Republican Senator Chuck Grassley Sets Sights on Medicare Advantage

By Wendell Potter - For years, whistleblowers, independent researchers, and journalists have warned about how Medicare Advantage (MA) plans manipulate risk scores to overcharge taxpayers. Now, a powerful Republican senator — one of the original champions of the program — is demanding answers. Read Full Article…

HVBA Article Summary

1. Grassley’s Scrutiny of UnitedHealth’s Medicare Advantage Billing: Senator Chuck Grassley’s letter to UnitedHealth Group CEO Andrew Witty highlights concerns over the company’s Medicare Advantage billing practices, citing a Wall Street Journal investigation that found UnitedHealth’s in-home health risk assessments (HRAs) and chart reviews led to $8.7 billion in additional Medicare payments in 2021. The Department of Justice is investigating whether these practices resulted in inflated or inaccurate diagnoses, raising questions about systemic overbilling in Medicare Advantage.

2. A Shift in Republican Stance on Medicare Advantage: Grassley, a key architect of Medicare Advantage, has historically defended private insurers’ role in Medicare but is now demanding transparency and accountability from UnitedHealth. His inquiry signals a potential shift among Republicans, particularly as the GOP-led Congress looks for ways to cut government spending. This suggests growing bipartisan scrutiny of Medicare Advantage’s financial impact on taxpayers.

3. Potential Financial and Policy Repercussions: With the Congressional Budget Office estimating that eliminating payments for diagnoses found only through home visits could save taxpayers $124 billion over a decade, Medicare Advantage may face increased regulation and funding cuts. UnitedHealth denies wrongdoing, but with mounting evidence and political pressure, the industry may soon face stricter oversight to curb alleged abuses and ensure Medicare funds are used appropriately.

Fired HHS civil servants, veterans fear for the future of US healthcare

By Noah Tong - [Last] month, the federal government fired thousands of probationary federal workers spanning critical health agencies and the Department of Veterans Affairs (VA), taking a chainsaw to the workforce and fulfilling a longtime mission of conservatives to gut the "deep state." Read Full Article…

HVBA Article Summary

1. Mass Terminations and Institutional Knowledge Loss: Thousands of experienced federal workers, including experts in public health, drug regulation, and healthcare administration, have been abruptly fired, disrupting the continuity of critical government functions. The loss of institutional knowledge threatens the effectiveness of agencies like the FDA, VA, and HHS, potentially impairing healthcare policy implementation and public health responses for years to come.

2. Legal and Workplace Uncertainty: While labor unions and state attorneys general are challenging the firings in court, legal proceedings are slow, leaving many former employees in financial distress. The administration's aggressive approach, including a controversial "fork in the road" buyout program and abrupt return-to-office mandates, has created confusion and instability within the federal workforce, raising concerns about due process and fair employment practices.

3. Impact on National Health Programs and Public Trust: The administration’s push to reduce government spending under the guise of eliminating waste, fraud, and abuse has resulted in deep cuts to health equity programs, AI oversight, and Medicaid administration. The sudden removals and policy shifts have raised fears of deteriorating healthcare services, increased regulatory inefficiencies, and a loss of public confidence in the government’s ability to manage national health initiatives effectively.

Texas could limit PBM contract references to outside documents

By Allison Bell - A legislator in Texas has introduced a pharmacy benefit manager bill that could change what provider contracts look like. Rep. Cole Hefner, R-Mount Pleasant, Texas, introduced the new PBM bill in an effort to make PBM contracts more fair to pharmacies and easier for pharmacists to understand. Read Full Article…  ^{_{(Subscription required)}} 

HVBA Article Summary

1. Simplified and Transparent Contracts: The bill would require all financial terms, including reimbursement rates and methodologies, to be explicitly stated within the contract itself, preventing PBMs from referencing external documents. This change could make provider contracts easier to understand for providers, employers, and benefits advisors who lack legal expertise.

