House GOP leaders set sights on dental, vision markets following PBM reform

By Allison Bell – Three of the House Republicans who put the pharmacy benefit manager transparency provisions in the Consolidated Appropriations Act of 2026 are now turning their attention to dental plans and vision plans. The lawmakers involved are Rep. Brett Guthrie, R-Ky., chairman of the House Energy and Commerce Committee; Rep. Morgan Griffith, R-Va., the chairman of the committee's Health Subcommittee; and Rep. Early "Buddy" Carter, R-Ga., the former chairman of the Health Subcommittee. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Dental Insurance Markets Show High Concentration: The U.S. Government Accountability Office analyzed 2024 data from the National Association of Insurance Commissioners and found that the top three group dental insurers in a state control a median 66.8% of the market. Affiliates of Delta Dental or Blue Cross and Blue Shield were the largest group dental insurers in 30 states, with Delta Dental leaders averaging 46% market share and Blue Cross and Blue Shield leaders averaging 39%. Other companies leading individual state markets include Renaissance Life & Health Insurance Company of America in eight states, Cigna in three states, MetLife in three states, and Guardian Life Insurance Company of America in two states.

2. Vision Insurance Markets Even More Concentrated: The GAO report found that the top three group vision insurers in a state hold a median 77.4% of the market, indicating an even higher level of concentration than in dental insurance. While market insiders reported little evidence that insurer ownership of providers significantly affects dental markets, they indicated that vertical integration does influence the vision insurance market. The GAO conducted this analysis in response to a request from members of Congress but did not provide policy recommendations in its report.

3. Legislation Targets Dental and Vision Network Practices: The findings come as lawmakers continue debating federal regulation of dental and vision insurance networks. The proposed Dentist and Optometric Care Access Act of 2025introduced by Buddy Carter would restrict insurers from setting prices for services they do not substantially cover, except dental cleanings. The bill would also limit contract durations for limited-scope dental or vision benefits and prevent plans from restricting providers’ choice of laboratories or suppliers, potentially increasing employer and benefits advisor attention to dental and vision provider networks.

We Destroyed One of the Best Health IT Systems Ever Built — and Replaced It With Something Worse

By Rachel Madley, PhD – There is a pattern in American policy that repeats itself so often it begins to feel inevitable. A public program succeeds against the odds. It proves that government can solve complex problems. Private companies recognize both a threat and an opportunity. Lobbyists descend on Washington. And gradually the successful public system is dismantled or replaced with a privatized alternative that costs more and often works worse. Read Full Article...

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1. VistA’s Success and Replacement: The Veterans Affairs’ VistA electronic health record system was widely regarded as a highly effective, user-friendly, and innovative public-sector health IT solution. Despite its strong performance and international recognition, the system was replaced by a commercial alternative through a non-competitive process. The decision was influenced by political pressure and lobbying, rather than a transparent evaluation of the system’s merits.

2. Cost and Efficiency Concerns: The transition from VistA to the Oracle Cerner Millennium platform has proven to be significantly more expensive than maintaining and modernizing the original system. While VistA could have been updated for a fraction of the cost, the new system’s implementation has already exceeded initial budget estimates, with total expenses projected to reach up to $50 billion. This shift has raised questions about the fiscal responsibility and efficiency of privatizing public digital infrastructure.

3. Impact on Care and Data Ownership: The new commercial system has faced operational challenges, including reduced clinical productivity and concerns about patient safety at deployment sites. Additionally, the privatization of the health IT platform introduces ambiguity regarding the use and value extraction from veterans’ clinical data by private vendors. The article argues that this change represents a broader trend of prioritizing private revenue streams over public benefit, potentially undermining both care quality and public sector innovation.

Ransomware groups target vendors to get into hospitals

By Ron Southwick – Ransomware groups have targeted hospitals for years, and they are expanding their targets even as they refine their tactics. While criminals are certainly trying to get into hospitals, they are also more and more apt to go after the vendors that health systems rely on for so many business functions, says Russell Teague, chief strategist and security officer of Fortified Health Security, a cybersecurity firm. “The third-party landscape is one of the fastest growing and largest attack surfaces that any hospital has to deal with,” Teague tells Chief Healthcare Executive®. Read Full Article...

HVBA Article Summary

1. Third-Party Vendors as Entry Points: Ransomware attackers are increasingly targeting third-party vendors that hospitals depend on for various business functions. This shift is due to the growing number of partnerships hospitals form to enhance their operations, which inadvertently expands their vulnerability to cyberattacks. As a result, the security of vendors is becoming as critical as the security of the hospitals themselves.

2. Resource Constraints for Smaller Hospitals: Smaller hospitals and health systems are perceived as easier targets because they often lack the resources to invest heavily in cybersecurity compared to larger organizations. Leaders at these institutions face difficult choices between allocating funds for patient care or for cyber defenses. This financial dilemma leaves them more exposed to ransomware threats and increases their risk of operational disruption.

