It’s Been a Long Time Coming: Massachusetts Health Care Market Review 2.0

By Deborah A. Daccord, Cassandra L. Paolillo, Kate F. Stewart, and Giselle Mota - The latest entrant in a national wave of policymakers enacting health care market oversight laws that have a significant impact on providers and investors, Massachusetts Governor Maura Healey has signed into law House Bill 5159, “An Act enhancing the health care market review process” (the Act). Read Full Article…

HVBA Article Summary

1. Expanded Transaction Oversight by the Health Policy Commission (HPC):
   The Act significantly broadens the scope of the HPC’s review process, now encompassing a wider variety of transactions, such as those involving significant equity investors, real estate sale-leasebacks, and conversions of nonprofit providers to for-profit entities. This expansion introduces rigorous disclosure requirements for investors and management service organizations (MSOs), aiming to ensure greater scrutiny of financial and operational impacts on the Massachusetts health care market.

2. Enhanced Authority for Regulatory Bodies:
   The Massachusetts Attorney General’s Office (AGO), the Center for Health Information and Analysis (CHIA), and the HPC gain increased powers to monitor cost trends and market dynamics. New provisions bring additional actors under oversight, including pharmaceutical manufacturers, pharmacy benefit managers (PBMs), and health care REITs. These entities will face heightened financial reporting requirements and potential liabilities, such as expanded applicability of the Massachusetts False Claims Act.

3. Implications for Transactions and Ongoing Compliance:
   The Act imposes longer timelines and more comprehensive pre-closing and post-closing obligations on transaction participants. Entities involved in health care transactions must prepare for delays due to expanded regulatory scrutiny, comply with extensive financial transparency requirements, and anticipate assessments funding state regulatory bodies. Early planning and robust disclosure practices will be critical for navigating these changes effectively.

Inaccurate provider directories frustrate value-based care efforts

By Alan Goforth - Many employers are turning to value-based care this year as costs continue to climb. However, provider directories that often include inaccurate addresses, phone numbers, specialties and availability can frustrate their efforts to provide efficient, affordable health care. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Inaccurate Health Plan Directories: Research from Garner reveals that only 27% of health plan directories contain accurate provider information, making it difficult for members to access the right care. This issue is exacerbated in value-driven health plans where network accuracy directly affects out-of-pocket costs and care accessibility.

2. Limited Specialty Representation: Most health plan directories list only 23 specialties, while employees often need access to a broader range of 82 subspecialties. This limitation forces members into a frustrating trial-and-error process, especially when searching for highly specialized care.

3. Impact on Value-Driven Care Success: The success of value-driven health plans relies heavily on accurate provider directories, as members must identify high-quality, in-network providers to manage costs effectively. Employers risk undermining the benefits of these plans if directory inaccuracies persist, potentially deterring employees from seeking necessary care.

UnitedHealth-owned insurance companies ordered to pay $165M over sales strategies

By Allison Bell - A state court in Massachusetts has ordered affiliates of UnitedHealth to pay about $165 million in penalties and restitution over allegations that their agents violated state health insurance marketing rules when selling supplemental health insurance products. Read Full Article…

HVBA Article Summary

1. Restitution and Penalties: Suffolk County Superior Court Judge Helene Kazanjian ordered HealthMarkets and its affiliates to pay $50,095,562.07 in restitution to consumers and $115,142,000 in penalties for misleading health insurance sales practices. The Massachusetts Attorney General Andrea Campbell emphasized the decision as holding the companies accountable for deceptive marketing.

2. Deceptive Marketing Practices Alleged: The court found that HealthMarkets and its affiliates engaged in deceptive sales tactics, including misrepresenting agents' roles, bundling products without clarity, and targeting low-income consumers with unnecessary supplemental policies. The order cited misleading descriptions of discount programs and failure to disclose when major medical insurance was not included in sold bundles.

3. Defense and Appeal: UnitedHealth, which acquired HealthMarkets in 2019, announced plans to appeal the decision, arguing the court's findings were legally and factually flawed. The defense also claimed procedural violations in the state's lawsuit filing process and emphasized that Chesapeake Life had paid benefits and informed consumers about the limitations of critical illness insurance.

Telehealth Relief Extension for HDHPs Expires

By Remy Samuels - Plan sponsors that offer high-deductible health plans paired with health savings accounts will no longer be permitted to cover telehealth services before a participant’s deductible is met. This is because Congress failed to include extension of the safe harbor allowing this benefit in the American Relief Act of 2025—the law that passed on December 21, 2024, to fund the federal government for the next few months. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Telehealth Exception Expiry: The legislation initially included an extension of the telehealth service exception, but it was excluded from the final version, leading to its expiration on December 31, 2024, for calendar year plans. However, there is potential for retroactive reinstatement by the 119th Congress, which could take several months.

2. HDHP Telehealth Flexibility and Compliance: The telehealth safe harbor for HSA-qualified HDHPs, initially introduced under the CARES Act in March 2020, allowed coverage of telehealth services before meeting deductibles. Subsequent extensions are set to expire on January 1, 2025. The Wagner Law Group advises employers to amend their HDHPs and consult benefits advisers to ensure ongoing legal compliance.

3. Pharmacy Benefit Manager (PBM) Reforms: The original bipartisan bill included significant reforms targeting pharmacy benefit managers, such as transparency requirements, 100% pass-through of rebates in ERISA plans, and modifications to hospital billing practices. President-elect Donald Trump has expressed interest in revisiting PBM reforms, potentially revisiting policies from his first administration that were rolled back under President Biden.

