Report Shows How UnitedHealth Group Is Enriching Itself At The Expense Of Our Nation’s Veterans

By Wendell Potter - At a recent Congressional hearing in Washington, Rep. Mark Takano (D-California), the top Democrat on the House Veterans Affairs Committee, directed a series of questions to the CEO of the health care company Optum, a wholly owned subsidiary of UnitedHeath Group. The exchange helped expose an alarming and growing problem in veterans’ health care in this country: massive overbilling by large, for-profit insurance conglomerates. Read Full Article…  

HVBA Article Summary

1. Massive Overpayments to TPAs – The Veterans Health Administration (VHA) overpaid third-party administrators (TPAs) like Optum and TriWest by more than $1 billion between 2020 and 2024, with Optum alone receiving over $105 million in excess payments from 2020 to 2022. These overpayments stem from incorrect rate charges and contractual loopholes that allow insurers to bill the government beyond their actual reimbursement costs.

2. Systemic Billing Abuses – Investigators found that private insurers administering the Veterans’ Community Care Program engage in practices similar to Medicare Advantage overbilling, including upcoding and double billing. A previous 2021 OIG report highlighted that providers billed higher-paying evaluation and management codes at disproportionately high rates, costing the VA an additional $59.6 million between 2020 and 2022.

3. Rep. Takano’s Accountability Push – Through his questioning, Rep. Takano exposed how these massive healthcare corporations profit at the expense of veterans, highlighting systemic flaws in VA contracting and oversight. His efforts underscore the need for stronger safeguards and accountability measures to protect veterans and taxpayers from financial exploitation.

Congress extends Medicare telehealth flexibilities for 6 months

By Emily Olsen - The continuing resolution signed into law Saturday allows temporary changes to telehealth rules first enacted during the COVID-19 pandemic to continue, such as allowing patients to receive telehealth care in their homes or expanding the types of providers who can offer virtual care. Read Full Article…

HVBA Article Summary

1. Temporary Extension of Medicare Telehealth Flexibilities – The latest short-term government funding bill extends Medicare telehealth flexibilities through September 30, preventing their expiration just weeks before the deadline. While telehealth groups welcomed the extension, they also emphasized the need for a permanent policy to ensure stability for providers and patients.

2. Ongoing Uncertainty in Telehealth Policy – Despite bipartisan support, telehealth remains in policy limbo, with previous attempts to secure long-term extensions failing due to cost concerns. The unpredictability of Medicare’s virtual care coverage makes it difficult for healthcare providers to plan investments and for insurers to align their policies accordingly.

3. Expansion of Acute Hospital Care at Home Program – Along with telehealth flexibilities, the bill extends the Acute Hospital Care At Home program through September. However, other key telehealth provisions, like first-dollar coverage for telehealth on high-deductible plans, were left out, raising concerns about gaps in virtual care access.

'This cannot be another fleeting moment in time'

By Paul Wilson - Benefits advisors and their peers and partners are no strangers to change. For years — OK, decades — now, upheaval and uncertainty have been the norm. So far, 2025 is no exception, and in many cases, is even ratcheting things up to a new level. As Tracy Watts, senior Partner and National Leader of U.S. Health Policy at Mercer puts it, “It’s a challenging time, but when isn’t it?” Read Full Article…  ^{_{(Subscription required)}}

HVBA Article Summary

1. Regulatory Uncertainty and Industry Disruption – The incoming Trump administration brings a wave of regulatory upheaval, with significant changes in leadership and health care policy. Experts highlight the unprecedented nature of this transition, marked by uncertainty and the need for agility in navigating shifting regulations and rapid industry changes driven by technology and disruptors.

2. Crisis of Trust and Industry Accountability – The assassination of UnitedHealthcare CEO Brian Thompson has underscored a deepening crisis of trust within the health care system. Consumers are demanding accountability, transparency, and systemic reform. This moment serves as a stark reminder of the growing disconnect between industry stakeholders and the public, prompting urgent calls for meaningful change.

3. Strategic Adaptation and Long-Term Commitment – Amid rising costs and evolving regulatory landscapes, industry professionals must focus on long-term strategies rather than quick fixes. Experts emphasize the importance of proactive engagement, education, and advocacy to drive sustainable health care solutions. The industry faces a critical inflection point—will it resist change or lead the charge toward transformation?

Ransomware Attacks Continued To Increase during 2024's Final Quarter

By Captive.com - Organizations experienced an increase in ransomware attacks during the fourth quarter of 2024, according to the Q4 2024 Cyber Threat Report from The Travelers Companies, Inc. The report, which is based on data collected from ransomware leak sites, showed ransomware groups using repeatable attack methods such as targeting virtual private network accounts that had weak credentials and were not protected by multifactor authentication (MFA). Read Full Article…

HVBA Article Summary

1. Basic Attack Techniques Remain Effective – Despite advancements in cybersecurity, ransomware groups continue to find success using fundamental attack methods. Businesses must prioritize proven security controls, such as multi-factor authentication (MFA), to strengthen their defenses.

2. Emergence of New Ransomware Groups – Law enforcement actions against major Ransomware-as-a-Service platforms have led to the rise of smaller, more agile cybercriminal groups, increasing the overall threat landscape.