3. Evolving Tactics with AI and Regulatory Gaps: Ransomware groups are leveraging artificial intelligence to automate the search for vulnerabilities, such as outdated or unsupported systems within hospital networks. While some industries have benefited from stronger regulatory frameworks that reduce attack frequency, healthcare is still catching up. Experts recommend that hospitals proactively strengthen their cybersecurity measures rather than waiting for new regulations, as attackers continue to innovate and exploit gaps.

CMS threat to Elevance could bring financial consequences

By Caroline Catherman – CMS and Elevance are playing a game of Risk. In a Feb. 27 letter, the federal regulator threatened sanctions that would be effective March 31—including freezing new Medicare Advantage Prescription Drug (MA-PD) plan enrollment—in response to the payer’s alleged “substantial and persistent noncompliance” with Center for Medicare and Medicaid Services (CMS) rules. The letter claims Elevance hasn’t been properly uploading necessary data to calculate patient risk scores, a metric that determines the size of government payments to MA plans. Elevance allegedly didn’t report or return associated overpayments, either. Read Full Article...

HVBA Article Summary

1. CMS Sanctions and Data Compliance: The Centers for Medicare and Medicaid Services (CMS) has accused Elevance of failing to properly upload risk score data and not returning overpayments, which are both required for accurate Medicare Advantage payments. Instead of using the mandated electronic systems, Elevance submitted corrections via encrypted USB drives, a method CMS explicitly rejected. This alleged noncompliance has persisted for over seven years, prompting CMS to threaten sanctions including freezing new plan enrollments.

2. Potential Financial Impact Beyond Enrollment Freeze: While Elevance was already planning to reduce its Medicare Advantage enrollment due to rising medical costs, the CMS sanctions could have broader financial consequences. If Elevance is required to refund overpayments for unsupported diagnoses, the financial exposure could be significant and potentially more impactful than the enrollment suspension itself. The exact amount Elevance might have to repay is unclear, but the Medicare Payment and Advisory Commission estimates the government overpays Medicare Advantage plans by tens of billions of dollars annually.

3. Industry Precedent and Regulatory Scrutiny: CMS has previously imposed similar sanctions on other insurers, such as Cigna, which faced a lengthy process to regain enrollment privileges after violations. However, experts note that pairing an enrollment freeze with the possibility of large-scale recoupment is unusual and could set a new precedent for regulatory enforcement. This situation highlights increasing scrutiny of Medicare Advantage plan compliance and the financial risks for insurers that do not adhere to CMS rules.

FTC seeing 'progress' in discussions with Optum, Caremark in insulin case

By Paige Minemyer – The Federal Trade Commission (FTC) may be nearing settlements with the remaining two pharmacy benefit managers involved in a lawsuit over insulin pricing. In a court filing (PDF) posted this week, the agency disclosed that it is making "significant progress" in talks with both CVS Health's Caremark and UnitedHealth Group's Optum Rx on the heels of a broad settlement with Cigna's Express Scripts. In late January, the FTC suspended the administrative case against Express Scripts, indicating a settlement was in the works. That settlement was later confirmed Feb. 4, with the PBM agreeing to a slew of changes to resolve allegations that it unlawfully and artificially inflated the price of insulin. Read Full Article...

HVBA Article Summary

1. Ongoing Negotiations with Major PBMs: The FTC is currently in advanced discussions with CVS Caremark and Optum Rx regarding their roles in alleged insulin price inflation. These negotiations follow a recent settlement with Express Scripts, another major pharmacy benefit manager (PBM) involved in the case. The agency has extended the timeline for hearings and arguments to allow more time for potential settlements.

2. Details of Express Scripts Settlement: Express Scripts agreed to several changes, including not listing drugs at high wholesale acquisition costs and offering lower-cost options on its formularies. The company will also provide a standard benefit that bases out-of-pocket costs on the net price of drugs, rather than the list price, and will include the TrumpRx platform in its offerings. These measures aim to address concerns about rebate-driven pricing models that may have contributed to higher insulin costs.

3. Potential Impact and Uncertainty: The FTC's lawsuit centers on the allegation that the "Big Three" PBMs—CVS Caremark, Optum Rx, and Express Scripts—artificially raised insulin prices by prioritizing rebates over net prices. While the settlement with Express Scripts is public, the specifics of any agreements with Optum or Caremark have not been disclosed. If settlements are not reached, the case could proceed to hearings and a commission ruling later in the year.

Hospitals, Drugmakers, and U.S. Government Continue Battle Over 340B Program

By Joyce Frieden – A federal judge handed down a decision this week in a lawsuit involving the 340B prescription drug discount program as hospitals, physicians, and drug manufacturers continue to battle over how the program should be run. "The 340B program is definitely getting squeezed in various ways, and 340B entities are having some success in preventing the squeeze," said Sven Collins, partner at the Hooper Lundy & Bookman law firm in Denver. "They're trying to make the program work according to how it's written in the statute, which is trying to provide discounted drugs for safety-net hospitals ... And drug manufacturers are trying to throw wrenches in the works." Read Full Article...