Novel drug confers weight loss of up to 20% at 1 year in phase 2 study

By Erik Swain - Maridebart cafraglutide, a novel injectable GLP-1 receptor agonist/GIP receptor antagonist, reduced body weight by up to approximately 20% at 1 year in patients with overweight or obesity without a weight loss plateau, according to a presentation. Read Full Article…

HVBA Article Summary

1. Significant Weight Loss and Cardiometabolic Benefits: Maridebart cafraglutide (MariTide) led to significant weight loss in both non-diabetic and diabetic cohorts, with the highest average weight reduction of approximately 20% and 17%, respectively, after one year. Cardiometabolic improvements included reductions in systolic blood pressure, LDL cholesterol, triglycerides, glucose levels, and high-sensitivity C-reactive protein, highlighting its potential beyond weight management.

2. Innovative Dual-Action Mechanism and Safety Profile: MariTide is a first-in-class peptide antibody conjugate targeting both GLP-1 receptor activation and GIP receptor antagonism, with a long half-life for sustained effects. The safety profile was favorable, with mild to moderate gastrointestinal side effects primarily during initial dosing, and no significant impact on bone mineral density or heart rate changes beyond typical responses seen with other weight-loss medications.

3. Ongoing Research and Future Directions: The phase 2 trial continues with a second part focusing on the sustainability of weight loss, dose optimization for maintenance, and further exploration of long-term effects. The phase 3 MARITIME program will expand research into broader populations, including those with type 2 diabetes, kidney disease, cardiovascular issues, and other conditions, with a focus on a unique monthly or less frequent dosing regimen.

Are Patients On GLP-1s Getting the Right Nutrients?

By Batya Swift Yasgur, MA, LSW - As the use of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) continues to exponentially expand obesity treatment, concerns have arisen regarding their impact on nutrition in people who take them. Read Full Article…

HVBA Article Summary

1. Balanced Nutrient Intake During GLP-1 RA Treatment: Due to the appetite-suppressing effects of GLP-1 RAs, which can reduce caloric intake by 16%-39%, patients must prioritize nutrient-dense foods. Ensuring adequate consumption of macronutrients (protein, fat, carbohydrates) and micronutrients (vitamins, minerals) is critical to avoid malnutrition and support overall health.

2. Potential Nutritional Risks and Recommendations: The decreased appetite from GLP-1 RAs may lead to insufficient protein intake, increasing the risk of sarcopenia, as well as deficiencies in essential micronutrients and fiber. Clinicians should educate patients on healthy eating patterns, recommend protein-rich foods, encourage hydration, and consider meal replacements if necessary.

3. The Importance of Multidisciplinary Support: Effective management of patients on GLP-1 RAs requires a holistic approach involving dietary counseling, physical activity recommendations, and mental health support. Collaboration with registered dietitians and mental health professionals can help address the psychological effects of weight loss and ensure long-term dietary quality and emotional well-being.

What will it take to lure small employers back to the fully insured group health insurance?

By Allison Bell - Employers are running away from the fully insured small-group health insurance market as if it were full of rabid bears. The percentage of U.S. residents with coverage from small, fully insured employer-sponsored health plans fell to 11.5 million in 2021, down 39% from the total in 2011, according to academic researchers' analysis of data from the Centers for Medicare and Medicaid Services. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. State-Specific Mandates and Costs: State-specific mandates, such as additional essential health benefits and taxes on premiums, contribute to rising costs for small employers, leading many to opt for self-insurance or other alternatives to avoid regulatory burdens and higher premiums.

2. Administrative Challenges and Compliance Risks: Varying state healthcare mandates create significant administrative challenges for multi-state employers, including complex reporting requirements. These logistical issues can discourage insurers from participating in small-group markets, reducing coverage options for small businesses.

3. Potential Solutions for Small Employers: Small businesses can mitigate these challenges by adopting strategies like offering Individual Coverage Health Reimbursement Arrangements (ICHRAs), advocating for policy reforms, and leveraging available tax credits to manage healthcare costs and maintain competitive benefits packages.

Novel drug confers weight loss of up to 20% at 1 year in phase 2 study

By Erik Swain - Maridebart cafraglutide, a novel injectable GLP-1 receptor agonist/GIP receptor antagonist, reduced body weight by up to approximately 20% at 1 year in patients with overweight or obesity without a weight loss plateau, according to a presentation. Read Full Article…

HVBA Article Summary

1. Significant Weight Loss and Cardiometabolic Benefits: Maridebart cafraglutide (MariTide) led to significant weight loss in both non-diabetic and diabetic cohorts, with the highest average weight reduction of approximately 20% and 17%, respectively, after one year. Cardiometabolic improvements included reductions in systolic blood pressure, LDL cholesterol, triglycerides, glucose levels, and high-sensitivity C-reactive protein, highlighting its potential beyond weight management.

2. Innovative Dual-Action Mechanism and Safety Profile: MariTide is a first-in-class peptide antibody conjugate targeting both GLP-1 receptor activation and GIP receptor antagonism, with a long half-life for sustained effects. The safety profile was favorable, with mild to moderate gastrointestinal side effects primarily during initial dosing, and no significant impact on bone mineral density or heart rate changes beyond typical responses seen with other weight-loss medications.

3. Ongoing Research and Future Directions: The phase 2 trial continues with a second part focusing on the sustainability of weight loss, dose optimization for maintenance, and further exploration of long-term effects. The phase 3 MARITIME program will expand research into broader populations, including those with type 2 diabetes, kidney disease, cardiovascular issues, and other conditions, with a focus on a unique monthly or less frequent dosing regimen.