Mark Cuban and FTC's Lina Khan at White House to discuss PBM reform

By Alan Goforth - The push to rein in pharmacy benefit managers moved from the Capitol Hill to the White House on Monday. Billionaire entrepreneur Mark Cuban and Democratic Kentucky Gov. Andy Beshear joined FTC Chair Lina Khan in calling for reform. Read Full Article…  ^{_{(Subscription required)}}

HVBA Article Summary

1. Mark Cuban Criticizes CEOs’ Misunderstanding of PBM Rebates: Mark Cuban argues that many CEOs do not grasp how healthcare costs, particularly PBM rebates, actually function. He contends that these rebates are not funded by drug manufacturers, as commonly believed, but rather by companies' sickest and oldest employees, ultimately driving up healthcare expenses.

2. Push for Transparency and Regulatory Action Against PBMs: Cuban advocates for states to cut ties with the top three PBMs—Caremark, Express Scripts, and Optum Rx—while Kentucky Governor Andy Beshear highlights state-level transparency efforts. However, federal action may be delayed, as Sen. Ron Wyden suggests that pending PBM-related legislation in the Senate Finance Committee might not pass until after the November elections.

3. FTC Investigates PBMs Amidst Industry Pushback: The FTC is actively investigating PBMs and has warned that some companies have not complied with document requests, with Chair Lina Khan asserting that the agency will enforce compliance. Meanwhile, the Pharmaceutical Care Management Association (PCMA), representing PBMs, criticized the White House meeting on PBMs, claiming it lacked balance and failed to recognize the competitive nature of the PBM market.

Dozens of health systems file 'opt-out' antitrust lawsuits against Blue Cross Blue Shield

By Jakob Emerson - Dozens of health systems and other provider groups have filed new antitrust lawsuits against the Blue Cross Blue Shield Association and its 33 independent entities, alleging anticompetitive practices that led to suppressed payments to providers. The lawsuits, filed March 4 in federal courts in Pennsylvania, California and Illinois, come after hospitals and other providers opted out of a $2.8 billion class-action settlement reached in October 2024 with BCBS. Read Full Article…

HVBA Article Summary

1. Allegations of Anti-Competitive Practices: The plaintiffs, including physician groups, surgery centers, and home health providers, allege that BCBS companies conspired to divide geographic markets, restrict competition, and fix reimbursement rates. They claim these practices limited providers' ability to negotiate fair contracts, artificially suppressing payments to hospitals and physicians.

2. Previous Antitrust Settlements: The new lawsuits follow two major BCBS antitrust settlements: a $2.67 billion agreement in 2020 resolving employer and individual claims and a 2024 settlement addressing provider concerns. These settlements required operational changes, but the new complaints argue they have not fully addressed BCBS’s anti-competitive behavior.

3. Legal and Financial Stakes: The new lawsuits challenge the adequacy of the 2024 settlement, with hospitals seeking treble damages under federal antitrust law, potentially tripling the prior $2.8 billion settlement amount. The plaintiffs also request injunctive relief to prevent BCBS from continuing alleged collusive practices that harm healthcare providers.

US judge bars copies of Lilly weight-loss drug

By Patrick Wingrove and Brendan Pierson - A U.S. federal judge has refused to allow compounding pharmacies to keep making copies of Eli Lilly's (LLY.N), popular weight-loss and diabetes drugs Zepbound and Mounjaro in the United States. The decision was filed late on Wednesday in response to an October lawsuit from a compounding industry group against the U.S. Food and Drug Administration's decision last year that there was no longer a shortage of the medicines' active ingredient, tirzepatide. Read Full Article…

HVBA Article Summary

1. FDA Enforcement and Compounding Restrictions: The FDA had previously allowed compounders to produce copies of obesity drugs like tirzepatide due to a declared shortage but is now enforcing restrictions since the shortage designation has been removed. Smaller compounding pharmacies must cease production immediately, while larger outsourcing facilities have until March 19.

2. Legal Challenge and Court Ruling: The Outsourcing Facility Association and compounders challenged the FDA's decision, arguing that the agency relied solely on Lilly’s statements in determining the shortage status. They sought a court order to prevent enforcement actions, but the judge rejected their request, though the ruling remains sealed.

3. Impact on Patients and Industry Response: Without access to compounded versions, many patients who relied on lower-cost alternatives may face higher out-of-pocket costs, as insurers often do not cover brand-name weight-loss drugs. Lilly has welcomed the ruling, stating it effectively ends mass compounding of its drugs, while compounders are considering further legal action.

