The PBM Lobby Has Launched the Biggest Advertising Campaign in Its History

By Wendell Potter – Only a few months after Congress enacted some of the most significant federal reforms to date of the business practices oft pharmacy benefit managers, the PBM industry’s chief lobbying group says it has launched the biggest advertising campaign in its history. Read Full Article...

HVBA Article Summary

1. PBM Trade Group Responds to Federal Reforms With Major Ad Push: The Pharmaceutical Care Management Association (PCMA), which represents pharmacy benefit managers, has launched what it describes as the largest advertising campaign in its history. The move comes shortly after Congress enacted significant reforms aimed at increasing transparency and altering how PBMs are compensated in Medicare Part D. PCMA’s CEO acknowledged that the industry had been too passive in explaining its role, signaling a strategic shift toward more aggressive public messaging. The campaign appears designed to reshape how policymakers and the public perceive the industry amid heightened scrutiny.

2. Market Concentration and Vertical Integration Under Scrutiny: Three companies—CVS Caremark, Express Scripts, and Optum Rx—control roughly 80% of U.S. prescription drug claims and are embedded within larger insurance conglomerates. Regulators have expressed concern that this concentration, combined with vertical integration, allows these firms to influence drug access, pharmacy choice, and patient costs. Federal Trade Commission investigations have examined whether such market power has enabled practices that inflate prices or disadvantage independent pharmacies. The structure of the industry has therefore become central to ongoing policy debates.

3. Regulatory and Legal Pressure Is Mounting Nationwide: Beyond federal reforms, dozens of states have passed their own measures targeting PBM practices, reflecting bipartisan concern. The FTC has reported that the largest PBMs generated more than $7 billion in excess revenue from specialty generic drug markups between 2017 and 2022 and has sued major firms over insulin pricing practices. Express Scripts has reached a settlement with the FTC, while CVS Caremark and Optum Rx have entered settlement discussions. Lobbying disclosures show PCMA spent nearly $18 million on federal lobbying in 2024, underscoring the high stakes surrounding continued oversight.

The top 10 nonprofit health systems by 2025 operating revenue

By Dave Muoio – The 2025 fiscal year saw across-the-board performance improvements for the country’s 10 largest nonprofit health systems, if not necessarily an expansion of their business. Solid demand for services was a constant among the organizations’ financial reports. Several noted efficiency improvements that allowed them to cycle through more patients, and to keep accompanying labor and supply expense increases at least somewhat in check. Outpatient numbers were a particular bright spot for some, and for those organizations, it was viewed as a justification of their efforts to flesh out care networks with sites like urgent cares or ambulatory surgical centers. Read Full Article...

HVBA Article Summary

1. Revenue Growth With Margin Improvement Across the Largest Systems: Collectively, the 10 largest nonprofit health systems increased total operating revenues by 7.7% from fiscal 2024 to 2025, even though that pace slowed from the prior year’s 10.6% gain. Each of the top 10 reported year-over-year operating margin improvement, including those that remained in negative territory. Kaiser Permanente retained the top spot with $127.7 billion in revenue, while several others—including Advocate Health, UPMC, AdventHealth and UC Health—posted double-digit percentage revenue increases. However, divestitures at Providence and Ascension pulled down their top-line figures, highlighting how portfolio changes affected aggregate growth.

2. Outpatient Expansion and Volume Gains Drove Performance: Many systems attributed their financial improvements to higher patient volumes and stronger outpatient activity. For example, UC Health increased admissions by 22.4% and outpatient visits by 15.1%, while AdventHealth reported mid- to high-single-digit increases across admissions, surgeries and emergency visits. UPMC cited a 10% jump in average outpatient revenue per workday, reflecting a continued shift from inpatient to ambulatory care. These trends underscore a broader strategic focus on ambulatory networks, urgent care sites and surgery centers as engines of growth.

3. Strategic Restructuring and Investment Income Shaped Bottom Lines: Several organizations relied on restructuring efforts, divestitures and investment gains to stabilize or enhance their financial positions. CommonSpirit narrowed its operating loss to $225 million as adjusted, while Ascension reduced its operating loss to $490.9 million following portfolio changes and cost controls. Nonoperating income played a substantial role for many systems, such as Trinity Health’s $1.5 billion in investment earnings and Mass General Brigham’s nearly $1.8 billion in investment income. At the same time, leaders signaled caution about looming headwinds, including inflationary pressures and potential Medicaid funding cuts, prompting ongoing cost management and strategic realignment efforts.

