HFMA CEO Ann Jordan: ‘It’s now or never’

By Ron Southwick – Los Angeles - Ann Jordan says it’s time to recognize the uncomfortable truth. The president and CEO of the Healthcare Financial Management Association, Jordan says the healthcare industry is not financially sustainable. And she has plenty who are backing up that assessment. An HFMA survey of industry leaders and experts found 94% said the healthcare industry is not financially sustainable. Read Full Article...

HVBA Article Summary

1. Healthcare Industry at a Financial Crossroads: Ann Jordan, CEO of HFMA, emphasizes that the healthcare sector is approaching an existential tipping point within the next three to five years. She notes that the industry’s financial model is unsustainable, with rising costs and decreasing affordability for patients. This situation is prompting urgent calls for action and systemic reform rather than continued discussion.

2. Hospital Closures and Medicaid Cuts Pose Major Risks: Jordan highlights that hospitals, especially those serving low-income populations, are already experiencing closures and anticipate more due to impending Medicaid funding cuts. These financial pressures are forcing health systems to reconsider their service models, potentially shifting care from hospitals to urgent care centers and impacting access for vulnerable communities. The uneven impact of these changes may exacerbate disparities based on community wealth and payer mix.

3. Technology and Value-Based Care Are Not Cure-Alls: While Jordan is optimistic about the potential of technology and value-based care, she cautions that technology alone cannot fix a broken system. She stresses the need for broader adoption of value-based care models, which focus on keeping people healthy rather than fee-for-service, but acknowledges the financial risks and operational challenges involved in this transition. Collaboration among stakeholders and significant investment in technology and prevention are seen as essential for achieving long-term sustainability.

CMS receives record comments on controversial Medicare Advantage payment proposal

By Rebecca Pifer Parduhn – Federal regulators received a record number of comments on their proposal to keep Medicare Advantage rates flat next year, Trump administration officials said Tuesday during an industry event, as insurers continue to lobby heavily for higher reimbursement. “We appreciate all the input. I mean, obviously there’s been a little bit more input this year than we typically get,” John Brooks, the CMS’ chief policy and regulatory officer, said during the Better Medicare Alliance’s summit in Washington, D.C. In January, the Trump administration proposed an average rate bump of less than 0.1% for MA plans in 2027, along with tighter guardrails around how plans adjust for the health risks of their members. The rule sparked uproar from health insurers and kicked off a full-court lobbying press from the industry. Read Full Article...

HVBA Article Summary

1. Unprecedented Public Response: The Centers for Medicare & Medicaid Services (CMS) received nearly 47,000 comments on its proposed Medicare Advantage (MA) payment rule, marking an all-time high for feedback on such proposals. This surge in responses reflects the high level of concern and engagement from insurers, industry groups, and other stakeholders regarding the potential impact of the rule. The volume of comments underscores the contentious nature of the proposed changes and the significant attention the issue is receiving from the healthcare sector.

2. Industry Pushback on Payment and Risk Adjustment: Insurers and MA associations have strongly opposed the proposal to keep MA rates essentially flat and to tighten risk adjustment calculations. They argue that the CMS is not adequately accounting for rising healthcare costs, which could force insurers to cut benefits or exit markets, thereby reducing options for the more than 35 million seniors enrolled in MA plans. The main dispute centers on the CMS's projection of medical spending growth, with industry groups questioning the methodology and transparency behind the agency's calculations.

3. Broader Implications for Program Stability and Oversight: The debate over the payment proposal highlights broader concerns about the stability and integrity of the Medicare Advantage program. While insurers warn of potential benefit cuts and plan exits, federal officials emphasize the need for payment integrity and responsible stewardship of taxpayer funds, citing research that suggests significant overpayments to MA plans. The outcome of this rulemaking process could influence not only reimbursement rates but also the long-term sustainability and public trust in the Medicare Advantage program.

FDA ramps up crackdown on GLP-1 drug compounding with fresh batch of 30 warning letters

By Zoey Becker – The FDA is taking no prisoners as it continues its efforts to combat widespread GLP-1 drug compounding. In its latest offensive, the agency has unleashed a fresh set of 30 warning letters targeting telehealth companies it says make “false or misleading” claims about compounded versions of popular obesity drugs. The new warning letters, which were sent Feb. 20 and made public March 3, are an extension of the FDA’s September crackdownof misleading direct-to-consumer (DTC) drug advertising, the agency said in a press release. They also follow last month’s promise by FDA Commissioner Marty Makary, M.D., to take “swift action” against companies that mass-market copycat drugs. Read Full Article...

HVBA Article Summary

1. FDA Enforcement Escalates: The FDA has issued 30 warning letters to telehealth companies accused of making misleading claims about compounded GLP-1 drugs. This action is part of a broader effort to address concerns over the marketing and sale of non-FDA-approved versions of popular obesity medications. The agency is signaling a more aggressive stance against companies that do not comply with federal drug approval and advertising standards.

