The Inflation Thermometer Isn’t Measuring Health Care’s Heat

By Wendell Potter – If you remember American politics from the 1990s, then you remember the famous phrase from Bill Clinton’s political adviser James Carville that when it came to winning voters, “It’s the economy, stupid.” But if you listen to [the] political debate, you’ll hear a different word. Whether it’s President Donald Trump struggling to defend his record or Democrats attacking Trump’s lack of success, the buzzword has become “affordability” – and there’s a very good reason why. Read Full Article...

HVBA Article Summary

1. Limitations of Official Inflation Measures in Capturing Healthcare Costs: The article argues that widely cited economic indicators such as the Consumer Price Index (CPI) may not accurately reflect Americans’ real health care expenses because they primarily measure prices paid by insurers rather than patients’ direct costs. While overall inflation has fallen to roughly 3%, national health care spending has increased at about 7% annually, and rising copays, deductibles, and uncovered services are largely excluded from CPI calculations. Economists cited in the article contend that this methodological gap may help explain why economic data can show improving conditions even as many households continue to report worsening affordability.

2. Rising Household Healthcare Spending and Insurance Costs: Research referenced in the article finds that a typical working U.S. family paid approximately $3,960 in health care costs in 2024, much of it through out-of-pocket expenses, while the highest-spending 10% of families averaged about $14,800 annually. About 13.3% of households spend more than one-tenth of their income on medical expenses, and roughly one-third of Americans under age 65 report struggling to afford care. The article also highlights recent premium increases, including an average 6% rise for employer-sponsored insurance and a 21% increase for Affordable Care Act marketplace plans, contributing to growing financial pressure on families.

3. Effects on Access to Care and Financial Decision-Making: The article reports that rising premiums and deductibles are influencing how Americans use health care and manage household finances. Approximately 36% of adults say they delayed or skipped needed medical treatment due to cost, and more than one in five individuals did not fill prescribed medications because they could not afford them. Many households have switched to lower-premium insurance plans with higher deductibles—averaging $7,476 for Bronze ACA plans compared with $2,912 overall—or dropped coverage entirely, trends linked in the article to increased financial strain and reduced access to care.

Legal uncertainty clouds direct-to-consumer drug program after OIG advisory and Senate scrutiny

By Diana Shaw – A newly released advisory by the U.S. Department of Health and Human Services' Office of Inspector General (HHS OIG) on how direct-to-consumer (DTC) prescription drug programs intersect with the federal Anti-Kickback Statute (AKS) has thrown pharmaceutical manufacturers and market participants into an uncertain legal environment — and prompted scrutiny from U.S. senators over how aggressively oversight should proceed. Read Full Article...

HVBA Article Summary

1. Regulatory Guidance on Direct-to-Consumer Drug Programs and AKS Risk: The article explains that the HHS Office of Inspector General (OIG) issued a Special Advisory Bulletin outlining when manufacturer-led direct-to-consumer (DTC) prescription drug programs may present lower risk under the Anti-Kickback Statute (AKS). The guidance identifies factors such as prescriptions issued by independent third-party clinicians, cash-pay transactions that avoid federal reimbursement claims, transparent pricing not tied to future purchases, and limits on marketing activities as key safeguards intended to expand patient access to medications while maintaining compliance with federal fraud and abuse laws.

2. Congressional Concerns and Ongoing Regulatory Uncertainty: Despite the OIG’s effort to clarify compliance expectations, the article highlights continued uncertainty surrounding platforms like TrumpRX, particularly regarding the independence of telehealth prescribers and affiliated vendors. A Senate inquiry raised questions about potential prescription steering, conflicts of interest, and whether existing oversight sufficiently addresses emerging telehealth-enabled distribution models, illustrating broader policy tension between encouraging innovation and protecting federal health care program integrity.

3. Legal and Compliance Risks for Companies Participating in DTC Models: The article emphasizes that pharmaceutical manufacturers and platform operators involved in DTC prescription drug programs face substantial legal exposure if financial arrangements are found to improperly influence clinical decision-making or violate federal fraud and abuse statutes. Potential consequences include criminal liability, civil monetary penalties, False Claims Act exposure, exclusion from Medicare and Medicaid participation, and reputational harm, prompting companies to adopt comprehensive compliance programs, conduct risk assessments, and engage proactively with regulators.