PCMA joins in lawsuit over Tennessee law restricting PBMs

By Alan Goforth – The Pharmaceutical Care Management Association has joined the growing list of lawsuits against the state of Tennessee over its new Freedom, Access and Integrity in Registered Pharmacy (FAIR Rx) Act, which bans pharmacy benefit managers from also owning pharmacies in the state. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Industry Challenge to Ownership Restrictions: The Pharmaceutical Care Management Association has filed a federal lawsuit seeking declaratory and injunctive relief against Tennessee’s FAIR Rx Act. The law prohibits PBMs from owning pharmacies in the state and is scheduled to take effect in July 2028. PCMA argues the measure would force the closure of more than 160 PBM-affiliated retail, specialty and mail-order pharmacies. The group contends this would create new barriers for patients and disrupt existing pharmacy services.

2. Broader Legal Pushback from Major PBMs: PCMA’s action follows similar lawsuits from major pharmacy benefit managers, including Express Scripts by Evernorth and CVS Health’s Caremark. These companies are challenging the same statute in federal court. The coordinated legal response signals significant industry opposition to the law’s structure and potential operational impact. The cases will test how far states can go in regulating vertically integrated PBM and pharmacy businesses.

3. Implications for Employers and Federal Preemption Questions: Opponents argue the law could destabilize employer-sponsored insurance by introducing state-specific requirements for multistate benefit plans and potentially threatening jobs. The statute limits ownership stakes to no more than 5% for companies that also operate as health insurance issuers and PBMs, requiring divestiture plans by the end of 2028. PCMA maintains the measure conflicts with federal law and is unconstitutional. A similar Arkansas law was blocked last year by a federal judge on federal preemption grounds, a precedent that may influence the Tennessee case.

Workers are often too confused by their health coverage to use it

By Allison Bell –  Many Americans are often too confused by their health coverage to try to use it. Analysts at eHealth, a web-based health insurance broker, talk about the confusion problem in a summary of results from a survey of about 1,000 U.S. adults that was conducted in early May. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Coverage Confusion Is Affecting Access to Care: More than half of survey respondents (53%) said uncertainty about their health benefits kept them from seeking medical care in the past year. The issue appears more pronounced among those with employer-sponsored insurance, where 60% reported confusion-related access problems. By comparison, 45% of Medicare enrollees reported similar challenges. The findings suggest that misunderstanding plan details may be a significant barrier to care, particularly for workers covered through their jobs.

2. Cost Concerns Mirror Benefit Confusion: Worries about out-of-pocket expenses also discouraged people from getting care, with 58% of those in employer plans citing cost-sharing fears. Among Medicare participants, 46% said concerns about their financial responsibility prevented them from seeking treatment. The parallel between benefit confusion and cost anxiety indicates that complexity and perceived financial risk often go hand in hand. Together, these factors may compound hesitation to access necessary medical services.

3. Understanding Coverage Details Is a Key Pain Point: When asked about specific sources of confusion, 30% of respondents pointed to uncertainty about out-of-network costs and 29% said they struggled to understand what their plans actually cover. Far fewer blamed inaccurate provider directories (12%) or difficulty reading insurance documents (6%) as major issues. This suggests that high-level benefit design and cost exposure create more confusion than technical document literacy. Clearer explanations of covered services and network rules could potentially reduce barriers to care.

With 42% of men skipping preventative care, improving these 4 health categories is critical

By Lee Hafner – Halfway through Men's Health Month, new data from eHealth reveals it's the perfect opportunity for benefit leaders to advocate for better participation in preventive care. Forty-two percent of men skipped recommended preventive care last year, 60% said they delay care unless family encourages them to go, and 82% reported putting their family's needs ahead of their own health, according to eHealth's findings. Communicating critical health checks such as wellness exams and routine screenings, and the benefits that can help them do so, can have a big impact on participation, stressed Whitney Stidom, VP of consumer enablement at eHealth. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Cost and confusion are major barriers to preventive care: Among men who skipped recommended medical care, 33% cited cost concerns as the primary reason. The article notes that many preventive services are available at little or no cost under insurance plans, yet employees may not understand what is covered. Clear, step-by-step communication about how to find a primary care provider and schedule appointments can reduce uncertainty. Employers that simplify benefits education may help close this participation gap.

2. Screening awareness gaps persist across age groups: Survey data show that 51% of men either did not know or were incorrect about when colonoscopy screenings should begin, despite the recommended starting age having shifted from 50 to 45. In addition, only 21% of men age 30 and older were aware of the recommended starting age of 50 for prostate exams. These knowledge gaps suggest that eligibility and timing for screenings are not widely understood. Targeted education campaigns could help ensure men access screenings at appropriate ages.

