and fiscal responsibility, influencing Republican leadership's approach to legislative priorities.

2. Healthcare Provisions at Risk: The bill includes critical healthcare measures, such as extending Medicare telehealth flexibilities and addressing pharmacy reimbursement inequities. However, Republican concerns over broader spending could jeopardize bipartisan support, threatening these hard-fought healthcare initiatives.

3. Legislative Gridlock: Amid internal GOP divisions and Democratic frustration over broken agreements, Speaker Mike Johnson faces challenges in rallying sufficient support. The potential exclusion of disaster aid and other provisions underscores the fragility of the legislative process, with significant implications for healthcare and broader government funding.

New 'must pass' House package includes employer plan PBM section

By Allison Bell - House leaders have put 97 pages of requirements for employers' pharmacy benefit managers in a critical new legislative package. Members of Congress drafted the 1,547-page "Further Continuing Appropriations and Disaster Relief Supplemental Appropriations Act, 2025" to keep the federal government from shutting down.  Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Reforming PBM Practices for Employer Plans: The proposed provisions mandate that PBMs serving large employer health plans pass 100% of prescription drug rebates or discounts to the employer plan sponsor, increasing transparency and accountability. The rules also impose detailed reporting requirements for PBMs, including disclosures on drug pricing, discounts, and out-of-pocket costs, with penalties of up to $100,000 for false reporting.

2. Stakeholder Reactions to PBM Reforms: The American Pharmacists Association praised the reforms, emphasizing the need to restore essential healthcare services affected by PBM practices. However, the Pharmaceutical Care Management Association criticized the measures, arguing they would raise costs for employers and patients while benefiting pharmaceutical companies, and described them as an unwarranted intrusion into private market contracts.

3. Broader Implications and Legislative Uncertainty: The PBM provisions are part of a larger appropriations package aimed at advancing multiple bills, including disaster relief funding. While the provisions enjoy bipartisan support, their fate remains uncertain due to objections from President-elect Donald Trump, potentially delaying or reshaping the legislative package amidst ongoing government shutdown negotiations.

Congress' healthcare package: Key wins for hospitals, telehealth and physician pay

By Alan Condon - Lawmakers have unveiled a sweeping government funding deal containing a significant healthcare package that would extend Medicare telehealth flexibilities, increase physician reimbursement rates and implement new regulations targeting pharmacy benefit managers, among other provisions. Read Full Article… 

HVBA Article Summary

1. Key Legislative Highlights in Healthcare: Congress's continuing resolution package includes crucial healthcare provisions such as extending telehealth flexibilities through 2026, delaying Medicaid disproportionate hospital share payment cuts until 2027, and temporarily increasing Medicare physician fees to offset scheduled cuts. These measures aim to safeguard access to essential healthcare services, particularly for rural and vulnerable populations.

2. Reactions from Healthcare Organizations: National hospital groups and medical associations have largely praised the bipartisan healthcare package. Leaders from the American Hospital Association and Federation of American Hospitals emphasize its role in protecting critical programs like telehealth and hospital-at-home care while addressing significant funding challenges faced by hospitals serving high-risk communities.

3. Areas of Concern and Omission: Despite broad support, healthcare leaders have voiced concerns about specific provisions, such as the costly requirement for unique billing identifiers in hospital outpatient departments. Additionally, the failure to include reforms addressing Medicare Advantage prior authorization has drawn criticism, with some groups highlighting it as a missed opportunity to alleviate growing administrative burdens on providers and improve patient access to timely care.

A New Weight Loss Drug With No Side Effects? Yes…So Far

By Christina Szalinski - For people with obesity or type 2 diabetes, glucagon-like peptide 1 (GLP-1) agonists (including Mounjaro, Wegovy, and Ozempic) have been labeled miracle drugs. But they aren’t miraculous for everyone. Research indicates a significant portion of people discontinue using them within a year. Read Full Article…

HVBA Article Summary

1. Challenges of GLP-1 Agonists: While effective for weight loss and diabetes management, GLP-1 agonists are expensive and frequently cause side effects like nausea, vomiting, and muscle loss. Up to 50% of weight lost in animal models comes from lean mass, posing significant drawbacks for long-term health.

