PSG report: Employers weigh 'unbundling' PBM models, GLP-1 coverage

By Paige Minemyer - As costs continue to rise, employers are looking to the levers they have available to get their arms around this challenge, and a new report examines some of the strategies they're considering. Analysts at the consulting firm Pharmaceutical Strategies Group released its annual drug benefit design report on Tuesday, where it found that there is a growing awareness among employers about new contracting models, including "unbundling," where a plan sponsor would decouple certain services from the main PBM contract and rely on other vendors. Read Full Article…

HVBA Article Summary

1. Limited but Growing Interest in Unbundling Pharmacy Benefits: While awareness of unbundling is still developing—48% of employers and 35% of health plans have heard "a little" about it—some employers are cautiously exploring modular approaches, such as carving out specialty pharmacy or formulary development, rather than fully replicating Blue Shield of California's more comprehensive unbundling model.

2. Cost and Transparency Drive Unbundling Considerations: Employers considering unbundling hope it will improve cost management and transparency, but many remain concerned about the complexity of coordinating multiple vendors and maintaining a seamless patient experience.

3. Significant Employer Concerns Around GLP-1 Drugs: A majority of employers (65%) are very concerned about the costs of GLP-1 drugs, particularly for obesity treatment, with 42% unwilling to cover them at any price for that use. Off-label use for weight loss also poses a cost concern, prompting some employers to implement stricter verification of medical necessity.

Elevance sues medical services firms over 'fraudulent' out-of-network care billing

By Allison Bell - Two health insurance companies owned by Elevance Health are suing health care providers and a billing service over claims for out-of-network care. The providers and the biller flooded No Surprises Act independent dispute resolution services, or IDR services, with disputes that were not eligible for the No Surprises Act IDR process, the Elevance subsidiaries say in court filings. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Lawsuits Filed by Elevance Subsidiaries: Two Elevance Health subsidiaries—Blue Cross Blue Shield Healthcare Plan of Georgia and Anthem Blue Cross and Blue Shield of Ohio—have filed lawsuits alleging that medical providers and billing entities, including HaloMD, engaged in fraudulent use of the federal Independent Dispute Resolution (IDR) process under the No Surprises Act to secure excessive reimbursements.

2. Allegations of IDR Abuse and Financial Harm: The insurers claim that many of the IDR disputes submitted by the defendants were ineligible under the No Surprises Act, resulting in substantial administrative costs and inflated reimbursement payouts. In Georgia, 70% of the disputes were deemed ineligible, while in Ohio, it was around 50%, according to the complaints.

3. Defendants Deny Allegations and Cite Physician Advocacy: HaloMD and the other defendants deny the fraud claims, framing the lawsuits as an attack on fair physician reimbursement and the No Surprises Act itself. They assert they are legally defending providers' rights to equitable payment for services delivered.

Big changes coming to Medicare Advantage

By Andrea Arlett Nabor Herrera - Starting in 2025, Medicare will implement a limit on out-of-pocket expenses for prescription drugs under Part D, capping them at $2,000 annually. This change eliminates the notorious 'donut hole,' where beneficiaries previously bore a significant portion of costs after reaching a spending threshold. Additionally, the new Medicare Prescription Payment Plan (MPPP) allows beneficiaries to spread their medication costs over several months, easing the financial burden. Read Full Article…

HVBA Article Summary

1. Premiums and Costs Rising: In 2025, traditional Medicare (Parts A and B) will see higher premiums, deductibles, and coinsurance rates to keep up with rising healthcare expenses and ensure long-term financial stability of the program. The Part A deductible increases by $44 to $1,676, while the standard monthly Part B premium rises by $10.30 to $185.

2. Medicare Advantage Adjustments: Medicare Advantage (MA) plans continue to attract growing enrollment, projected to reach 35.7 million in 2025, with many plans still offering $0 premiums. However, some MA plans are cutting back on supplemental benefits, such as over-the-counter drug coverage (dropping from 85% to 73% of plans), even as insurers receive a 3.7% average funding increase, raising questions about how much of this funding benefits enrollees versus insurers.

3. Expanded Coverage and Drug Cost Changes: Medicare is broadening its covered services to include additional mental health treatments, cardiovascular risk assessments, and dental care related to end-stage renal disease. Part D plans may now substitute biosimilar drugs mid-year without prior CMS approval to lower costs. Further drug cost reforms in 2026 will include a $2,100 out-of-pocket cap, $35 insulin price cap, free ACIP-recommended vaccines, and possible expanded coverage for obesity medications.

