Stop-loss cost trends are still getting worse, insurer reports

By Allison Bell – Stop-loss insurance claims increased a lot more than Tokio Marine HCC expected in 2025. The underlying trend for specific claims, or claims for individual patients with very high medical bills, was 9.5 percentage points higher than the average for the period from 2019 through 2023, the company said in a new 2025 stop-loss experience analysis. The 2025 increase compares with a 5-percentage increase in 2024. "We were undeniably surprised by these trends," analysts said in the report. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Market Tightening Expected to Continue: Tokio Marine HCC analysts indicated that the stop-loss market has already begun adjusting to higher claim trends but may need further pricing discipline to reach sustainable levels. The report suggests that renewal quotes for 2027 could resemble those seen for 2026, signaling continued pressure on employer health plan budgets. Insurers appear to be responding cautiously to persistent cost volatility rather than assuming the spike is temporary. This outlook points to an extended period of firm pricing conditions in the stop-loss sector.

2. Broad-Based Increase in High-Cost Claims: The insurer observed a rise in claim frequency across all severity levels, including catastrophic thresholds. Medical drivers cited include cancer treatments, complications affecting fetuses and newborns, and transplant-related care. Analysts also referenced external pressures such as trade tariffs, Medicare Advantage reimbursement cuts, demographic aging, expanded use of GLP-1 weight-loss drugs, and workforce shortages in health care. Together, these factors suggest that cost growth is being fueled by both clinical and systemic influences.

3. Self-Insured Employers Face Heightened Exposure: With roughly two-thirds of U.S. employers offering health benefits through self-insured plans, reliance on stop-loss coverage remains widespread. These employers depend on stop-loss insurance to shield their plans from unusually large claims, making trend volatility particularly consequential. After reduced care utilization during the COVID-19 pandemic, insurers began reporting a rebound and surge in claims starting in mid-2024. The ongoing escalation underscores the financial sensitivity of self-funded arrangements to shifts in high-cost medical utilization.

Commonwealth Fund: 21% of adults experienced a coverage denial in the past year

By Paige Minemyer – One in five adults with private insurance coverage said that they or a family member had a medical service denied in the past year, even though it was recommended by their physician. The Commonwealth Fund released its 2025 Affordability Survey and the results of focus groups on the subject, which found that 8% of coverage denials were due to denied claims, while 13% were due to prior authorization denials. One percent of the denied services fell into both categories, per the report. Read Full Article...

HVBA Article Summary

1. Prior Authorization Denials Often Cause Emotional and Care-Related Impacts: The study found that 63% of respondents who experienced a prior authorization denial reported significant worry or anxiety. Additionally, 41% said the denial delayed care for themselves or a household member, while 28% said a health condition worsened because of the delay. A smaller share (8%) reported learning about a serious medical concern later than they would have preferred as a result of the denial.

2. Denied Claims and Authorizations Can Increase Financial Burdens: Nearly one-third (31%) of respondents said a prior authorization denial ultimately cost them more money. Among those who experienced a denied claim, 69% reported higher costs and 43% said the denial contributed to medical debt. Survey results showed that many denied claims involved bills under $5,000, though some respondents faced charges exceeding $10,000.

3. Appeals Process Remains a Challenge for Many Patients: Less than half (47%) of respondents appealed a denied claim, and many who did not appeal cited uncertainty about their rights or next steps. More than half of non-appealers said they were unaware they could appeal, while others did not know whom to contact. Study authors noted that greater transparency, standardized review processes, and expanded appeal rights could help patients better navigate insurance coverage disputes.

Epic dismisses claims against SelfRx in medical record misuse lawsuit

By Emily Olsen – Epic is dismissing its claims against a defendant in a major lawsuit brought by the electronic health record alleging health data network Health Gorilla allowed several clients to improperly access patient records for financial gain. Legal claims will be dropped against chronic condition management firm SelfRx, after the company’s founder Martin Hensel denied requesting thousands of patient records from providers, according to court documents filed Wednesday. Read Full Article...

HVBA Article Summary

1. SelfRx’s Limited Record Requests: In written testimony, SelfRx founder Martin Hensel said the company requested records for only 21 patients and received data for 15 of them, totaling fewer than 100 health records. He disputed allegations that SelfRx sought more than 100,000 files and stated he did not know who accessed those records. Based on this testimony, Epic agreed to drop its claims against SelfRx. The dismissal narrows the scope of defendants in the ongoing case.

2. Broader Allegations Against Interoperability Partners: The lawsuit centers on claims that Health Gorilla and other intermediaries enabled improper access to patient data through interoperability frameworks like Carequality. Hensel said SelfRx worked with data broker Unit 387 but did not authorize it or Health Gorilla to request records on its behalf. He also claimed SelfRx never formally executed the written contract governing its participation in Carequality. Unit 387 could not be reached for comment, leaving questions about how the records were accessed.