3. Mental health and broader wellness require employer support: Only about 41% of men with a mental health condition receive treatment, yet men account for nearly 80% of suicide deaths in the U.S. The article encourages employers to promote mental health resources consistently and foster a culture where taking time off is supported. Suggestions include offering paid volunteer days, encouraging attendance at family events, and monitoring workloads to prevent burnout. Broader preventive checklists should also include vision, hearing and dental care due to their links to chronic disease and cognitive decline.

More Americans Are Surviving Cancer. But the Mental Health Challenges Can Persist.

By Natalie Krebs – The cancer diagnosis came as a shock, disrupting Morgan Newman's plans for launching her life. It was 2015, and she was working as a dental assistant in Des Moines, Iowa, while studying to become a social worker. Read Full Article...

HVBA Article Summary

1. Growing Survivor Population, Ongoing Psychological Strain: The number of people living after a cancer diagnosis continues to rise, with projections showing millions more survivors in the coming decade. While survival rates have improved, many individuals continue to experience anxiety, depression, and fear of recurrence long after treatment ends. A national survey found that roughly one-third of survivors worry about their cancer returning, yet only about 20% reported seeing a mental health professional. This gap suggests that psychological needs may be under-addressed in survivorship care.

2. Barriers to Specialized Mental Health Care: Access to therapists who understand the medical and emotional complexities of cancer can be limited, particularly in rural states such as Iowa. Some counties with high cancer incidence also face shortages of mental health workers, compounding access challenges. Survivors may cycle through multiple providers before finding one familiar with oncology treatments and their side effects. Cost, insurance coverage, and the logistical burden of ongoing medical appointments can further delay or interrupt therapy.

3. Oncology’s Evolving Approach to Whole-Person Care: Experts say cancer treatment has traditionally focused more on physical symptoms than on emotional well-being. Although professional guidelines recommend routine screening and referral for psychological distress, these practices are not consistently implemented. Some cancer centers are beginning to integrate services such as counseling, music therapy, and mindfulness into care. Clinicians argue that comprehensive cancer treatment should include systematic attention to patients’ emotional and social challenges, not just tumor control.

Eli Lilly cuts 340B discounts for hospitals resisting its claims data submission policy

By Dave Muoio – Hospitals say that Eli Lilly and Company has made good on its threat to end 340B discount pricing for providers that have not fallen in line with the drugmaker's claims data submission policy. Lilly implemented its policy on Feb. 1, which was widely panned by the hospital industry over concerns of substantial administrative burdens and similar rollouts from other drugmakers. Earlier this month Lilly said that it would begin enforcing the policy by telling its wholesalers to pull 340B pricing eligibility for an unspecified "initial set" of holdouts, which it characterized as predominantly large and wealthy health systems (see that story below the break). Read Full Article...

HVBA Article Summary

1. Dispute Over Claims Data Requirement: Eli Lilly’s policy requires 340B-covered entities to submit detailed claims-level data for pharmacy and medical dispensations, including in-house and contract pharmacy activity. The company says this data is needed to identify instances of duplicate discounts across overlapping programs. Roughly 70% of covered entities—about 2,350 organizations—have complied, while around 1,000 have not. Lilly argues that the level of compliance demonstrates the requirement is manageable and lawful.

2. Hospitals Call the Move Unlawful and Harmful: Hospital groups including 340B Health and the American Hospital Association contend that Lilly’s actions violate federal law governing the 340B program. They argue that revoking discounts will strain safety-net providers that account for 77% of Medicaid care and 67% of uncompensated care nationwide. Industry leaders are urging the Health Resources and Services Administration and the Department of Health and Human Services to intervene and enforce drugmakers’ statutory obligations. They warn that if unchallenged, other manufacturers could adopt similar policies, increasing financial pressure on hospitals serving low-income patients.

3. Escalation After Ultimatum and Limited Dialogue: Lilly had notified an unspecified initial group of hospitals that their 340B pricing eligibility would be withdrawn starting June 8 if they failed to submit the requested data. The company said it contacted the 50 largest holdouts in early May, with 11 not responding and 13 participating in discussions that did not produce commitments. Hospital representatives dispute Lilly’s characterization of engagement efforts and say attempts to collaborate went unanswered. The standoff adds to broader tensions around the rapidly expanding 340B program, including recent clashes over a proposed federal rebate pilot.

