Physicians slam Congress for failure to offset Medicare pay cuts

By Alan Condon - Congress has signed a pared-down funding bill to prevent a government shutdown but failed to pass measures in a previously proposed bipartisan package that would have offset the 2.83% Medicare pay cut physicians face in 2025. Read Full Article… 

HVBA Article Summary

1. Relief and Criticism Over Medicare Adjustments: The MGMA welcomed temporary extensions for telehealth flexibilities and the 1.0 work GPCI floor but strongly criticized Congress for failing to prevent a 2.83% cut in Medicare physician reimbursement rates starting January 1. These financial challenges, according to MGMA and AMA, jeopardize the viability of Medicare practices and their associated commercial and Medicaid contracts.

2. Long-Term Medicare Reimbursement Issues: Physicians' Medicare payment rates have decreased by 33% over the past two decades without adjustments for inflation or rising care costs, exacerbating financial pressures. The AMA emphasized that these cuts, alongside Congress's inaction on reforms, could lead to reduced access to care, closures of private practices, and an exodus of physicians from the profession.

3. Calls for Reform and Missed Opportunities: Both MGMA and AMA urged Congress to retroactively address the reimbursement cuts and implement lasting Medicare payment reforms. The AMA particularly criticized lawmakers for failing to pass bipartisan prior authorization reforms, calling it a missed opportunity to enhance patient care and reduce unnecessary insurance delays in treatment.

President signs anti-shutdown package, with no PBM provisions

By Allison Bell - The anti-shutdown package President Joe Biden signed into law Saturday left out the provisions related to pharmacy benefit managers, and Sen. Ron Wyden says Elon Musk, an advisor to President Donald Trump who's on track to lead a new Department of Government Efficiency, pushed the PBM provisions out of the package. Read Full Article… 

HVBA Article Summary

1. Key Provisions and Legislative Outcome: The American Relief Act, 2025, authorizes government operations to continue until March 14 and retains select Medicare and Medicaid provisions. It passed the House with a 366-34 vote and the Senate with an 85-11 vote, reflecting broad bipartisan support despite some contentious exclusions.

2. Controversial Exclusions and Political Maneuvering: Provisions aimed at regulating Pharmacy Benefit Managers (PBMs)—such as requiring them to pass negotiated rebates to employer-sponsored plans—were removed after interventions by former President Trump and Elon Musk. This move drew criticism, with Senator Wyden accusing them of prioritizing political agendas over reducing drug costs for taxpayers and seniors.

3. Future Prospects for PBM Regulation: Despite being excluded from the ARA, 2025, PBM reforms retain bipartisan support and could reemerge in standalone legislation or future must-pass bills. However, lawmakers like Rep. Tom Cole advocate for narrower, more focused legislation to improve public trust and legislative transparency.

CMS Dodges the Real Issues in its IRA FAQs

By William Sarraille - The Centers for Medicare and Medicaid Services released its inflation Reduction Act document entitled Medicare Drug Price Negotiation Program: “Frequently Asked Questions”. Read Full Article… 

HVBA Article Summary

1. Critical Gaps in the Implementation Plan: The FAQs reveal significant uncertainty about how pharmacies will receive accurate and timely payments under the Medicare negotiated price system set to launch on January 1, 2026. Without a robust mechanism in place, pharmacies risk financial strain if forced to purchase drugs at list prices while being reimbursed at discounted rates. This lack of clarity could lead to pharmacies choosing not to stock negotiated-price drugs, causing a domino effect of reduced patient access, loss of market share for manufacturers, and failure to achieve the cost-saving objectives of the IRA.

2. Unanswered Key Questions: The FAQs sidestep critical questions, such as how quickly the Medicare Transaction Facilitator will process payment data and resolve issues like 340B duplicates. Despite vague assurances, there is no timeline or actionable framework to address these challenges, leaving pharmacies and manufacturers in the dark. The proposed "complaint mechanism" offers little solace, as it hints at lengthy delays in resolving disputes, further exacerbating concerns about the program's viability.

3. Rising Support for a Manufacturer Rebate Model: The absence of concrete answers and operational readiness strengthens the argument for a manufacturer rebate model as an alternative. Stakeholders view the current plan as ill-prepared, with CMS implicitly signaling that manufacturers must compensate for its shortcomings. This lack of coordination and foresight fuels skepticism about the program’s success, amplifying calls for a more streamlined and accountable approach to ensure timely and equitable reimbursements.

This independent assessment can save employers billions on healthcare

By Joe LaMantia III and Donovan Pyle - As rising costs ignite frustration across the nation, a little-known aspect of our employee benefits purchasing system offers an opportunity to save billions on health care. This solution doesn't require Congressional intervention; instead, it invites us to reexamine existing frameworks to reduce expenses and improve access for millions of Americans.  Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Reevaluate the Role of Benefits Brokers: The traditional model of relying on benefits brokers, who are often financially incentivized by insurance providers, creates a conflict of interest that contributes to rising healthcare costs. Employers should critically assess their brokers' compensation structures and consider the implications for their healthcare purchasing decisions.

2. Explore Fee-Based Benefits Firms: Fee-based benefits firms provide unbiased advice by avoiding commissions or bonuses from insurers. Engaging these independent experts can help employers identify inefficiencies, optimize healthcare spending, and save a significant portion of the estimated 25% of healthcare costs currently wasted.

