How High is Too High? The Crippling Cost of Denial Rates

By Patrick Quigley - Recent data shows that insurers deny nearly one in five in-network claims, but this troubling statistic only captures the formal denials that occur after care is received. The real denial rate is much higher when you consider all the invisible barriers that payers implement to prevent care from happening in the first place — network restrictions that limit provider choice, prior authorizations that delay critical treatments, step therapy requirements that force patients to fail on cheaper medications first, and other administrative hurdles that effectively deny or delay care before a claim is ever submitted. Read Full Article…

HVBA Article Summary

1. The Harmful Impact of Insurance Barriers: High denial rates and prior authorization requirements are not just bureaucratic hurdles; they delay or prevent necessary care, contributing to financial hardship for millions of Americans. Research shows that 58% of insured adults face insurance-related problems, and for many, denied claims exacerbate financial struggles.

2. The Case for Transparency and Reform: A consumer-driven approach to health insurance, with upfront pricing, the removal of prior authorization, and the elimination of restrictive networks, has proven to significantly lower denial rates. Some modern plans have reduced denials to under 1%, ensuring patients receive timely and necessary care.

3. A Call to Action for Systemic Change: The healthcare system must prioritize care over control by aligning incentives, empowering patients with information, and eliminating unnecessary administrative obstacles. With the right commitment, the industry can shift toward a model where healthcare decisions remain between patients and their doctors.

Walgreens' parent acquired for $23.7B by private equity firm

By Allison Bell - Walgreens Boots Alliance — the parent of the Walgreens and Duane Reade drug store chains — said Thursday it has agreed to be acquired by Sycamore Partners, a private equity firm, for a total of up to $23.7 billion. The deal could affect employer-sponsored health plans by squeezing costs out of prescription drug distribution in the short run but helping Walgreens negotiate harder with health plans and pharmacy benefit managers in the long run. Read Full Article…  ^{_{(Subscription required)}}

HVBA Article Summary

1. Walgreens’ Struggles and Strategic Shift: Walgreens Boots Alliance has faced significant challenges, including the lingering effects of the COVID-19 pandemic on sales, efforts by health plans to cut prescription costs, and increasing competition from mail-order pharmacies run by pharmacy benefit managers. In response, the company has pursued a turnaround strategy that includes store closures, divestitures, and restructuring efforts.

2. Sycamore Partners Acquisition and Financial Considerations: Walgreens Boots Alliance has reached a deal with Sycamore Partners, a private equity firm, to support its turnaround. The deal structure includes an 80% immediate cash payment and a 20% contingent payment tied to the sale of VillageMD. Walgreens is also exploring other potential offers during a 35-day “go shop” period before finalizing the transaction.

3. Future Direction and Leadership Perspective: Walgreens' leadership, including CEO Tim Wentworth, views the transition to private ownership as a necessary step for long-term value creation. Sycamore Partners has expressed confidence in Walgreens' pharmacy-led model and aims to leverage its expertise in retail turnarounds to stabilize and grow the business while maintaining its headquarters and brand identity.

One year later: Lessons learned from the Change Healthcare cyberattack

By Paige Minemyer - Just over a year ago, cybercriminals launched a ransomware attack on clearinghouse Change Healthcare in what became the biggest hack to ever hit the healthcare industry. In late January, UnitedHealth Group, the parent company of Change, estimated that 190 million people were effected in the cyberattack. The hack also stymied provider payments nationwide for weeks, with some organizations still feeling the impacts today. Read Full Article…  

HVBA Article Summary

1. Enhancing Information Sharing and Security Clearances: There are still significant barriers to accessing critical cybersecurity information within healthcare. Bailey emphasized the need for hospital CISOs to have security clearances and for a structured mechanism to facilitate information sharing among industry stakeholders, ensuring preparedness for cyber threats.

2. Assessing and Mitigating External Vulnerabilities: Organizations must expand their cybersecurity assessments beyond their internal systems to include third-party vendors and external services. The Change Healthcare attack underscored how disruptions to external platforms can cause industry-wide consequences, making contingency planning essential.

3. Leveraging Cybersecurity Incidents for Organizational Change: The magnitude of the Change Healthcare breach provided a unique opportunity for technology leaders to push for increased cybersecurity investments. Bailey noted that incidents like this help elevate cybersecurity discussions to the executive level, driving proactive risk management and system integrations to prevent future breaches.

Will virtual-first oral care transform employee benefits in 2025?

By Brant Herman - When it comes to health care, today’s consumer expects convenience, choice and accessibility. Although many segments of the health care industry have evolved to meet these demands, dentistry has often lagged. The traditional reliance on physical dental offices creates barriers for many individuals and makes it challenging to prioritize oral health. What’s more, high costs, provider shortages, accessibility issues and dental anxiety frequently lead to deferred care. Read Full Article…

HVBA Article Summary

1. Declining Insurance Participation and Its Impact: A growing number of dentists are opting out of insurance networks due to declining reimbursement rates, with nearly 25% already having withdrawn and another 27% considering it. This trend is making dental care less accessible and could lead to increased out-of-pocket costs for patients.

2. The Role of Virtual-First Dental Care: Virtual-first oral care models offer a patient-focused solution by integrating teledentistry into employee benefits plans. This approach enhances accessibility, reduces treatment delays, and promotes preventive care, ultimately benefiting patients, providers, and insurers.

3. Long-Term Benefits of a Hybrid Dental Care Model: Virtual-first care not only improves convenience and affordability but also fosters a seamless connection between virtual consultations and in-office treatments. By prioritizing prevention and early intervention, this model helps lower healthcare costs, improves oral-systemic health integration, and enhances patient engagement.