Novo Nordisk to significantly reduce U.S. list price for GLP-1s beginning in 2027

By Michael Popke – Beginning Jan. 1, 2027, Novo Nordisk will lower the list price of Wegovy, Ozempic, and Rybelsus. The drug company's Feb. 24 announcement seeks to address access barriers, especially for patients whose out-of-pocket costs are linked to list price — including individuals with high-deductible health plans or co-insurance benefit designs. The price drop builds on concerted efforts by Novo Nordisk to improve patient access, particularly to weight-loss drugs Wegovy and Ozempic, according to company officials. Rybelsus, another GLP-1, is used to reduce the risk of major cardiovascular events such as heart attack, stroke, or death in adults with type 2 diabetes. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. List Price Reductions for Semaglutide Medications: The article reports that Novo Nordisk will lower the list price of several semaglutide-based treatments — including Wegovy injections (2.4 mg), Ozempic injections (0.5 mg, 1 mg, and 2 mg), and Rybelsus tablets (7 mg and 14 mg) — to $675 per month. The adjustment represents approximate price reductions of 50% for Wegovy and 35% for Ozempic compared with previous list prices, affecting commonly prescribed medications used to treat obesity and type 2 diabetes.

2. Expansion of Access Amid High Disease Prevalence: Novo Nordisk states that the price reductions are intended to improve treatment access in response to significant national health needs, noting that more than 100 million people in the United States live with obesity and over 35 million people have type 2 diabetes. Company leadership indicated that insurers, public payers, and patients have increasingly called for lower list prices as demand for GLP-1 medications continues to grow.

3. Limited Immediate Impact on Self-Pay Patients and Emphasis on Drug Indications: The article notes that the revised list prices will not affect direct-to-patient self-pay pricing, meaning some patients paying out of pocket may not experience cost changes. Novo Nordisk also highlights that semaglutide — the active ingredient in Wegovy and Ozempic — differs from other GLP-1 medications due to its multiple FDA-approved uses, including treatment for obesity, type 2 diabetes, chronic kidney disease, and cardiovascular disease risk reduction.

'Think of your hospital as a startup': Mark Cuban's plan to fix inpatient care

By Alan Goforth – Give celebrity entrepreneur Mark Cuban credit for thinking outside the box. He founded Cost Plus Drugs with a goal of lowering generic drug prices by eliminating pharmacy benefit managers and using a cost-plus pricing strategy. He believes he also could bring greater efficiency, transparency and outcomes to owning a hospital. "You've got to be able to get down like any other startup," he said during a recent interview on the Healthcare Bridge podcast. "You've got to think of your hospital as a startup and your first doctors as your first employees or your partners." Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Startup-Style Hospital Operations Focused on Efficiency and Fixed Margins: The article explains that Mark Cuban would manage a hospital similarly to a lean startup by prioritizing essential medical staff and technology while minimizing administrative layers and expensive infrastructure. Referencing his Cost Plus Drugs model, which operates on a fixed 15% margin, Cuban suggests hospitals could employ fewer workers but compensate physicians and staff at higher levels, eliminating nonessential ancillary services to reduce operating costs while maintaining organizational trust and efficiency.

2. Healthcare Pricing Transparency as a Competitive Advantage: Cuban proposes that hospitals could differentiate themselves by publicly disclosing detailed financial information, including physician compensation, operational overhead costs “down to the penny,” and Medicare reimbursement rates, then charging patients equivalent prices. In an industry where healthcare costs are often difficult to determine in advance, he argues that transparent pricing structures could strengthen patient trust, simplify billing expectations, and support long-term growth through clearer cost accountability.

3. Leadership Incentives and AI Automation to Improve Hospital Efficiency: The article highlights Cuban’s view that hospital expansion is frequently driven by executive compensation tied to revenue and scale, encouraging growth from facilities such as a single 100-bed hospital into large multi-hospital systems with thousands of beds rather than improving operational performance. He also emphasizes the potential role of artificial intelligence, citing a 250-bed private hospital with roughly 3,000 contracts that entered bankruptcy, where AI agents could automate contract verification and financial processes that would otherwise require large administrative teams, improving efficiency and profitability across healthcare organizations.

CBO estimates Medicare Trust Fund will run out in 2040

By Paige Minemyer – The Congressional Budget Office (CBO) has updated its estimates around the Medicare Trust Fund and now expects the fund to run dry in 2040. The CBO said in a blog post Monday that the trust fund's balance is set to grow each year through 2031, but, after that, spending will begin to overtake revenue until it eventually runs out in 2040. This marks a significant change from the organization's 2025 estimates, cutting 12 years off of the lifespan of the fund compared to previous projections. Read Full Article...

HVBA Article Summary

1. Medicare Part A Trust Fund Financing Structure: The article explains that the Medicare Trust Fund supports benefits under Medicare Part A, including inpatient hospital care, skilled nursing services, home health, and hospice care. The fund is financed through multiple revenue sources, with approximately three-quarters of projected income over the next 30 years expected to come from Medicare payroll taxes, supplemented by income taxes on Social Security benefits and other smaller funding streams that collectively sustain program operations.