Nearly half of large employers plan to raise worker healthcare costs, Mercer says

By Emilie Shumway – Nearly half of large U.S. employers — those with 500 or more employees — plan to change their healthcare plan offerings next year in a way that will shift more costs onto workers, according to a Thursday press release from Mercer. In addition to cost-shifting strategies like raising deductibles and copays, many large employers say they will pursue more affordable options for workers by exploring or planning to offer nontraditional plans, like a high-performance network or variable copay plan. While healthcare costs for workers may be going up, many large employers don’t plan to cut on benefits that have “become standard,” Mercer said. In vitro fertilization coverage, caregiving support and one-on-one financial counseling have become common among such employers and are likely to remain in place, Mercer found. Read Full Article...

HVBA Article Summary

1. Cost Pressures Are Driving Employer Plan Changes: Mercer surveyed 604 U.S. organizations in April and May, including 408 with 500 or more employees, and found significant movement toward redesigning health benefits. Employers are responding to continued medical inflation and broader economic strain affecting workers. The findings suggest that benefit changes are becoming a primary lever for managing rising healthcare expenses. Large employers, in particular, appear poised to adjust plan structures rather than absorb additional costs.

2. Prescription Drug Spending and GLP-1 Coverage in Focus: Mercer reported that prescription drug costs are projected to rise 9% in 2026, contributing heavily to overall health benefit growth. Coverage of GLP-1 medications for weight loss is a notable flashpoint, with 6% of large employers eliminating that coverage this year and another 5% considering or planning to do so. Employers have been divided on whether to cover these drugs when prescribed primarily for weight loss. The survey indicates that some organizations now see scaling back this benefit as a way to control pharmacy spending.

3. Potential Consequences for Workers and Employers: Research cited in the article shows that when out-of-pocket costs increase, employees may delay or reduce needed care. Such behavior can lead to more serious health issues and potentially higher long-term costs for both workers and companies. Although employees tend to attribute rising healthcare costs to insurers, employers remain aware of the financial strain on their workforce. The tension highlights the balancing act organizations face between cost containment and maintaining competitive, supportive benefits packages.

How ‘Ozempic Mouth’ Became a Thing — and How to Treat It

By Debbie Koenig – After all the headlines about “Ozempic mouth” — and “Ozempic breath” and “Ozempic teeth” — emerging research points to possible explanations, notably how GLP-1 drugs delay the emptying of the stomach and intestines. When the CEO of Hershey recently credited GLP-1 users with a spike in sales of sugar-free mints and gum, the drug’s oral-related effects got the attention that dentists had already noted. But as more patients taking GLP-1 report oral changes, reflected in a nascent but growing body of literature, questions arise for clinicians about how to manage them. And halitosis is far from the only issue. Read Full Article...

HVBA Article Summary

1. Delayed Gastric Emptying Drives Many Oral Symptoms: Experts say that GLP-1 therapies slow stomach and intestinal motility, which can create conditions for bacterial overgrowth and fermentation that contribute to bad breath. An analysis of records from more than 200,000 GLP-1 users found a 32.9% higher likelihood of gastroesophageal reflux disease, which can worsen odor and erode enamel. Vomiting has been reported in up to 24% of users, exposing teeth to stomach acid and increasing the risk of decay. Although direct causal evidence is still limited, clinicians say the physiologic mechanisms are consistent with known gastrointestinal effects.

2. Dry Mouth and Taste Changes May Have Direct Biological Links: Xerostomia is cited as the most common oral complaint among patients on GLP-1 drugs. A recent review suggests semaglutide may interact with salivary gland signaling pathways, potentially reducing saliva secretion and altering gland responsiveness over time. Reduced saliva undermines the mouth’s natural defenses, making cavities, gum inflammation, and halitosis more likely. GLP-1 activity may also influence taste perception both at the level of taste buds and in brain reward pathways, possibly diminishing sweetness and heightening bitterness.

3. Management Focuses on Symptom Relief and Preventive Care: Dental experts recommend reinforcing oral hygiene practices, including twice-daily brushing, daily flossing, and the use of fluoride-containing products. For dry mouth, strategies include hydration, sugar-free gum with xylitol, over-the-counter moisturizers, and in severe cases prescription agents to stimulate saliva. Patients experiencing reflux or vomiting are advised to avoid brushing immediately afterward and instead rinse with water and wait before cleaning their teeth. More frequent dental visits—every 3 to 4 months—may be warranted for those at elevated risk of tooth decay.