2. Legal and Regulatory Risks for Companies: Telehealth firms receiving these letters have been given 15 days to respond to the FDA’s concerns or face potential legal consequences, including product seizure and injunctions. The FDA also warned that it may notify foreign regulators if non-U.S. companies are involved in selling misbranded products to American consumers. This highlights the increasing legal risks for companies marketing compounded drugs without proper authorization.

3. Changing Landscape for Compounded GLP-1 Drugs: Compounded versions of GLP-1 drugs became more common during shortages of branded medications, but as supply has stabilized, the FDA has clarified that mass-marketing these compounded drugs is no longer permitted. Some companies have tried to justify continued compounding by claiming personalized dosing, but the FDA has stated it will use all available enforcement tools to address unsubstantiated claims and protect public health. The regulatory environment for compounded GLP-1 drugs is becoming more restrictive as the FDA prioritizes consumer safety.

The drug costing more than cancer treatment: Why 29% of employees would switch jobs to get it

By Jill Barth – The drugs best known for dramatic weight loss are quietly becoming a flashpoint in the competition for talent, and employers who have been slow to act on coverage may be running out of time. According to NFP’s (an Aon company) 2026 U.S. Benefits Trend Report, nearly one-third of employees say they would switch employers to gain access to GLP-1 coverage, elevating these medications from a line item in the pharmacy budget to a workforce strategy problem. At the same time, 51% of employers now cite GLP-1 diabetes and weight-loss medications as the top driver of prescription drug spend, surpassing oncology and autoimmune treatments. The result is a strategic bind. Employers cannot easily afford to cover these drugs broadly, and they increasingly cannot afford not to. Read Full Article...

HVBA Article Summary

1. GLP-1 Coverage as a Talent Strategy: The growing demand for GLP-1 medications for weight loss is shifting from a healthcare cost issue to a key factor in employee recruitment and retention. Nearly one-third of employees are willing to change jobs to obtain this benefit, making it a competitive differentiator for employers. This trend suggests that benefits packages are increasingly influencing workforce mobility and employer attractiveness.

2. Divergence in Employer Coverage Approaches: Employers are split on whether to cover GLP-1 drugs for weight management, with larger organizations more likely to offer this benefit. While coverage for diabetes is more commonly justified, decisions about weight-loss coverage remain inconsistent due to unresolved cost-benefit analyses. As a result, employee satisfaction with prescription benefits is declining, and many workers are seeking alternative ways to manage out-of-pocket costs.

3. Emergence of Hybrid Benefit Models: New approaches, such as partnerships with telehealth providers, are allowing employers to offer partial or conditional GLP-1 coverage. These models can provide clinical support and flexible cost-sharing, potentially improving medication adherence and health outcomes. However, research indicates that adding broad GLP-1 coverage could significantly increase health insurance premiums, and any long-term savings from improved health may take years to offset the initial costs.

Healthcare At Your Door Is Now The Expectation. There’s No Going Back

By Jane Flaherty – I rang the doorbell and waited patiently, wondering what my colleague and I would experience on the other side. When it comes to home visits, clinicians rarely know exactly what we’re walking into. Even I – someone who has only made a handful in my years of practice as a nurse – have walked into apartments where the heat was set low in the dead of winter because a patient had to decide between warmth and food, seen desolate pantries and living room floors cluttered with makeshift beds to make room for extended family. But on this cold, winter day in Michigan, we were met with a pleasant surprise: a warm welcome from a petite, older woman, her genuine grin stretching from ear to ear. Read Full Article...

HVBA Article Summary

1. Shift to Home-Based Care Accelerated by Pandemic: The COVID-19 pandemic forced a rapid transition to home-based healthcare, leading patients to question the traditional system that often required significant logistical challenges. Many patients adapted to virtual and at-home care, and this shift has not fully reversed even as the pandemic has waned. The convenience and accessibility of receiving care at home have become new expectations for many, especially older adults.

2. Home Visits Reveal Critical Social and Clinical Realities: Delivering care in the home environment allows clinicians to observe factors that are often invisible in clinical settings, such as living conditions and social challenges. This deeper understanding can explain why some patients struggle with adherence or frequent emergency visits, highlighting the importance of addressing social determinants of health. Home-based care can uncover needs and barriers that traditional clinic visits may miss, enabling more tailored and effective interventions.

3. Implications for Health Plans and the Healthcare System: Health plans benefit from home-based care through improved patient engagement, better adherence to care plans, and potentially lower downstream costs due to reduced hospitalizations and acute events. Patients have now experienced a more flexible model of care that fits into their lives, making it unlikely they will accept a return to less convenient systems. The healthcare industry faces a pivotal decision: whether to continue evolving care delivery around patients' real-life needs or revert to pre-pandemic norms.

Health care costs are soaring. Blame insurers, drug companies — and your employer

By Maria Aspan – The United States has the most expensive health care in the developed world. Now it's about to get even more expensive. Some 154 million people get health insurance through their employer — and many could see their paycheck deductions surge next year, by 6% to 7% on average. Some will likely also see their out-of-pocket costs rise as employers pass along the spiking costs of care. That's because employers will be paying a lot more — almost 9% more per employee on average, for the same level of coverage — to provide health benefits for their workers. Read Full Article...