3. Targeting of Key Industries and IT Services – Ransomware attacks are increasingly focusing on IT services and consulting firms, amplifying the impact due to their connections with multiple clients. The construction and healthcare sectors remain primary targets in 2024.

'Fully transparent' PBMs may not cut costs, Segal health expert says

By Allison Bell - A health benefits expert is telling state insurance regulators that he's skeptical about some of the pharmacy benefit manager rule change proposals now getting the most attention. Many current PBM prescription drug price transparency efforts have problems, and efforts to please pharmacies with "any willing provider" rules — which let any pharmacy willing to sell drugs at the prices requested by a health plan serve the plan's participants — may actually increase prices, according to Ed Kaplan, the national health practice leader at Segal. Read Full Article…  ^{_{(Subscription required)}}

HVBA Article Summary

1. Expanding Revenue Streams: Pharmacy Benefit Managers (PBMs) are no longer just intermediaries in drug pricing; they are actively increasing their revenue through at least 11 different mechanisms, including transaction fees and data-sharing fees. Now, they are further expanding their financial footprint by acquiring generic drug manufacturers and entering the drug production space, raising concerns about conflicts of interest and the potential impact on drug pricing.

2. Challenges of Transparency: While some PBMs claim to enhance price transparency in the pharmaceutical industry, Kaplan remains skeptical, emphasizing that, in practice, "pure transparency" does not yet exist. He argues that there is no concrete evidence that these transparency initiatives are driving down costs on a per-member, per-month basis, making it unclear whether they benefit consumers or simply serve as a marketing tool for PBMs.

3. Stronger Oversight & Accountability: To address rising drug costs and the opaque financial practices of PBMs, Kaplan calls for stricter regulatory oversight. He advocates for rules that ensure 100% of manufacturer rebates are passed directly to employer plan sponsors or participants. Additionally, he stresses the need for stronger audit rights and full disclosure of all manufacturer revenue sources, with protections in place through confidentiality agreements to safeguard sensitive business information.

GLP-1s Are Crazy Effective — Just Not Cost-Effective

By F. Perry Wilson, MD, MSCE - Much of my time in these videos is spent talking about whether a drug or supplement or diet or intervention works or not. That’s the central focus of medical science: Can we do something for a patient and make a difference in their health? But there’s a related question that we rarely discuss that is almost equally as important: Is this drug or supplement or diet or intervention worth it? Read Full Article…

HVBA Article Summary

1. Effectiveness vs. Cost – The GLP-1 receptor agonists, such as tirzepatide and semaglutide, are among the most effective weight loss drugs available, significantly reducing obesity, diabetes, and heart disease rates. However, their high cost—exceeding $200,000 per quality-adjusted life year (QALY)—makes them far less cost-effective than other interventions, such as smoking cessation programs or statins.

2. The Cost-Effectiveness Threshold – Economists and policymakers generally consider treatments that cost under $100,000 per QALY as cost-effective. At their current prices, GLP-1 drugs exceed this threshold, making them an unsustainable option for widespread insurance coverage unless prices drop significantly—by approximately 30% for tirzepatide and 82% for semaglutide.

3. Future Considerations – Prices for these drugs are expected to decline over time with generic competition (beginning in the 2030s), potentially improving cost-effectiveness. Alternative strategies, such as short-term use followed by lifestyle changes, could also improve affordability. However, until prices adjust, insurers are unlikely to broadly cover GLP-1 drugs based on long-term cost savings alone.

Copay Accumulator And Maximizer Programs: Stakes Rise For Patients As Federal Rulemaking Lags

By Kimberly Westrich, Lisabeth Buelt, Arjun Narain, John Michael O’Brien - Health care costs in the United States continue to rise, placing greater financial pressure on health care purchasers and consumers. According to the KFF’s 2024 Employer Health Benefits Survey, average annual premiums for employer-sponsored health insurance increased in 2024 to $8,951 for individual coverage and $25,572 for family coverage, an annual increase of 6 percent and 7 percent, respectively, outpacing both wage growth and inflation. Read Full Article…

HVBA Article Summary

1. The Growing Use of Copay Accumulator and Maximizer Programs
   Health care payers are increasingly adopting copay accumulator and maximizer programs to control prescription drug costs by shifting financial responsibility to patients and manufacturers. While these programs help insurers manage spending, they can lead to higher out-of-pocket (OOP) costs for patients, reduced medication adherence, and worsened health outcomes.

2. Regulatory and Legal Challenges
   Legal and regulatory developments at both state and federal levels have sought to address the impact of cost-shifting programs. A 2023 federal court ruling reinstated a rule requiring insurers to count manufacturer copay assistance toward patients' OOP costs, but enforcement remains uncertain as HHS has delayed action. Meanwhile, state-level bans on copay accumulators have demonstrated potential benefits for patient affordability and medication adherence.

3. The Need for Policy and Employer Action
   Employers, insurers, and regulators play a critical role in shaping the future of cost-sharing programs. Employers must assess the ethical and financial implications of these programs, health plans should improve transparency for enrollees, and federal agencies must establish clear guidelines to protect patient access to essential medications. Addressing these issues is crucial to ensuring equitable and sustainable health care financing.