What US Health Care Will Look Like in 2035: Key Takeaways from The Doctors Company

By R.E. Anderson - In a recent executive summary titled What U.S. Healthcare Will Look Like in 2035, Dr. Richard E. Anderson, chairman and CEO of The Doctors Company and TDC Group, outlines the significant challenges and transformations shaping the future of health care in the United States. The report examines trends in liability, workforce dynamics, technological advancements, and structural shifts within the healthcare system. Read Full Article…

HVBA Article Summary

1. Rising Malpractice Verdicts and Financial Impact: The increasing frequency of nuclear malpractice verdicts—those exceeding $10 million—is driving up malpractice insurance costs, ultimately leading to higher healthcare expenses for providers and patients. Social inflation and strategic litigation tactics have contributed to this trend, placing pressure on settlement negotiations and threatening established medical liability reforms, such as caps on noneconomic damages.

2. Healthcare Consolidation and Emerging Risks: With 77% of physicians now working in employed models, healthcare consolidation continues to reshape the industry. Despite initial expectations of cost reductions, consolidation has led to higher prices, regulatory scrutiny, and increased cybersecurity threats as larger organizations become prime targets for cyber attacks. Lawmakers are raising concerns over investor-driven decisions that may compromise the affordability and accessibility of essential healthcare services.

3. Expanding Roles and Liability Risks in Healthcare: The growing reliance on nurse practitioners and physician assistants to address the primary care physician shortage introduces new liability risks. As hospital-at-home programs expand and AI-driven technologies become more integrated into healthcare, malpractice coverage and legal frameworks must adapt to evolving risks. Additionally, cybersecurity vulnerabilities, AI-driven decision-making, and the rise of direct-to-consumer healthcare services present new challenges requiring regulatory oversight.

Merck Lowered the Price of Januvia—Insurers Dropped It from Formularies

By Lucia Mueller - In a move that should have been great news for patients, Merck significantly reduced the price of its blockbuster diabetes drug, Januvia (sitagliptin). However, instead of benefiting from the savings, many insured patients are discovering that their insurance plans no longer cover it. Read Full Article…

HVBA Article Summary

1. PBMs Prioritize Profits Over Patients: Despite Merck’s decision to lower Januvia’s price, Pharmacy Benefit Managers (PBMs) like CVS Caremark removed the drug from their formularies, prioritizing their rebate-driven revenue models over patient access to affordable medication. This highlights the misaligned incentives within the U.S. healthcare system.

2. The Rebate Game and Higher Drug Prices: PBMs negotiate large rebates with pharmaceutical companies in exchange for formulary placement. When Merck cut Januvia’s price, PBMs lost rebate revenue, leading them to favor higher-priced alternatives, even if they offer no additional clinical benefit.

3. Patient Backlash and the Urgent Need for Reform: Patients have voiced their frustration over losing insurance coverage for Januvia, exposing the harmful impact of PBM decisions on public health. Without significant PBM reforms, consumers will continue to struggle with access to necessary medications, regardless of drugmakers’ pricing adjustments.

5 benefits strategies for the 'big unknowns' of 2025

By Lisa Wolf - It’s often said the only constant is change — and 2025 is shaping up to be a banner year for just that. With unexpected crises, concerns about inflation, geopolitical volatility abroad and a new political and legislative landscape at home, employees face some big unknowns. And for many, that can be daunting. Read Full Article…  ^{_{(Subscription required)}}

HVBA Article Summary

1. Financial Pressures and Rising Costs: Employees are facing increasing financial stress due to rising rent prices, interest rates, and healthcare costs. With benefits expenses growing, employees are left to manage higher premiums, deductibles, and co-pays, while employers struggle to balance cost containment with offering competitive benefits.

2. Workforce Uncertainty Amidst Policy Changes: Rapidly shifting government policies and executive orders introduce unpredictability in the workplace, making it difficult for employers to assess and address potential impacts. This environment of constant change requires HR professionals to stay agile in managing evolving workforce needs.

3. Supporting Employee Well-Being Through Comprehensive Benefits: Employers can help mitigate workforce uncertainty by offering flexible and holistic benefits, such as financial wellness programs, caregiver support, mental health resources, and legal protections. These offerings help employees navigate life’s unpredictability while fostering a more engaged and resilient workforce.

Novo Nordisk slashes Wegovy price for patients lacking insurance benefits

By Daniel Gilbert - Novo Nordisk said Wednesday it will sell Wegovy for $499 a month in cash to patients who can’t get the blockbuster weight-loss drug through insurance, a bid to reach consumers who can’t afford the $1,349 list price. Read Full Article…  ^{_{(Subscription required)}}

HVBA Article Summary

1. Novo Nordisk's Direct Pharmacy Initiative: Novo Nordisk is launching its own pharmacy service to provide Wegovy directly to uninsured patients and those without coverage for obesity medications, aiming to recapture consumers who turned to compounded weight-loss drugs during the semaglutide shortage.

2. Competitive Pricing and Market Impact
   The company has reduced Wegovy’s out-of-pocket price to $499 per month for cash-paying patients, following a similar strategy by Eli Lilly with its Zepbound discount program. Despite the price cut, experts argue the drug remains costly compared to potential manufacturing costs and international prices.

3. Regulatory and Political Scrutiny
   Novo Nordisk continues to face political and regulatory pressure over drug pricing, with U.S. lawmakers questioning why semaglutide-based drugs are significantly cheaper in other countries. The Biden administration’s Medicare price negotiations and potential expansion of weight-loss drug coverage could impact the market dynamics further.