2. NK2R Agonists as a Promising Alternative: A new study highlights NK2R-targeted drugs as potential alternatives, offering weight loss benefits without muscle loss or adverse effects like nausea. These drugs appear to reduce appetite and enhance energy expenditure through thermogenesis in muscle, a unique mechanism that sets them apart from GLP-1 agonists.

3. Future Potential and Accessibility: NK2R agonists, being small molecules, promise to be cheaper to produce than peptide-based GLP-1 agonists. With human trials expected within a year and market availability projected in 6–7 years, these drugs could expand access to effective weight loss treatments, especially for people with diabetes and obesity.

Changing broker mindset would remove huge obstacle to healthcare fix

By Dave Chase - Changing the mindset of benefit brokers who are accustomed to all the misaligned incentives of U.S. healthcare is by far the biggest obstacle to fixing a perverse and opaque system that places profits ahead of patients. They measure their book of business in dollars or covered lives. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. The Shift Toward Transparency and Value in Health Benefits: Market dynamics and regulatory requirements, such as the Consolidated Appropriations Act of 2021, demand greater transparency in pricing and compensation for health and welfare benefits. Advisers must now prove their value through expertise, vendor knowledge, and measurable outcomes. This shift challenges traditional practices and incentivizes advisers to adopt innovative, client-centered strategies.

2. A Case Study in Transformation: Bryce Heinbaugh: Bryce Heinbaugh’s journey illustrates the potential for success when breaking away from conventional health plan management. By transitioning clients to high-performance plans, Bryce achieved substantial growth, expanding from a single employer with 38 employees to over 10,000 covered lives. His efforts also contributed to meaningful community impact, such as saving local school programs through healthcare cost reductions.

3. Empowering Advisers Through Industry Standards and Innovation: Organizations like the Nautilus Health Institute aim to redefine industry norms by providing resources and establishing gold standards for health plan procurement, contracting, and data management. These tools enable advisers to align their strategies with client and community interests, fostering ethical and effective approaches to benefit management.

Mark Cuban Says, 'I Don't Know Cars Or Rockets,' But Schools Elon Musk On How American Health Insurance Works

By Adrian Volenik - When Elon Musk took to X to question why Americans aren't “getting their money's worth” despite the United States leading the world in health care administrative costs, Mark Cuban stepped in with some tough truths. Read Full Article…

HVBA Article Summary

1. Reforming PBM Contracts for Cost Transparency: Mark Cuban emphasized that the opaque and restrictive nature of PBM agreements is a major driver of high health care costs and inefficiencies. He outlined issues like lack of access to claims data, restricted formularies, and unjustified drug markups, urging CEOs to adopt more transparent "pass-through" PBMs to control costs and improve care.

2. Empowering CEOs to Take Charge: Cuban encouraged leaders like Elon Musk to directly engage with health care providers and renegotiate contracts with transparency-focused solutions. He highlighted the importance of educating self-insured companies on prioritizing employee well-being through better contract practices and avoiding legal risks associated with neglecting these systemic issues.

3. Call to Action for Industry Leaders: With a sharp warning about impending legal challenges for companies ignoring these health care inefficiencies, Cuban urged CEOs to take immediate action. By leveraging their decision-making power, they can transform the system, ensuring more affordable and higher-quality health care for their employees and families.