The Employer’s Dilemma: When the Fully Insured Plan No Longer Works, What’s Next for Employers?

By Ben Light - For decades, we’ve faced the same yearly routine: Pay your premiums. Brace for renewal rates. Absorb the increases or pass them on to your employees. Can you repeat? It’s the benefits version of Groundhog Day — and in 2025, amid lingering inflation, economic uncertainty, shifting labor markets, and general distrust of the healthcare system, that routine is starting to break down for a growing number of businesses. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. The Fully Insured Model Is Losing Its Fit for Many Employers: Once seen as a simple and convenient solution, the fully insured health benefits model increasingly leaves employers financially responsible for rising costs they can’t control. This growing mismatch between accountability and influence is prompting many organizations to question whether the model still serves their workforce and business goals.

2. Add-On Solutions Can’t Fix a Flawed Structure — Deeper Change Is Required: While wellness programs, virtual care, and other point solutions offer some benefits, they don’t address the underlying problem of a system that places financial risk on employers without giving them the tools to manage it. Many companies are realizing that minor adjustments aren’t enough and that a fundamental shift in the benefits structure may be necessary.

3. Defined Contribution Models Like ICHRA Provide a More Sustainable Path: By moving away from the traditional group plan and adopting models like ICHRA, employers can decentralize risk across the broader individual market, stabilize costs, and give employees more choice and control. This approach offers organizations greater budget predictability, flexibility to adapt to changing business needs, and the ability to create a benefits strategy that better supports both financial and workforce objectives.

A patient’s genes may affect which GLP-1 obesity drugs work best, researchers say

By Allison Bell - Researchers say they have a new weapon against health plan prescription drug costs: information about which obese people have genes and measurable body characteristics that make them good candidates for use of the hot new anti-obesity drugs. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Genetic and behavioral factors can help predict which obesity drugs work better for individual patients: The study by Mayo Clinic and Phenomix Sciences found that patients classified as Hungry Brain (who overeat due to brain-driven hunger cues) tended to lose more weight with phentermine-topiramate (Qsymia), while Hungry Gutpatients (who require more food to feel full) responded better to liraglutide (a GLP-1 agonist like Victoza and Wegovy). This classification combines genetic markers, hormone levels, and behavioral assessments.

2. Personalized treatment could help reduce healthcare costs for employers and insurers: Since anti-obesity medications are costly — with GLP-1 agonists costing $1,400–$1,500 per month and Qsymia costing around $200 — matching patients to the most effective drug could help employers better manage the roughly 17% of prescription drug spending that goes toward weight loss drugs, while improving patient outcomes and preventing expensive complications like heart disease.

3. Further research is needed to refine genetic predictions and validate findings across diverse populations: Although certain genetic markers (SNPs) showed a correlation with obesity subtypes, the patterns were more complex than initially expected. The researchers aim to conduct larger, randomized studies that include more men, individuals with diabetes, and people from diverse socioeconomic backgrounds to improve the accuracy and applicability of personalized obesity treatments.

How to Keep Employees Focused When Current Events Create Stress

By Jesse Stanchak - The news is full of stressful topics lately: the rise of AI, economic disruptions, violent acts, and more. Perhaps you’ve thought about how those events might negatively impact your industry, supply chain, or customers, making competing more challenging than ever. But amid those headlines is another hidden danger: the toll of all this stress on your workforce. This isn’t a foregone conclusion, however. Both organizations and individual leaders have tremendous power to make it easier for workers to stay focused on their jobs — and even find a little bit of relief from the chaos of the world outside of work. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Negative mental health impacts at work significantly harm productivity and retention: When the workplace contributes to poor mental health, employees experience a 37% rise in absenteeism, an 18% drop in productivity, and a 60% increase in work errors. Additionally, more than half (51%) of those whose mental health is negatively affected at work actively look for new jobs, compared to only 19% whose mental health is positively supported.

2. External events like politics, the economy, natural disasters, societal conflict, and AI fears are major stressors: While organizations cannot eliminate these external pressures, they play a crucial role in lessening their impact by fostering a culture of civility, staying neutral on polarizing issues, maintaining transparent communication, and offering flexible work arrangements and accessible mental health resources to help employees manage stress.

3. Strong leadership, empathy, and adaptability are essential to support employees through uncertainty: Leaders must model healthy coping strategies, listen empathetically to employees' concerns, promote respectful conversations, and encourage flexibility and resilience. This proactive approach helps maintain focus, collaboration, and engagement even amid ongoing societal and organizational disruptions.