3. Continuing Legal and Industry Debate: Epic and several health systems allege that defendants abused data exchange networks by posing as providers and monetizing patient information. Health Gorilla has countered that the lawsuit could restrict legitimate data sharing and argues it acted in good faith when vetting clients. Another defendant, GuardDog Telehealth, has admitted to improperly accessing records and said Unit 387 masked itself as a predecessor firm to obtain data. The case has become a focal point in the broader debate over balancing interoperability with data security and oversight.

How predictive analytics is stabilizing renewals

By Ali Panjwani – Every broker I talk to has a version of the same story. A client group renews its stop-loss coverage, the carrier prices it based on last year's claims and then somewhere around month eight or nine, a handful of catastrophic cases blow up the numbers. The carrier raises rates at renewal, sometimes dramatically. The broker is left explaining why the plan that looked stable 12 months ago is suddenly unaffordable. And the employer is left wondering if self-funding was the right decision at all. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Retrospective Study Highlights Risk Concentration: In a study of 19 employer groups covering nearly 17,000 members, six groups ultimately generated underwriting losses for the carrier. The platform identified four of those six as highest-risk before losses materialized, and those four groups—just 21% of the cohort—accounted for 52% of total underwriting losses. The single worst-performing group produced a $2.3 million loss and had a risk score 1.5 times higher than any other group analyzed. These findings suggest predictive models may help pinpoint a small subset of employers that disproportionately drive financial volatility.

2. Potential Financial Impact on Loss Ratios: The analysis indicated that if pricing had reflected the forward-looking risk signals, the carrier’s loss ratio could have improved from 83.6% to 55%. This implies that more precise underwriting based on predictive analytics may materially change financial outcomes for stop-loss carriers. By aligning premiums more closely with projected risk, carriers may reduce the need for broad, conservative pricing increases. The approach also suggests a pathway to stabilizing renewals for employer groups over time.

3. Shift From Reactive to Proactive Benefits Strategy: The article argues that traditional underwriting relies heavily on trailing claims data and demographics, which only describe past performance. Predictive analytics aims to distinguish between temporary high-cost events and underlying risk patterns such as chronic conditions or specialty drug exposure. With earlier insight, brokers and employers could implement preventive care initiatives, optimize provider networks and select pharmacy benefit partners more strategically. This forward-looking perspective may reduce renewal shock and support more informed decisions about whether self-funding is appropriate.

Trump signs AI cybersecurity executive order: 7 things to know

By Naomi Diaz – President Donald Trump on June 2 signed an executive order directing federal agencies to strengthen AI-enabled cybersecurity across government systems, expand protections for rural hospitals and critical infrastructure, and provide the federal government with access to the most advanced AI models up to 30 days before developers release them to other partners. Read Full Article...

HVBA Article Summary

1. Expanded AI-Driven Cyber Defenses Across Sectors: The executive order directs the Department of Homeland Security to broaden the use of AI-powered cybersecurity tools across civilian federal systems. It also extends support to state and local governments, rural hospitals, community banks and other operators of critical infrastructure. In addition, the Treasury Department is tasked with launching a voluntary cybersecurity clearinghouse to coordinate vulnerability scanning and streamline patch management. Together, these measures aim to strengthen cyber resilience beyond federal agencies and into critical community institutions.

2. Structured Oversight of Advanced AI Models: The order calls for the creation of a classified process to identify highly advanced and potentially sensitive AI systems, referred to as “covered frontier models.” Developers may voluntarily provide the federal government with early access to these systems under confidentiality and intellectual property protections. At the same time, the order explicitly prohibits using this framework to impose mandatory licensing or permitting requirements on AI developers. This approach attempts to balance national security visibility with protections for private-sector innovation.

3. Emphasis on Enforcement and Workforce Development: The attorney general is directed to prioritize prosecution of individuals who use AI tools to unlawfully access computer systems or steal data. The Office of Personnel Management is also instructed to expand cybersecurity hiring pathways through the U.S. Tech Force to bolster federal talent. The order builds on earlier cybersecurity and AI initiatives issued in 2025, reinforcing a broader strategy to integrate AI into national cyber defense. Collectively, these steps reflect a dual focus on deterrence and capacity building within the federal government.

Eli Lilly moves to cut off 340B pricing from noncompliant hospitals

By Alan Goforth – Eli Lilly and Company announced on Monday that it will end 340B discount pricing for hospitals that are not complying with the revised claims submission policy it implemented earlier this year. "A minority of entities -- led by the country's largest and best-resourced hospitals and organized through their trade associations -- continues to refuse to submit data and are recycling the same pretextual objections," the company wrote in a letter to Thomas Engels, the administrator of the Health Resources and Services Administration, which oversees the program. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Enforcement of Revised Data Policy: Eli Lilly is moving to revoke 340B pricing eligibility for hospitals that fail to comply with its updated claims submission requirements. The policy requires claims-level data for all pharmacy and medical drugs dispensed, including those handled through in-house and contract pharmacies. The company says the change is intended to increase transparency and ensure appropriate use of discounted drugs. Hospitals that do not submit the required information by the stated deadline will lose access to discounted pricing.