2. Potential for Outdated Agreements: While improving transparency, the requirement to specify all terms directly in contracts may lead to contracts becoming outdated more quickly. Any necessary updates to standard provisions would need to be addressed on a contract-by-contract basis, rather than through centralized document updates.

3. Implications for Texas Health Policy and ERISA Plans: The legislation is part of a broader push by health care providers against restrictive network negotiation tactics. Although ERISA limits states' authority over self-insured plans, Texas has been actively challenging those restrictions in court, suggesting the state may seek ways to extend these protections beyond fully insured employer plans.

Health Advocacy Groups Urge SCOTUS to Protect Free Preventive Healthcare Services

By Pietje Kobus - United States of Care (USofCare) together with 47 other health advocacy groups filed an amicus brief on February 25 in Kennedy v. Braidwood (formerly Braidwood v. Becerra) urging the Supreme Court of the United States to protect access to free preventive services for nearly 151 million people ahead of oral arguments expected in April. Read Full Article…

HVBA Article Summary

1. Public Health Implications of Limiting PrEP Access: Lambda Legal, GLAD Law, and other advocacy groups have filed an amicus brief warning of the severe public health risks posed by restricting access to PrEP, a medication proven to reduce HIV transmission by 99%.

2. Constitutional Debate Over the Preventive Services Task Force: The case of Braidwood Management, Inc. v. Becerra challenges whether the U.S. Preventive Services Task Force members are "principal officers" requiring Senate confirmation, a distinction that could significantly impact the future of free preventive healthcare services.

3. Broad Healthcare and Economic Consequences: Experts and advocates argue that eliminating free preventive services would exacerbate healthcare costs, create financial burdens for millions of Americans, and disproportionately harm marginalized communities, undermining efforts to improve public health and economic stability.

UnitedHealth Hit with 2 New Federal Probes in 1 Week

By Katie Adams - The federal government has been cracking down on healthcare giant UnitedHealth Group over the past year, and it’s showing no signs of slowing down. For instance, the Department of Justice began an antitrust probe into the company last February, and then in March, HHS launched an investigation into the catastrophic cyberattack suffered by UnitedHealth subsidiary Change Healthcare. The DOJ also filed a lawsuit to block the UnitedHealth Group’s $3.3 billion acquisition of Amedisys in November. Read Full Article…

HVBA Article Summary

1. Medicare Advantage Billing Investigation: Senator Chuck Grassley (R-Iowa) has launched an inquiry into UnitedHealth Group’s Medicare Advantage billing practices following a Wall Street Journal report alleging the company manipulated diagnosis codes to increase reimbursements. UnitedHealth has denied the claims and any DOJ investigation. Grassley has requested compliance documents and training materials from CEO Andrew Witty to assess the company’s billing practices.

2. Care Quality Concerns at Optum Clinics: Representative Pat Ryan (D-New York) initiated a community inquiry into declining care quality at Optum-owned clinics in New York’s Hudson Valley. The probe follows constituent complaints about reduced accessibility, billing issues, and worsening healthcare services at CareMount Medical and Crystal Run Healthcare, both acquired by Optum. Ryan is actively seeking more feedback from affected patients and healthcare workers.

3. UnitedHealth’s Response: UnitedHealth has strongly denied the allegations related to its Medicare Advantage billing, calling The Wall Street Journal’s reporting misinformation. Meanwhile, Optum has stated it is committed to improving patient care through new scheduling and medication refill support systems, as well as technology investments. The company also acknowledged challenges due to the national healthcare provider shortage and expressed willingness to collaborate with policymakers on healthcare solutions.