3. Prioritize Transparency and Legal Compliance: Under the Consolidated Appropriations Act of 2021, brokers are required to disclose all forms of compensation, empowering employers to identify potential conflicts of interest. Employers should leverage this transparency to meet their fiduciary responsibilities, ensuring ethical and financially sound benefits decisions.

Deloitte: Healthcare executives take a favorable outlook on 2025

By Paige Minemyer - Despite significant headwinds coming to bear over the past several years, healthcare executives are expecting a favorable 2025, according to a new survey from Deloitte. Read Full Article…

HVBA Article Summary

1. Positive Outlook and Revenue Growth: Nearly 60% of healthcare executives surveyed by Deloitte expressed a favorable outlook for the coming year, up from 52% last year. Additionally, 69% anticipate revenue growth in 2025, while 71% expect increased profitability, driven by growth strategies and a focus on consumer affordability.

2. Key Focus Areas for 2025: Growth strategies and managing affordability emerged as top priorities, with 65% of executives prioritizing growth and 46% focused on affordability. Within these themes, cybersecurity (55%), consumer experience improvements (53%), and investments in tech platforms (36%) are highlighted as essential components.

3. Sector-Specific Challenges and Opportunities: Health system leaders are preparing for workforce challenges and core technology enhancements, while insurance executives foresee regulatory changes and transformative technologies, such as generative AI, shaping their strategies. Both sectors are also emphasizing health equity as a long-term priority to drive broader industry and economic gains.

Physicians embrace cash-based payment models

By Erica Carbajal - Amid shrinking reimbursement rates and growing frustrations with administrative burdens, more physicians are turning to cash-only or direct primary care models. Read Full Article… 

HVBA Article Summary

1. Growth of Cash-Based Models: Cash-based medical models are gaining traction as they offer a predictable and potentially lucrative revenue stream for physicians. These models, where patients pay an annual or monthly fee for a defined set of services, differ from concierge medicine, which combines membership fees with insurance billing.

2. Driving Factors: Physician interest in cash-based models is driven by rising medical school debt, extensive administrative burdens, and declining reimbursement rates. For patients, the appeal lies in direct access to care, shorter wait times, and transparent pricing.

3. Equity Concerns: While cash-based models provide convenience and price clarity for some patients, they raise concerns about affordability and accessibility, potentially widening disparities for those unable to bear out-of-pocket costs.

FDA Approves Second Generic Daily GLP-1 Drug for T2D

By Miriam E. Tucker - The US Food and Drug Administration has approved a generic once-daily injectable version of the glucagon-like peptide-1 receptor agonist (GLP-1 RA) liraglutide (Victoza, Novo Nordisk) to lower blood sugar in people aged 10 years or older with type 2 diabetes (T2D), as an adjunct to diet and exercise. Read Full Article… 

HVBA Article Summary

1. FDA's Commitment to Access: The approval of a generic version of exenatide by the FDA highlights its efforts to address shortages of GLP-1 medications and improve patient access. This initiative is part of the FDA's broader strategy to prioritize the development and approval of complex generic drugs to ensure affordability and availability.

2. Key Developments in GLP-1 Medications: Liraglutide, initially approved in 2010 for type 2 diabetes (T2D) treatment, has paved the way for other GLP-1 receptor agonist-based drugs addressing T2D, obesity, and related conditions. The FDA's approval of generics like liraglutide injection underscores ongoing advancements in this category, enhancing treatment options.

3. FDA's Drug Competition Action Plan: The recent generic approval aligns with the FDA’s Drug Competition Action Plan, launched in 2017 to promote generic competition for complex drug products. By granting approval to Hikma Pharmaceuticals USA Inc., the FDA reinforces its mission to provide safe, effective, and high-quality generics, addressing both cost and accessibility challenges for patients.

Investing in telehealth: A win-win for employees and their families

By Kristen Donahoe - Concerns about technology's adverse effects on children's mental health are well-founded—especially regarding social media and screen addiction. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. The Impact of Social Media and Screen Time on Teens: Social media and excessive screen time are significantly impacting teens' mental health. Studies reveal that high social media usage correlates with poor mental health, including increased rates of depression, anxiety, sleep disorders, and even physical conditions like obesity. The U.S. Surgeon General has highlighted these issues, calling for cautionary measures, such as warning labels on social media platforms.

2. The Promise of Telehealth for Mental Health Solutions: Despite the challenges posed by technology, telehealth services are emerging as a powerful tool for addressing mental health issues among youth. Virtual therapy improves access to care, especially in underserved areas, reduces logistical barriers for families, and has proven as effective as in-person therapy for conditions like anxiety, ADHD, and depression. Smartphones, often associated with overuse, are also instrumental in delivering these telehealth services, making care more accessible and convenient.

3. Opportunities for Employers to Support Mental Health: Employers, particularly HR leaders, can play a pivotal role in addressing youth mental health challenges by offering comprehensive telehealth benefits. These programs not only provide critical resources for employees' children but also support employees themselves, fostering a healthier and more engaged workforce. By investing in technology-driven mental health solutions, organizations can help mitigate the harms of digital overuse while promoting healing and resilience in the workplace and beyond.