2. Revenue Pressures from Policy Changes and Economic Projections: The article notes that recent legislative changes under H.R. 1, including reduced tax rates and a new tax deduction for individuals aged 65 and older, are projected to decrease revenue flowing into the trust fund by reducing Social Security–related tax income. In addition, Congressional Budget Office (CBO) projections of lower future earnings are expected to reduce payroll tax collections, further weakening long-term funding expectations for Medicare Part A.

3. Rising Medicare Spending and Accelerated Trust Fund Depletion: The article highlights that updated CBO projections show faster growth in medical costs across both traditional Medicare and Medicare Advantage plans, contributing to higher per-enrollee spending. These revised estimates are based on recent fee-for-service spending data and higher-than-anticipated Medicare Advantage plan bids for upcoming plan years, indicating that increased expenditures—combined with reduced income—are expected to accelerate the drawdown of the Medicare Trust Fund.

Worker did not plausibly argue obesity was a disability, 1st Circuit finds

By Emilie Shumway – Whittemore v. Cigna was first filed in a Maine district court in June 2024. The plaintiff was enrolled in a Cigna-administered health plan through her employment with the University of Maine system. She sued under the Affordable Care Act’s Section 1557, which protects individuals with disabilities from discrimination in the design and administration of their health coverage. As the 1st Circuit noted, Section 1557 borrows from Section 504 of the Rehabilitation Act and the definition of “disability” from the Americans with Disabilities Act — a “physical or mental impairment that substantially limits one or more major life activities.” Read Full Article...

HVBA Article Summary

1. Courts Require Detailed Evidence to Establish Obesity as a Disability: The 1st U.S. Circuit Court of Appeals determined that simply stating obesity affects major life activities is not enough to qualify as a disability under the ADA. The plaintiff’s allegations were considered conclusory because they lacked individualized factual support demonstrating how her obesity substantially limited her daily functioning. This decision emphasizes that courts may expect plaintiffs to provide concrete, case-specific evidence rather than relying on general descriptions of obesity’s potential health impacts.

2. Continued Judicial Skepticism Toward Obesity-Based Disability and Discrimination Claims: The ruling reflects a broader hesitation among courts to treat obesity as a presumptive disability. Legal analysis indicates that courts may also be reluctant to accept arguments that exclusions for weight-loss treatments function as indirect discrimination based on obesity. Together, these developments suggest that employers and insurers may face fewer legal challenges unless plaintiffs can clearly link obesity to recognized disability protections under existing law.

3. Growing Momentum Toward Coverage of GLP-1 Weight-Loss Medications: As GLP-1 medications become more widely used for weight loss, employers and insurers are increasingly evaluating whether to include coverage in health plans. Industry expectations suggest that insurance coverage for these medications may soon become more common or unavoidable. At the same time, emerging research indicates that sustained GLP-1 use could reduce long-term employer healthcare costs by improving health outcomes and lowering expenses associated with chronic conditions.

Study Finds Nearly Half of All Telehealth Visits for Non-Mental Health Conditions

By Matt MacKenzie – A new study published in Annals of Internal Medicine found that nearly half of telehealth visits are for non-mental health conditions. The researchers “examined healthcare visit data from a nationally representative sample of nearly 15,000 Medicare users during 2021 to 2023 to learn how telehealth is being used nationwide. Nearly half of mental health appointments were performed remotely, amounting to 31 million annual visits. But there were almost as many telehealth appointments for non-mental health conditions: 29 million annually.” Read Full Article...

HVBA Article Summary

1. Significant Use of Telehealth for Non-Mental Health Conditions: The study reveals that telehealth is not limited to mental health services; nearly half of telehealth visits are for non-mental health issues. These visits primarily address common chronic conditions such as diabetes and high blood pressure, indicating a broad application of telehealth across various medical needs. This highlights telehealth's growing role in managing chronic diseases remotely.

2. Telehealth Users Tend to Have Greater Medical Vulnerability: Individuals using telehealth services for non-mental health conditions are more likely to have limitations in daily activities like bathing and dressing. They also report poorer overall health compared to others, suggesting that telehealth is particularly valuable for patients with significant health challenges who may find in-person visits difficult. This underscores telehealth's potential to improve access to care for vulnerable populations.

3. Implications for Healthcare Delivery and Policy: Understanding who uses telehealth and for what reasons can help healthcare systems optimize care delivery models. The data can guide decisions on how telehealth services are provided and reimbursed, potentially leading to more consistent and predictable care experiences for patients. This insight is crucial for shaping future healthcare policies and ensuring telehealth's effective integration into routine care.