Ex-Aetna CEO calls for end to employer-based health coverage

By Alan Goforth - Eliminating employer-sponsored health insurance would help defuse frustration over the U.S. health care system, the former CEO of Aetna said. “Probably the most important thing is that health care has now become very individualistic: ‘I want it to be fit for me,’” Mark Bertolini, now the CEO of Oscar Health, told CNBC “And when my employer buys my health care coverage, they buy for the average.” Read Full Article…

HVBA Article Summary

1. Expanding in the Individual Coverage HRA Market: Oscar Health is strategically targeting the Individual Coverage Health Reimbursement Arrangement (ICHRA) market, aiming to serve individuals not covered by employer-sponsored insurance, which currently insures over 160 million Americans. By offering customizable individual plans, Oscar seeks to compete against larger insurance firms and meet diverse consumer needs.

2. Challenges in Employer-Sponsored Insurance: Rising insurance premiums, which have increased 50% for single coverage from 2010 to 2022, and diminished bargaining power for small- and mid-sized employers have exacerbated frustrations with the U.S. healthcare system. Bertolini advocates for shifting from traditional group plans to individual plans tailored to employees' health profiles to provide cost-effective and personalized coverage.

3. Oscar’s Position and Challenges: Despite partnering with Cigna in 2020 to penetrate the group insurance market, Oscar Health has faced financial losses and operational struggles. However, its pivot to focus on the ICHRA market aligns with the Republican preference for consumer choice and market-driven solutions, positioning the company for long-term growth in a competitive landscape.

Optum AI chatbot was left publicly accessible

By Naomi Diaz - An internal AI chatbot developed for Optum employees was inadvertently left publicly accessible online, allowing unrestricted access via a web browser, TechCrunch reported Dec. 13. Read Full Article…

HVBA Article Summary

1. Purpose and Functionality: The Optum SOP Chatbot was designed as a demo tool to assist employees in navigating standard operating procedures, particularly regarding patient health insurance claims and disputes. It leveraged Optum's internal documentation to answer questions but was not used in real-world scenarios or trained with protected health information (PHI).

2. Security and Accessibility: While hosted on an internal Optum domain and requiring employee login to access internal documents, the chatbot's IP address was publicly exposed, allowing unrestricted internet access without password protection. This raised potential security concerns despite the limited scope of its usage.

3. Optum’s Clarification: Optum emphasized that the chatbot was a proof-of-concept demo, never scaled for production, and was only tested with a small subset of SOP documents. The tool served to enhance access to existing resources without making autonomous decisions, and its public accessibility period remains unclear.

Johnson & Johnson sues Cigna units for alleging draining funds intended for copays: report

By Naomi Diaz - Johnson & Johnson (NYSE:JNJ) has sued two units of health insurer Cigna (NYSE:CI), alleging that they worked with a drug-benefit middleman to drain the pharmaceutical giant’s financial-assistance funds set aside for patients who take some of its more costly drugs, The Wall Street Journal reported Friday. Read Full Article…

HVBA Article Summary

1. Expanded Lawsuit Against Express Scripts and Accredo: Johnson & Johnson (J&J) has amended its ongoing lawsuit, initially filed under seal, to include Cigna’s Express Scripts and Accredo as defendants. J&J alleges that these entities collaborated with SaveOnSP, a drug middleman, in a program that forced J&J to incur over $100 million in additional drug copay assistance costs.

2. Allegations of Exploitation and Misappropriation: J&J claims that Express Scripts markets SaveOnSP’s services to its customers while sharing fees collected by SaveOnSP. Meanwhile, Accredo is accused of serving as the exclusive pharmacy for most patients in SaveOnSP's program. J&J contends that this arrangement diverts patient assistance funds away from patients and toward vertically integrated companies, harming patients’ access to necessary medications.

3. Diverging Perspectives on Copay Assistance Programs: J&J maintains that programs like SaveOnSP exploit patient assistance funds for profit, undermining the purpose of such support. In contrast, SaveOnSP and its partners argue that their approach helps make specialty drugs more accessible and affordable for patients, disputing J&J’s claims and framing the issue as a disagreement over the use of patient assistance dollars for high-cost medications.