2. Compliance Rates and Scope of Impact: According to Lilly, about 70% of 340B participants have complied with the new reporting requirements. The company has sent two follow-up letters to roughly 1,000 covered entities that have not yet submitted the requested data. Those entities risk losing 340B pricing eligibility beginning June 8. The figures suggest that while a majority are complying, a significant number of providers could be affected.

3. Escalating Dispute With Hospital Groups: The American Hospital Association has strongly criticized Lilly’s decision, arguing that the policy is unlawful and harmful to vulnerable patients. AHA President and CEO Rick Pollack has called on the Department of Health and Human Services to intervene and prevent the company from enforcing the changes. Lilly, in turn, contends that hospital trade groups are resisting transparency measures that would reveal misuse of the program. The dispute reflects broader tensions over oversight and accountability within the 340B Drug Pricing Program.

Why migraine support needs to be part of your chronic care strategy

By Lee Hafner – Migraines are a debilitating type of headache that impact nearly 40 million Americans, resulting in reduced quality of life, missed work, and high healthcare costs. In May, Hinge Health, a digital health clinic focused on preventing and treating musculoskeletal (MSK) conditions, launched a migraine program to help employees manage their condition. Approximately 75% of those who suffer from migraine pain also have MSK pain, said Jim Pursley, president at Hinge Health. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Integration of Migraine and MSK Care: Hinge Health expanded its digital clinic to include migraine management, building on its existing focus on musculoskeletal conditions. Company leaders note that a significant overlap exists between migraine sufferers and those experiencing MSK pain, which supports a more integrated care model. The program combines a neuromodulation wearable device, AI-based trigger tracking and lifestyle interventions with access to a care team. Early participant feedback cited in the article indicates meaningful reductions in reported pain levels.

2. High Economic and Productivity Costs: Migraines are classified by the World Health Organization as one of the most disabling illnesses and can last from four to 72 hours per episode. With sufferers averaging one to two episodes per month, the condition can significantly disrupt work schedules and daily functioning. Hinge Health estimates that migraine-related care exceeds $16,000 per person annually, contributing to more than $70 billion in total yearly costs when factoring in medication, disability leave and lost productivity. These figures highlight why employers are examining migraine care as part of broader cost-containment strategies.

3. Employer Impact and Healthcare Utilization: Trinity Captive Group incorporated the migraine offering after observing that unmanaged cases were driving emergency room visits, urgent care use and reliance on specialty medications. According to early data from Hinge, participants may regain five to 10 work days over a year through improved management. Leaders at Trinity emphasize that migraine affects employees across industries and demographics, making it a broadly relevant benefit. By improving symptom control, employers may reduce downstream medical expenses while enhancing employee engagement and quality of life.

7 conditions GLP-1s may treat beyond weight loss

By Ella Jeffries – GLP-1 medications were approved for diabetes and obesity. But a rapidly expanding body of research — backed in some cases by large clinical trials and, in at least one, an FDA approval — suggests the drug class may have meaningful effects on conditions with no obvious metabolic connection. Here is a snapshot of where the evidence is strong, where it’s promising, and where it fell short. Read Full Article...

HVBA Article Summary

1. Expanding FDA approvals beyond metabolic disease: GLP-1 drugs have moved into new therapeutic territory, including obstructive sleep apnea, cardiovascular disease and chronic kidney disease. Zepbound became the first prescription medication approved for moderate-to-severe obstructive sleep apnea in adults with obesity after 52-week trials showed meaningful reductions in breathing interruptions. Wegovy earned approval to reduce cardiovascular death, heart attack and stroke risk in overweight or obese adults with heart disease, and Ozempic was cleared to reduce worsening kidney disease risk in adults with Type 2 diabetes and chronic kidney disease. These regulatory milestones signal a shift from weight management to broader chronic disease modification.

2. Mixed but promising data in cancer and other emerging areas: Multiple observational studies and analyses have linked GLP-1 use to lower risks of certain cancers, including reported reductions of 17% in overall cancer risk in one large study of 86,632 individuals and a 70% reduction in endometrial cancer risk when combined with progestin therapy. A Cleveland Clinic study of 10,225 patients associated GLP-1 use with reduced progression across several tumor types. However, a Harvard review of 48 trials involving more than 94,000 participants found no significant reduction in obesity-related cancer risk, underscoring uncertainty and the need for longer follow-up. Research is also exploring potential roles in substance use disorders and mental health, with federal regulators removing prior suicidal ideation warnings after reviewing extensive safety data.

3. Operational and clinical implications for health systems: As indications expand, health systems face more complex formulary and access decisions. Prior authorization teams must adapt to new eligibility criteria tied to each additional approval, while pharmacy leaders are increasingly involved in cross-specialty treatment decisions. Long-term data, such as research suggesting up to 14,400 fewer knee replacements annually if eligible osteoarthritis patients used GLP-1s for three years, raise potential cost and utilization impacts. At the same time, setbacks like semaglutide’s failure to slow Alzheimer’s progression in phase 3 trials illustrate that not all investigational uses will translate into clinical benefit.