HVBA Article Summary

1. Employer Health Care Costs Reach 15-Year High: A survey of more than 1,700 organizations by Mercer found that employers are facing the largest increase in health care benefit costs in about 15 years. In 2023, the average U.S. employer spent more than $19,000 per employee to provide family coverage, while employees contributed about $6,000 toward premiums. The total average family premium reached $25,572, representing a 52% increase over the past decade.

2. Majority of Employers Plan to Shift Costs to Workers: Mercer’s survey reported that 59% of employers expect to pass rising health care expenses on to employees through cost-sharing measures. These changes may include higher deductibles, increased copayments, and greater out-of-pocket costs for services such as prescription medications. Because most Americans under age 65 receive health insurance through their jobs, employer decisions significantly influence workers’ overall health care spending and take-home pay.

3. Multiple Factors Are Driving Rising Health Care Prices: Health care costs are increasing due to a combination of higher demand for services, new but expensive treatments, and consolidation across hospitals, insurers, and other health care organizations. After pandemic-related delays in care, more patients are returning for medical services, contributing to greater demand and rising prices. At the same time, employers often treat health benefits as part of total compensation, meaning higher benefit costs may limit future wage increases for workers.

Will DOL create a new pharmacy benefit manager language?

By Allison Bell – To make the new draft pharmacy benefit manager transparency regulations useful to employers and benefits advisors, federal regulators need to develop a standard PBM transparency language. Benefits advisors at Butler Benefits & Consulting gave that advice in a comment on the draft regulations. The draft would require PBMs that work with self-insured employers to send the employers detailed prescription benefits transaction reports. "Disclosures should be standardized enough to allow fiduciaries to compare PBM arrangements over time and across vendors," Butler Benefits told the Employee Benefits Security Administration, the arm of the U.S. Department of Labor that developed the draft. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Call for Standardized PBM Reporting: Butler Benefits & Consulting recommends that the Department of Labor (DOL) establish standardized language and definitions for pharmacy benefit manager (PBM) disclosures. This would help employers and fiduciaries compare PBM contracts more effectively across different vendors and over time. Clear definitions, especially regarding indirect or 'other' compensation, are seen as crucial to avoid confusion and ensure transparency.

2. Potential Impact on Employer Plan Sponsors: The proposed regulations would require PBMs working with self-insured employers to provide detailed transaction reports. Butler Benefits argues that such transparency, combined with enforceable disclosure requirements and audit rights, can empower employers to negotiate better agreements and reduce unnecessary drug spending. Incomplete or delayed disclosures, by contrast, may lock employers into unfavorable contracts and obscure the true costs and risks involved.

3. Broader Regulatory and Legislative Context: The DOL's Employee Benefits Security Administration (EBSA) is still accepting comments on the draft regulations, with the comment period ending April 15. Any new definitions developed for these regulations could influence how recent PBM transparency mandates in federal law are interpreted and implemented. The process of defining key terms in benefits regulations is often lengthy, and ongoing efforts to clarify terms like 'fiduciary' highlight the complexity of regulatory implementation in this area.

CMS' Chris Klomp on what it will take for AI to succeed in healthcare

By Ngai Yeung – For AI to succeed in healthcare, it must be deregulated, reimbursed and able to access data easily, HHS chief counselor and CMS’ Medicare Director Chris Klomp said Monday. The three criteria must be met for AI to be successful, Klomp said at Cornell University’s Health Tech Summit in New York. Agencies must deregulate the technology enough to let companies move faster with new ideas, he said. Many existing regulations are rigid and rule-based. What’s needed are ones guided by principles. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Healthcare Moves Toward Interoperable Data Systems: Healthcare organizations are increasingly expected to adopt systems that allow patient data to be easily shared and used across different platforms. The Centers for Medicare & Medicaid Services (CMS) and other government bodies are implementing policies that discourage “data blocking,” where hospitals or electronic health record vendors restrict access to patient data for competitive reasons. These regulations aim to improve care coordination and ensure that patient information can move more freely across the healthcare ecosystem.

2. New Reimbursement Pathways for Digital Health Tools: Sustainable reimbursement models are needed for artificial intelligence tools used in healthcare. A CMS initiative known as the ACCESS program is designed to open new payment opportunities for companies developing digital solutions to help manage chronic health conditions. Establishing reimbursement pathways could encourage broader development and adoption of AI-driven healthcare technologies.

3. AI Could Function as a Background Support for Providers: Experts envision AI operating as a largely invisible tool that extends the capabilities of healthcare providers. These systems could analyze data from wearable devices to detect health changes, summarize trends over time, and present key insights to physicians before patient visits. AI may also support mental health by engaging elderly individuals through conversational voice interactions and alerting caregivers if concerning patterns or risks are detected.