Physician Groups, Lawmakers, Urge Trump Administration to Investigate Anthem Over New Hospital Payment Policy

By Wendell Potter – HEALTHCARE un-covered has learned that a bipartisan group of physicians in Congress is asking the Trump administration to investigate Anthem Blue Cross to determine the legality of a controversial new policy they contend could put patients and the hospitals that treat them in financial peril. As we first reported in November, Anthem, which is part of the for-profit conglomerate Elevance Health Inc., notified hospitals across the country that it will automatically deduct 10% of payments to the hospitals every time a doctor who is not in Anthem’s network treats a patient enrolled in one of the company’s health plans. Read Full Article...

HVBA Article Summary

1. Anthem’s New Policy Targets Out-of-Network Physician Use at In-Network Hospitals: On January 1, Anthem began enforcing a controversial “facility administrative policy” in 11 of the 14 states where it operates. Under this policy, hospitals risk being removed from Anthem’s network if they permit out-of-network physicians to treat patients, even within in-network facilities. This policy potentially affects a significant portion of Anthem’s 45 million health plan enrollees. Anthem claims the change is aimed at closing "costly loopholes" in the No Surprises Act, asserting that some physicians are exploiting the system to gain excessive payments during disputes with insurers.

2. Strong Pushback from Over 80 Medical Organizations and Congressional Physicians: The policy has drawn unified opposition from major medical organizations, including the American Medical Association, the American Hospital Association, and 86 other state and specialty societies. These groups argue that expecting perfect alignment between hospitals and the average 20.2 health plan contracts that physicians maintain is “unrealistic,” particularly for small practices, which still average 13.5 contracts. Critics warn that this policy could destabilize care for critical specialties like surgery, obstetrics, cardiology, oncology, and radiology, and that it puts financial strain on independent practices already under pressure.

3. Concerns Over Patient Access, Physician Autonomy, and Financial Motivation: Lawmakers and medical groups argue the policy could limit access to emergency and specialty care, increase wait times, and weaken patient-provider continuity. They warn it may further pressure independent physicians to become hospital employees, accelerating the decline of physician-owned practices. Critics also question whether the move is financially driven, noting Elevance’s $6 billion in profits in 2024 and a recent 18% drop in share price. The policy will be scrutinized in a January 22 congressional hearing alongside other major insurers.

House passes ACA tax credit extension, with support from 17 Republicans

By Paige Minemyer – The House of Representatives passed a bill that would extend the enhanced Affordable Care Act tax credits for three years, with 17 Republicans breaking with party leadership to support the measure. The bill passed by a 230 to 196 margin, and will now make its way to the Senate, where it faces an uphill battle. Read Full Article...

HVBA Article Summary

1. Expiration of Enhanced ACA Subsidies and Legislative Proposals: The enhanced premium tax credits available through the Affordable Care Act (ACA) officially expired on January 1 after Congress was unable to reach a consensus. Democrats advocated for a "clean" extension to maintain the credits for a few more years while working toward long-term solutions to high premium costs. Republicans generally supported allowing the credits to lapse, favoring alternative measures such as expanded use of health savings accounts. A bipartisan group of senators is now developing a proposal to bring back the subsidies for two years, incorporating reforms like income caps and minimum premium payments to control overall costs.

2. Legislative Activity in Both Chambers of Congress: Efforts to resolve the issue are underway in both the Senate and the House. In the Senate, bipartisan negotiations are focused on crafting a compromise bill that would revive the subsidies while introducing cost-sharing reduction payments and expanded access to health savings accounts. Meanwhile, House Democrats are pushing a discharge motion to force a vote on a three-year extension of the subsidies. Notably, several moderate Republicans are supporting this effort, signaling a rare moment of cross-party alignment, although any legislation would still face significant hurdles in the Senate.

3. Presidential Involvement and Industry Engagement: President Donald Trump has entered the discussion by signaling a willingness to negotiate directly with major health insurers to bring down premium costs. He has also urged Republican lawmakers to be more flexible on issues such as the Hyde Amendment, which restricts federal funding for abortion services—an issue that has previously stalled healthcare negotiations. Trump announced plans to meet with leaders from 14 insurance companies, expressing confidence that he can convince them to significantly reduce plan prices, potentially by 50% or more, through direct talks modeled after his recent efforts with pharmaceutical companies.