HVBA Article Summary

1. 340B Program Provides Drug Discounts for Safety-Net Providers: The 340B Drug Pricing Program allows hospitals and healthcare providers that serve a high proportion of low-income patients to purchase outpatient medications at discounts averaging 25%–50%. These savings are intended to help providers expand services, reach more eligible patients, and reduce overall drug costs. The program aims to stretch limited federal healthcare resources while supporting broader access to care.

2. Federal Court Rules Against HRSA Child Site Registration Requirement: A federal judge ruled in Albany Med Health System v. Kennedy that HRSA’s requirement for hospitals to register each off-campus “child site” before dispensing 340B drugs conflicts with the statute. Hospitals argued the approval process could take up to two years, preventing eligible locations from accessing discounted drugs during that time. The decision represents a significant legal victory for hospitals participating in the 340B program, although it may still be appealed.

3. Ongoing Disputes Over Data Reporting and Medicare Reimbursement: Drug manufacturers Eli Lilly and Novo Nordisk have asked hospitals to provide claims data for their drugs in order to receive 340B discounts, a proposal hospital groups say could add administrative burdens and restrict access to the program. At the same time, policymakers are debating Medicare reimbursement rates for drugs purchased under 340B, with CMS proposing to collect survey data that could support lower payments to hospitals. Stakeholders continue to disagree over transparency requirements and whether program savings are being used to benefit patients.

Lilly Employer Connect Adds Flexibility for Employers But Isn’t Revolutionary, Expert Says

By Marissa Plescia – Rising prescription drug costs are top of mind for employers, and GLP-1s are partly responsible. The drugs — while proven highly effective — come at a hefty price tag, leading to many employers having to make tough decisions around GLP-1 coverage for weight loss. Recognizing this, Eli Lilly launched Lilly Employer Connect on Thursday, a platform that provides tailored coverage options for obesity care in partnership with over 15 digital health companies. However, while the platform provides more flexibility for employers, it isn’t a monumental improvement, at least one expert says. Read Full Article...

HVBA Article Summary

1. Incremental Flexibility for Employers: Eli Lilly’s Employer Connect platform offers employers more tailored options for covering obesity medications, particularly GLP-1s like Zepbound. While this approach allows employers to choose from a variety of digital health partners and potentially negotiate better terms, experts note that the changes are not transformative. The platform is seen as a step forward in providing flexibility but does not drastically alter the cost or access landscape for most employers.

2. Shift in Industry Dynamics: The launch of this platform reflects a broader shift in how pharmaceutical companies and pharmacy benefit managers interact with employers and independent vendors. Previously, employers risked losing rebates if they worked with independent vendors for GLP-1 access, but now manufacturers like Lilly are embracing direct partnerships. This evolution signals growing acceptance of alternative distribution models and increased employer control over drug benefits.

3. Market Trends and Cost Pressures: Experts anticipate that increased competition from digital and direct-to-consumer platforms, specialty compounders, and new oral obesity treatments will likely lead to price compression in the market. Lilly’s move acknowledges both the significant economic impact of obesity and the growing demand for affordable, accessible treatment options. However, the current pricing structure of the Employer Connect program is not substantially lower than what many employers already pay, suggesting that major cost savings may still be out of reach for now.

Why pet insurance is becoming an expected benefit

By Ron Agatep – For years, pet insurance sat in the nice-to-have category of workplace benefits, but that perception has shifted dramatically in recent years. Brokers are finding that the employee populations they serve no longer view pet insurance as an appreciated add-on. Rather, it's something they're asking for outright. This is especially true for younger workers who view pets as true members of their household and want the same level of protection for them that they expect for themselves. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Changing Employee Expectations: Pet insurance has evolved from a niche benefit to a mainstream expectation among employees, particularly younger generations. Millennials and Gen Z are increasingly prioritizing their pets' well-being and are seeking benefits that reflect their lifestyles and values. This shift is prompting employers to reconsider what constitutes a competitive benefits package.

2. Financial Security and Ease of Use: The rising costs of veterinary care can create financial stress for employees, making pet insurance an attractive option for those seeking stability. Employers offering pet insurance help their teams avoid unexpected expenses and demonstrate an understanding of employees' real-life concerns. Additionally, modern pet insurance is designed to be simple and user-friendly, with quick claims processing and minimal administrative burden.

3. Overcoming Employer Misconceptions: Some employers hesitate to offer pet insurance due to misconceptions about complexity or perceived lack of interest among staff. However, pet insurance is typically employee-paid and can be integrated into existing voluntary benefits platforms without additional employer funding. With a significant portion of U.S. households owning pets, providing this benefit can enhance employee satisfaction and retention.