2025 advisor outlook: Steer clients toward programs that keep pace with rapid change

By Allison Myers - Health care costs associated with benefit programs are projected to increase by almost 8% in 2025. Inflation, rising pharmaceutical and treatment costs, and higher utilization of benefits are among the factors driving the average annual cost of health benefits per employee upwards of $16,000. With almost half of adults (43%) reporting that someone in their household has delayed medical care due to cost, these expenses could continue to rise. Read Full Article…  ^{_{(Subscription required)}}

HVBA Article Summary

1. Navigating Rising Costs with Strategic Benefits Planning: With increasing healthcare expenses, businesses must determine whether to absorb cost hikes, redesign their benefit packages, or take a hybrid approach. Benefits advisors play a key role in guiding clients through cost-conscious strategies that maintain employee satisfaction while managing financial constraints.

2. Enhancing Workforce Engagement Through Tailored Benefits: The shift to hybrid work, the rise of freelance and part-time labor, and evolving employee expectations require businesses to adopt human-centric benefits. Advisors can help employers design flexible and personalized offerings—such as wellness programs, voluntary benefits, and mental health support—to improve retention, productivity, and overall workforce well-being.

3. Developing Leadership and Workplace Culture to Support Employee Well-being: Beyond traditional benefits, organizations must foster a culture of care and intentional leadership to enhance employee experience. Advisors can encourage businesses to provide mental health resources, communication training for managers, and workplace policies that support work-life balance, ensuring a more engaged and resilient workforce.

BCBSA report: Addressing hospital, pharma costs could save $1T over next decade

By Paige Minemyer - The federal government under the Trump administration has turned its focus to cutting costs, and a new report from the Blue Cross Blue Shield Association highlights policy efforts it says could save nearly $1 trillion in healthcare costs over the next decade. Read Full Article…  

HVBA Article Summary

1. Site-Neutral Payments and Provider Cost Transparency: The report highlights the largest potential savings—$484 billion over 10 years—through the adoption of site-neutral payments in Medicare, which would prevent hospitals from charging higher rates for the same services performed in physician offices they acquire. Additional transparency measures, such as requiring separate provider identifiers for off-campus facilities, could save another $11 billion.

2. Provider Market Reforms and Cost Controls: Enhancing antitrust enforcement in the healthcare provider space could save $78 billion by preventing monopolistic practices, while prohibiting anti-tiering provisions in payer-provider contracts could yield $16 billion in savings. Other cost control measures include mandating administrative cost reporting and efficiency standards ($40 billion) and requiring two-sided risk participation in Medicare payment models ($54 billion).

3. Pharmaceutical Cost Reduction Strategies: The report proposes several measures to curb drug costs, including eliminating tax deductions for direct-to-consumer drug advertising ($137 billion in savings), shortening the exclusivity period for biologics from 12 to 7 years ($134 billion), and addressing tactics that delay biosimilar competition ($53 billion). These reforms aim to drive down drug prices and improve affordability for patients and insurers alike.

When Treating Obesity, Don’t Forget the Mental Health Angle

By Jen Colletta - When the 42-year-old patient came to see Yarickza Lopez, MSN, FNP-C, the 5-ft woman weighed 260 lb and had severe depression and anxiety, type 2 diabetes, high blood pressure, polycystic ovary syndrome, and high cholesterol. Read Full Article…

HVBA Article Summary

1. The Critical Link Between Mental Health and Obesity: Research highlights the bidirectional relationship between obesity and mental health, with obesity contributing to depression, anxiety, and disordered eating while psychological factors can drive unhealthy eating behaviors. Experts emphasize the need for integrated care that addresses both physical and mental health aspects in obesity treatment.

2. The Importance of Behavioral and Psychological Support in Obesity Care: Cognitive behavioral therapy, self-talk strategies, and habit optimization play crucial roles in obesity treatment, as demonstrated in patient success stories. Experts stress that obesity medications can reduce food cravings but do not address underlying psychological and emotional factors, making mental health interventions essential for long-term success.

3. Challenges and Innovations in Integrating Mental Health into Obesity Treatment: Despite the proven benefits of incorporating mental health screenings and support into obesity care, many patients do not receive adequate psychological interventions. Innovative approaches, such as interdisciplinary teams, social support networks, and addressing social determinants of health, can enhance treatment outcomes and improve overall patient well-being.