How Insurers Can Tackle the Challenges of Unstructured Data with AI-Powered Solutions

By Chaz Perera - Unstructured data—such as the contents of emails, forms, invoices, and contracts, where data is fragmented, siloed, or of insufficient quality—lacks a consistent organization, making it difficult to review and analyze using traditional methods (i.e., human power, robotic process automation, intelligent document processing, optical character recognition). In the insurance industry, critical information is locked in these formats, with much of the work still handled manually by personnel in underwriting and claims. Read Full Article…

HVBA Article Summary

1. Identifying and Resolving Data Bottlenecks: Insurers must first conduct a comprehensive data audit, assess data quality, and ensure seamless accessibility to optimize AI-powered automation. Addressing inefficiencies in data flow enhances underwriting and claims management performance.

2. Enhancing Underwriting and Claims Efficiency with AI: AI-driven automation accelerates submission intake, triages underwriting processes, extracts loss histories, and improves claims indexing and processing. This reduces manual effort, speeds up decision-making, and enhances accuracy.

3. Strategic AI Implementation: Build vs. Buy: Insurers must decide between developing in-house AI models, requiring substantial investment in technology and expertise, or partnering with AI solution providers for faster deployment and industry-specific solutions, ensuring long-term competitiveness and efficiency.

Democrats' 'long-shot' healthcare package abruptly fails in last-ditch effort

By Emma Beavins and Noah Tong - A last-ditch effort to pass a bipartisan healthcare package pushed aside at the end of 2024 that includes telehealth extensions and pharmacy benefit manager reform, reverses doc pay cuts and addresses the opioid crisis has failed. Read Full Article…

HVBA Article Summary

1. Legislative Roadblocks and Political Maneuvering: The Bipartisan Healthcare Act, despite having broad bipartisan support, was blocked from fast-tracked approval due to a single objection from Sen. Rick Scott, R-Florida. The attempt to pass the bill via unanimous consent, a method that requires no opposition, failed, highlighting the challenges of navigating healthcare reforms through a divided Congress.

2. Key Healthcare Provisions in the Bill: The legislation aimed to extend Medicare telehealth flexibilities until 2026, implement pharmacy benefit manager (PBM) reforms to curb pricing abuses, and provide a 3.5% increase in Medicare physician payments to counteract previous reductions. Additionally, it proposed Medicaid improvements, public health funding extensions, and support for opioid treatment programs.

3. Budget and Policy Considerations: Despite being budget-neutral, meaning its costs are offset by savings from healthcare reforms, the bill faced opposition from Republicans who may prefer to save cost offsets for future budget reconciliation efforts. Meanwhile, Congress continues to prioritize a stopgap funding bill to prevent a government shutdown, further delaying healthcare reform efforts.

Two studies indicate telehealth didn't increase total Medicare visits, but did drive down post-visit costs

By University of Michigan - Within weeks, the future of telehealth coverage under Medicare will be decided, as pandemic-era flexibilities either expire or Congress acts to extend them or make them permanent. That decision will likely affect telehealth coverage under other forms of health insurance, potentially affecting the care of most Americans. Current Medicare coverage for most telehealth will expire March 31. Read Full Article…

HVBA Article Summary

1. Telehealth Does Not Increase Total Visits: Research findings show that telehealth has not driven up the total number of healthcare visits among Medicare beneficiaries. Instead, telehealth has replaced in-person visits for managing physical and mental health conditions, demonstrating its role as a substitute rather than an additive service.

2. Telehealth Lowers Post-Visit Costs: A study found that Medicare spending in the 30 days following an initial telehealth visit was $82 lower per patient compared to those who had in-person visits. The reduction in costs was attributed to fewer lab tests and imaging studies, despite telehealth patients being slightly sicker on average.

3. Policy Implications for Telehealth in Medicare: The findings provide crucial data for policymakers considering the future of telehealth in Medicare. The research suggests that telehealth increases flexibility for both patients and providers without leading to excessive healthcare utilization or costs, supporting its continued integration into healthcare policy.

Cigna announces major leadership overhaul: New president, COO, and CFO named

By Alan Goforth - The Cigna Group is restructuring its leadership team to accelerate its growth strategy and sharpen its focus on customers and patients. "These leadership changes create a sharpened structure to build upon our strengths for continued growth, enhance our customer focus and deliver even greater value for those we serve," Chairman and CEO David M. Cordani said. Read Full Article…  ^{_{(Subscription required)}}

HVBA Article Summary

1. Leadership Transitions for Strategic Growth: Cigna announced key leadership changes to strengthen its executive team, including Brian Evanko as president and COO, Ann Dennison as executive vice president and CFO, and an expanded role for Nicole Jones, aligning enterprise marketing with her existing responsibilities.

2. Executive Departure and Legacy: Eric Palmer, who played a significant role in Cigna's growth, particularly in the Evernorth Health Services business, will depart at the end of April after a 25-year tenure, leaving behind a legacy of expansion and innovation.

