CMMI to cut participation in payment models, estimates $750M in savings

By Noah Tong - The Center for Medicare and Medicaid Innovation (CMMI) will stop certain payment models by the end of the year. Without going into specifics initially, the Centers for Medicare & Medicaid Services' (CMS') Innovation Center said it conducted a “data-driven review” of all the agency’s models. Some of the models will “conclude as scheduled,” while others will stop by the end of 2025, a news release said. The CMS said this should result in $750 million in savings, without giving more details. Read Full Article…

HVBA Article Summary

1. Strategic Realignment and Model Terminations: The CMS Innovation Center is shifting its strategy to align with the priorities of the new administration, leading to the termination of several models, including the Medicare $2 Drug List Model, the Total Cost of Care Model in Maryland, and multiple primary care models. This restructuring aims to streamline initiatives while maintaining a focus on affordability and innovation in healthcare payment systems.

2. Preserving Drug Cost Initiatives and Future Plans: Despite the discontinuation of the Medicare $2 Drug List Model, CMS has reiterated its commitment to making prescription drugs more affordable. Provisions from the Inflation Reduction Act will continue to shape Part D benefits, and a revised version of the $2 Drug List Model is expected to launch in 2027.

3. Shifting Focus and Reducing Program Scope: CMS is not only eliminating underperforming models but also reassessing the scope of existing programs, such as the Integrated Care for Kids awards. Additionally, it will transition the Maryland Total Cost of Care Model to the AHEAD Model, indicating a broader shift in approach toward cost containment and targeted healthcare improvements.

House passes bill with short-term wins for hospitals

By Alan Condon - House Republicans on March 11 passed legislation to keep the government running through Sept. 30 and extend several critical healthcare provisions that were due to expire March 31. Read Full Article…

HVBA Article Summary

1. Key Healthcare Extensions: The continuing resolution, narrowly passed in the House, extends crucial healthcare provisions through Sept. 30, including the elimination of Medicaid disproportionate share hospital cuts, telehealth waivers, the hospital-at-home program, and rural healthcare funding adjustments.

2. Medicare Physician Pay Concerns: Despite these extensions, physicians and medical groups have criticized lawmakers for not addressing the 2.83% cut to Medicare physician reimbursement. A temporary 2.5% pay increase that took effect on Jan. 1 was omitted from the latest funding package.

3. Potential Medicaid Cuts Loom: The Senate is expected to vote on a Republican-backed proposal to cut federal spending by up to $2 trillion over the next decade, with Medicaid likely to face significant reductions. A Congressional Budget Office report warns that achieving $880 billion in savings would require deep cuts to Medicaid or the Children's Health Insurance Program.

Lawmakers revive PBM reporting bill after near-passage last session

By Allison Bell - A Republican and a Democrat are bringing back a pharmacy benefit manager reporting bill that nearly became law during the 118th Congress. Rep. Erin Houchin, R-Ind., and Rep. Joe Courtney, D-Conn., introduced a version of the Hidden Fees Disclosure Act bill for the 119th Congress Tuesday. Read Full Article…  ^{_{(Subscription required)}}

HVBA Article Summary

1. Increased Transparency for PBMs and TPAs: The bill would require pharmacy benefit managers (PBMs) serving self-insured employer health plans to provide detailed reports on all compensation received, including negotiated rebates, discounts, and payments to other service providers. Similarly, third-party administrators (TPAs) would need to disclose financial transactions related to fees, rebates, and recoveries from service providers.

2. Legislative Progress and Political Context: The bill was included in the Lower Costs, More Transparency Act, which passed the House with bipartisan support (320-71) in December. However, it was removed from a larger spending package following Elon Musk’s push for a leaner bill, though his and former President Donald Trump's specific stance on PBM-related provisions remains unclear.

3. Ongoing Debate Over PBMs’ Role: While PBMs argue that their cost-management strategies help control drug prices and reduce profit margins for pharmacies and wholesalers, critics claim that the industry is too concentrated, hinders competition, and retains excessive savings from negotiated discounts. Lawmakers supporting the bill, such as Rep. Erin Houchin, argue that it will help expose hidden healthcare costs to patients and policymakers.

What does Trump's new price transparency order mean for insurers?

By Jakob Emerson - President Donald Trump signed an executive order in February that directs HHS, and the Labor and Treasury departments to "rapidly implement and enforce" price transparency regulations that were introduced during his first term. Read Full Article…

HVBA Article Summary

1. Enhanced Price Transparency Enforcement: The new executive order mandates that hospitals and insurers disclose actual prices instead of estimates, strengthening enforcement mechanisms to ensure compliance. This move aims to provide consumers with clear, straightforward, and accessible healthcare pricing information.

2. Uniform Application and Consumer-Friendly Data: While insurers have been required to disclose pricing information since 2022, the challenge has been ensuring the data is presented uniformly and in a consumer-friendly manner. The order pushes for standardization across hospitals and insurers to improve accessibility and comparability.

3. Empowering Consumers and Driving Innovation: By making price data more actionable, the order enables consumers to make informed decisions about their healthcare choices, reducing reliance on intermediaries. This transparency also opens the door for technology-driven solutions, such as AI and digital tools, to further enhance consumer engagement and cost efficiency in healthcare.