2026 Will Bring Progress on Simplifying Prior Authorization

By AHIP – Prior authorization is an important safeguard used by both public and private payers to help ensure patients receive care that is safe, evidence-based and as affordable as possible – ultimately ensuring that every health care dollar is spent wisely. This safeguard helps hold down out-of-pocket costs for patients and premiums for everyone. Read Full Article...

HVBA Article Summary

1. Health Plans Commit to Streamlining Prior Authorization Processes: In an effort to address longstanding frustrations with fragmented and outdated prior authorization practices, major health plans—including those representing nearly 270 million Americans—have joined AHIP, BCBSA, HHS, and CMS in making voluntary multi-year commitments. These initiatives aim to simplify and modernize prior authorization procedures across Commercial, Medicare Advantage, and Medicaid managed care programs, with the overarching goal of improving access to care and reducing systemic inefficiencies.

2. Initial 2026 Measures Focus on Immediate Improvements: Beginning January 1, 2026, health plans started implementing initial commitments that include reducing the number of services subject to prior authorization, based on local market needs. Additionally, plans now offer a 90-day transition period to honor existing prior authorizations when patients switch insurance carriers, helping to maintain continuity of care. Plans are also enhancing transparency by providing clearer, more understandable authorization determinations, including appeal support. Furthermore, all clinical denials will continue to be reviewed by qualified medical professionals, reaffirming existing standards.

3. Long-Term 2027 Goals Target Technology Modernization: Looking ahead, the initiative includes two significant technological goals for 2027. First, at least 80% of electronic prior authorization requests—when submitted with complete clinical documentation—will receive real-time responses. Second, health plans are working to standardize electronic submission processes by adopting FHIR® APIs to streamline data and reduce turnaround times. These improvements are expected to enable routine point-of-care approvals and a more consistent, efficient experience for providers and patients alike. However, achieving these outcomes will require substantial collaboration, especially as nearly half of all prior authorizations are still submitted via fax or phone.

Appeals court affirms temporary pause to contentious 340B rebate pilot

By Dave Muoio – A three-judge panel has denied the federal government's appeal of a district court decision temporarily blocking the launch of a hospital industry-opposed pilot swapping upfront 340B drug discounts for after-the-fact rebates. The 1st U.S. Circuit Court of Appeals, on Jan. 7, wrote that the Department of Health and Human Services and its agencies had "failed to carry its burden of 'mak[ing] a strong showing that [it is] likely to succeed on the merits.'" Read Full Article...

HVBA Article Summary

1. Court Denies Government's Request to Proceed with 340B Rebate Pilot: The U.S. Court of Appeals upheld a lower court's preliminary injunction that halted the launch of the 340B Rebate Model Pilot Program, originally set to begin on January 1. The court agreed that the government failed to justify the program under the Administrative Procedure Act (APA), particularly for not considering how the shift from upfront drug discounts to after-the-fact rebates would impact hospitals that rely heavily on the current system. The court also found no evidence of irreparable harm to the government if the program was delayed, and therefore denied the government’s request for a stay pending appeal.

2. Concerns Over Administrative Burden and Financial Impact on Hospitals: Hospital organizations, including the American Hospital Association (AHA), raised strong objections to the pilot program, arguing it would place a significant administrative and financial burden on participating providers—particularly safety-net hospitals. These entities warned that shifting to a rebate model would disrupt cash flow by requiring them to wait for reimbursement and manage complex reporting requirements. They also expressed concern that giving drugmakers control over the rebate process could open the door to delays or denials in payment, exacerbating the financial strain on providers serving vulnerable populations.

3. Criticism of the Program’s Hasty Rollout and Lack of Transparency: The pilot program was criticized for being rapidly implemented with minimal stakeholder engagement and limited regulatory transparency. Hospitals and lawmakers pointed to the tight timeline—from the July announcement to the planned January rollout—as insufficient for reviewing public comments or preparing for operational changes. The court found that the administrative record lacked evidence of meaningful consideration of these concerns. Critics also highlighted that the applications from participating drug manufacturers were not publicly disclosed, raising further questions about oversight, accountability, and the integrity of the pilot’s design.

Healthcare, life sciences leaders expect more mergers in 2026

By Ron Southwick – Even with an uncertain landscape, most healthcare and life sciences leaders say they expect to be pursuing more mergers and acquisitions in 2026, according to a new KPMG survey. The survey found nearly three quarters (73%) of life sciences executives expect to see more merger activity, according to the survey, which was released Thursday morning. Healthcare leaders were a bit less optimistic, but still a solid majority (61%) said they expected to look at more deals. Read Full Article...