3. Financial Confidence and Future Outlook: Cigna reaffirmed its strong financial projections for 2025, including an adjusted income from operations of at least $29.50 per share, demonstrating confidence in its continued growth and operational success.

Middlemen impact Burke pharmacies, drug prices

By Nathanael Eure - In Burke County, a visit to the local pharmacy is more than just a routine errand - it’s a familiar stop where you can count on a friendly smile behind the counter and personalized care. But small-town pharmacies across the country are facing a looming threat, one that many residents might not even realize exists: Pharmacy Benefits Managers or PBMs. Read Full Article…

HVBA Article Summary

1. Pharmacy Benefit Managers (PBMs) Control Drug Pricing and Reimbursement: PBMs, such as CVS Caremark, Express Scripts, and OptumRx, control about 79% of the market, dictating drug prices and reimbursement rates for pharmacies. Their influence has led to higher costs for patients and financial strain on small, independent pharmacies.

2. Impact on Small-Town Pharmacies: Due to PBM practices like spread pricing, DIR (Direct and Indirect Remuneration) fees, and patient steering, many local pharmacies struggle to stay afloat. Some are forced to sell prescription drugs at a loss, while others are being pushed toward closure, reducing access to essential medications in rural areas.

3. Legislative Efforts and Call for Reform: Efforts to regulate PBMs in North Carolina have faced legislative roadblocks, such as the stalling of House Bill 246. However, lawmakers, including Rep. Hugh Blackwell, have introduced House Bill 163 to push for greater transparency and fair practices to protect small pharmacies and consumers.

JPMorgan faces employee lawsuit over its handling of CVS-run prescription drug plan

By Dulan Lokuwithana - A group of current and former employees of JPMorgan Chase (NYSE:JPM) has filed a lawsuit alleging that the company, through its prescription drug plan run by CVS Health (NYSE:CVS), overpaid for medicines, resulting in higher expenses for its workers, according to Bloomberg News. Read Full Article…

HVBA Article Summary

1. Allegations of Overpriced Medication Purchases: The lawsuit claims that JPMorgan paid significantly higher prices for prescription medicines than uninsured employees would pay, with an analysis showing an average markup of over 200% on hundreds of generic drugs.

2. Disbanding of Haven Healthcare Initiative: The plaintiffs argue that JPMorgan prematurely shut down its joint healthcare venture with Amazon and Berkshire Hathaway, which aimed to provide affordable healthcare for employees, citing external pressures.

3. Claims of Industry Backlash: The complaint alleges that JPMorgan discontinued the Haven project due to opposition from major banking clients in the healthcare sector, suggesting potential conflicts of interest in the company’s healthcare strategy.

PBM rebate law leads to dramatic premium reductions in West Virginia

By Allison Bell - West Virginia insurance regulators have evidence that requiring pharmacy benefit managers to pass all prescription drug rebates through to employers could lead to huge premium savings in the small-group health insurance market. Read Full Article…  ^{_{(Subscription required)}}  

HVBA Article Summary

1. Significant Cost Reduction for Small-Group Employers – The state's PBM rebate pass-through law reduced the average 2025 small-group rate increase by 52%, with final rate changes averaging 9.5% instead of the projected 18.2% without the requirement. Individual issuer savings ranged from 39.7% to 63.9%.

2. Moderate Impact on Large-Group Market – In the large-group market, the rebate pass-through requirement led to an average rate savings of 16.7%, with some insurers experiencing no impact while others saw savings up to 33.2%.

3. Unresolved Questions About PBM Practices – While the West Virginia report supports concerns raised by PBM critics like Mark Cuban, it relies on insurer-reported data without detailed methodology, leaving uncertainty about the true impact of rebate pass-through requirements on insurance premiums.

The High Price of Treatment Resistant Depression for Employers

By Marcus Capone - Employer healthcare costs are surging. This year, they’re projected to rise 9%, yet one of the biggest cost drivers remains ignored: treatment-resistant depression (TRD). Untreated mental health conditions cost U.S. businesses $193 billion annually in lost productivity, absenteeism, and turnover. Read Full Article…

HVBA Article Summary

1. The Cost of Ignoring TRD: Treatment-resistant depression (TRD) leads to lower productivity, increased absenteeism, and higher turnover, all of which drive up the overall cost per employee. Traditional Employee Assistance Programs (EAPs) are not enough for those who have exhausted standard treatments, making TRD a financial risk employers can no longer ignore.

2. The Need for Innovative Solutions: Breakthrough treatments like ketamine-assisted therapy (KAT) are delivering real results, offering faster recovery and improved productivity. With growing adoption by leading medical institutions and FDA-approved treatments like Spravato (esketamine), forward-thinking employers are integrating these therapies into their benefits programs.

3. A Strategic Approach to Workplace Mental Health: Employers can reduce medical costs, enhance productivity, and improve retention by incorporating evidence-based mental health solutions. By expanding benefits, integrating innovative treatments like KAT, and fostering a supportive work environment, businesses can create healthier workplaces while safeguarding their bottom line.