Women spend 30% more out-of-pocket for health care than men, study finds

By Alan Goforth - Women in the United States consistently spend 30% more out-of-pocket on health care than men do, new research from GoodRx found. Last year alone, women spent $39.3 billion, which was $8.8 billion more than the $30.5 billion spent by men. Read Full Article…  ^{_{(Subscription required)}}  

HVBA Article Summary

1. Higher Health Care Utilization Drives Costs: Women tend to visit doctors more frequently, fill more prescriptions, and manage more chronic conditions than men. This results in higher out-of-pocket costs, but also helps prevent even greater medical expenses in the long run. If left untreated, conditions like migraines, anxiety, and asthma can significantly impact productivity, quality of life, and overall health expenditures.

2. The Steepest Price Gap Affects Women in Their Prime Years: Women aged 18 to 44 experience the largest health care cost disparity, spending up to 64% more than men on prescriptions alone. This burden persists as women age, with those aged 45 to 64 spending 35% more and women over 65 still outspending men by 17%. These disparities reflect both higher utilization rates and the financial toll of gender-specific health conditions.

3. Women Bear a Disproportionate Mental Health Cost: Women spend significantly more on mental health treatments, including 113% more on depression medications and 103% more on anxiety treatments compared to men. Higher prescription fill rates further amplify these costs, with women filling depression prescriptions 112% more often than men and spending 58% more on insomnia medications. These disparities highlight the hidden financial burden of gendered health care expenses.

Trump administration proposes ACA program integrity rule that would decimate enrollment

By Rebecca Pifer - The Biden administration made it easier and more affordable to sign up for ACA plans, causing enrollment to swell to an all-time high. This year, 24 million Americans choose plans in the the exchanges set up by the decade-old law.. Read Full Article…

HVBA Article Summary

1. Restricting ACA Access and Enrollment: The proposed rule introduces stricter verification requirements for special enrollment periods, reduces the timeframe for subsidy eligibility reconciliation, and imposes a $5 monthly premium for automatically re-enrolled individuals. These measures could make it harder for Americans, especially lower-income individuals, to access and maintain ACA coverage.

2. Targeting Fraud but Affecting Vulnerable Populations: While the rule aims to combat fraudulent enrollments, experts argue that it primarily burdens enrollees rather than addressing unscrupulous brokers. Limiting special enrollment periods and shortening the open enrollment window could disproportionately impact those who need coverage the most, potentially destabilizing ACA risk pools.

3. Broader Policy and Industry Implications: The rule aligns with broader Trump administration priorities, including rolling back gender-affirming care protections and restricting coverage for “Dreamers.” It also poses risks for insurers that have relied on ACA marketplace growth, as tighter regulations may shrink enrollment and affect profitability.

To reduce healthcare costs, address chronic conditions

By Lee Hafner - Your company is spending a lot on traditional healthcare coverage — and probably multiple supplemental wellness offerings — to help workers manage chronic conditions. Providing a single-point solution that helps employees manage multiple conditions can improve their health, consolidate benefits and cut down on employer costs. Read Full Article…  ^{_{(Subscription required)}}

HVBA Article Summary

1. The Burden of Chronic Conditions in the U.S.: Compared to other high-income countries, the U.S. has the highest rate of adults managing multiple chronic conditions, leading to significant healthcare costs and financial losses for employers due to absenteeism and reduced productivity. Managing these conditions also results in higher prescription drug usage, with individuals suffering from chronic illnesses requiring multiple medications.

2. Challenges in Navigating Healthcare and Medication Management: Many individuals with chronic conditions interact frequently with the healthcare system but face difficulties navigating multiple providers and employer-provided health solutions. Patients often receive numerous prescriptions from different doctors without comprehensive oversight, making medication management complex and inefficient.

3. The Role of Integrated Health Management Platforms: Integrated health management platforms provide personalized guidance, pharmacist support, and AI-driven insights to help individuals manage their health more effectively. Employers benefit from improved engagement, better health outcomes, and long-term cost savings by simplifying healthcare access and coordination for employees with chronic conditions.

Women under financial strain: 4 in 10 report high stress levels

By Michael Popke - Four in 10 women are experiencing high stress levels about their household finances, which is higher than the rate for men. As a result, 63% of women agree that workplace benefits are integral to their overall financial wellness, and nearly 7 in 10 say their employer should provide benefits that address their financial stress. Read Full Article…  ^{_{(Subscription required)}}

HVBA Article Summary

1. Financial Concerns and Retirement Security: Women, particularly younger women and those with financial dependents, are more likely than men to worry about financial stability, including saving for retirement, building an emergency fund, covering long-term care expenses, and managing potential income loss due to disability.

2. Gaps in Benefits Understanding and Satisfaction: Women report lower confidence in understanding their employee benefits, such as life insurance and retirement plans, and are less satisfied with their overall benefits package compared to men. This is influenced by factors like part-time employment status and limited access to benefits. Even among full-time employees, only 42% of women express satisfaction with their benefits.

3. Need for Better Education and Communication: To improve women's financial wellness and job satisfaction, employers should provide more frequent and accessible benefits education. While most women currently receive benefits information only during open enrollment, 70% prefer ongoing updates throughout the year. Enhanced communication, along with a focus on mental health support, can foster a more engaged and satisfied female workforce.