HVBA Article Summary

1. Hospital M&A Activity Shows Unexpected Resilience Despite Challenges: Despite significant financial and policy headwinds, such as uncertain federal healthcare policies and pressure on reimbursement rates, hospital and health system leaders remain optimistic about mergers and acquisitions. An increase in deal activity was noted in the second half of 2025, indicating a continued interest in consolidation to strengthen long-term viability, especially among smaller systems facing Medicaid cuts.

2. Mixed Valuation Outlook Reflects Sector Differences and Financial Strain: The KPMG survey revealed a more cautious outlook from healthcare leaders, with only 41% expecting valuation increases—unchanged from the prior year—compared to 60% of life sciences leaders, a decline from 72% in 2024. The disparity reflects greater optimism in life sciences versus hospitals, where leaders anticipate financial strain from rising uninsured patient volumes due to expiring ACA tax credits and Medicaid reductions.

3. Technology Investments Prioritized, With Focus on AI, Telehealth, and Behavioral Health: Healthcare and life sciences organizations plan to expand investments in artificial intelligence, behavioral health, and virtual care. AI is viewed as a promising tool for improving profitability, while telehealth—especially in rural areas—is expected to grow due to shifting patient preferences and lessons learned during the pandemic. These investments reflect a strategic shift toward digital transformation and patient-centered care.

Employers brace for voluntary benefits suits

By Allison Bell – A law firm recently startled the benefits legal community by filing federal suits over voluntary benefits programs at four big employers. The plaintiffs in the suits allege that the employers violated Employee Retirement Income Security Act fiduciary duty obligations by failing to check to see whether the voluntary insurance products offered a good level of value for the money spent. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Employers Should Reassess Voluntary Benefits Programs: In light of recent federal lawsuits, employers are encouraged to closely evaluate their voluntary benefits offerings—particularly their selection processes, vendor contracts, broker and vendor compensation structures, premium levels, and insurance product loss ratios. Collaborating with experienced benefits advisors and legal counsel can help organizations identify weaknesses and reduce potential compliance risks.

2. ERISA Safe Harbor Requirements Are Not Automatic: Many employers assume their voluntary benefits plans are exempt from ERISA fiduciary duties through a safe harbor provision. However, this exemption only applies if specific conditions are met, such as employees paying the full premium and the employer refraining from promoting the plan—making it essential for employers to verify they truly qualify.

3. Courts May Scrutinize Benefits Advisors’ Conduct: Legal experts note that courts may place more weight on the actual behavior of benefits advisors than on whether those advisors formally claim fiduciary status. This means employers could still face liability if advisors act in ways that imply fiduciary responsibility, even if their official role suggests otherwise.

Brain Stimulation Matches Semaglutide for Weight Loss

By Devyani Gholap – Repetitive transcranial magnetic stimulation (rTMS) produced 12-month weight loss comparable to semaglutide 0.5 mg/wk and greater than that achieved with SGLT2 inhibitors in adults with obesity and type 2 diabetes (T2D). Read Full Article...

HVBA Article Summary

1. Comparable Weight Loss with rTMS and Semaglutide: Repetitive transcranial magnetic stimulation (rTMS) and semaglutide (0.5 mg/week) were both associated with significantly greater weight loss at 12 months compared to SGLT2 inhibitors in patients with obesity and/or type 2 diabetes (T2D). The average weight loss was 8.2 kg for rTMS and 5.7 kg for semaglutide, with no statistically significant difference between the two treatments. These findings suggest that rTMS may be a viable non-pharmacological alternative for weight management in this population.

2. Sustained Effects Differ Across Treatments: Weight loss with both rTMS and semaglutide was sustained from 6 to 12 months, while patients on SGLT2 inhibitors initially lost weight at 6 months but regained some by 12 months. This suggests rTMS and semaglutide may offer more durable weight loss benefits in this population. The continued decline in weight over a full year with rTMS and semaglutide indicates a potentially superior long-term effect compared to SGLT2 inhibitors.

3. Study Limitations May Affect Interpretation: The study was retrospective and used a submaximal dose of semaglutide (0.5 mg/week), which may underestimate its full efficacy. Differences in baseline A1c levels and exclusion criteria for the rTMS group could also impact comparability across groups. As such, results should be interpreted with caution and confirmed through prospective, randomized controlled trials using full therapeutic doses.