31 million Americans borrowed money for health care last year: Poll

By Lauren Irwin - More than 31 million Americans borrowed money last year to pay for health care, a new survey found. Those Americans borrowed about $74 billion, despite most of them have some form of health insurance, the West Health-Gallup survey found. Read Full Article…

HVBA Article Summary

1. Medical Debt Burdens Young and Middle-Aged Adults: The majority of borrowers who took on medical debt were between the ages of 18-49, indicating that younger and middle-aged Americans are facing significant financial strain due to healthcare costs. In contrast, only 2% of those over 65 reported borrowing, possibly due to Medicare coverage, highlighting the uneven distribution of medical debt across age groups.

2. Racial Disparities in Healthcare Borrowing: Black and Hispanic Americans were significantly more likely to borrow for medical expenses than white adults, with 23% of Black respondents and 16% of Hispanic respondents taking out loans, compared to just 9% of white adults. This disparity points to systemic inequities in healthcare affordability and access, which disproportionately impact communities of color and contribute to long-term financial burdens.

3. Widespread Concern Over Healthcare Costs: A majority of Americans (58%) worry that a major health event could lead to debt, illustrating the deep financial insecurity caused by high healthcare costs. This concern spans income levels, suggesting that even those with stable earnings are not immune to the financial risks associated with unexpected medical expenses, further underscoring the need for policy reforms to address affordability and accessibility in the healthcare system.

3 GLP-1 updates

By Paige Twenter - As patients scramble for Ozempic and other blockbuster GLP-1 medications, the FDA has set a deadline for compounded versions and health plans are continuing to further restrict coverage. Three updates on the drug class. Read Full Article…

HVBA Article Summary

1. Insurance Barriers and Cost Challenges: Despite strong demand for GLP-1 medications, insurance restrictions remain tight, with over 80% of commercially insured patients facing prior authorization or step therapy hurdles. About 6 million people lost coverage for these drugs between 2024 and 2025, contributing to high out-of-pocket costs, often exceeding $1,000 per month. Drugmakers like Eli Lilly and Novo Nordisk have introduced direct-to-consumer pricing strategies to improve access, offering discounted versions of their weight loss drugs.

2. Regulatory Shifts for Compounded Semaglutide: With the FDA declaring the semaglutide shortage over on Feb. 21, compounding pharmacies must stop selling compounded versions of the drug by April 22, and outsourcing facilities must cease production by May 22. However, some compounding pharmacies may continue offering modified formulations by adjusting dosage, ingredients, or administration methods.

3. Evolving Research on GLP-1s: Recent studies provide mixed insights into GLP-1 therapies. A 96-week trial found that exenatide, a GLP-1 drug, does not slow Parkinson’s disease progression, despite earlier optimism about its potential neuroprotective effects. Meanwhile, new research suggests that tirzepatide could be a promising alternative treatment for congenital generalized lipodystrophy, offering a less painful option than metreleptin injections.

Sycamore Partners to take Walgreens private in deal valued at $10B

By Paige Minemyer - Private equity firm Sycamore Partners has entered into a definitive agreement with Walgreens Boots Alliance to acquire the struggling retail pharmacy chain. Sycamore has agreed to pay $11.45 per share for the company, an equity value of about $10 billion, according to The Wall Street Journal. Walgreens said in a press release that accounting for debt and future payouts, the value could reach up to $23.7 billion. Read Full Article…  

HVBA Article Summary

1. Walgreens' Transition to Private Ownership: Sycamore Partners has confirmed its acquisition of Walgreens, taking the company private to focus on long-term turnaround efforts without public market pressures. The deal includes Walgreens, Boots, and its portfolio of consumer brands while maintaining its headquarters in Chicago.

2. Potential Divestiture of VillageMD: As part of the transition, Walgreens will explore strategic options for VillageMD, including a possible sale. A committee will be formed to evaluate ways to enhance the unit’s financial performance and maximize its value ahead of any future monetization.

3. Regulatory Approvals and Shareholder Vote: The transaction is expected to close in Q4 2025, pending regulatory approvals and Walgreens shareholders' consent. Walgreens will also engage in a 35-day "go shop" period to assess potential better offers, though it remains uncertain whether a superior bid will emerge.

Supreme Court ruling strengthens protection against abrupt federal funding shifts

By Allison Bell - The U.S. Supreme Court issued a short ruling Wednesday that could help employers and benefits advisors fight sudden changes in federal program rules and funding levels. The ruling affects efforts by the AIDS Vaccine Advocacy Coalition, the Global Health Council and other nonprofit organizations to get paid by the U.S. State Department for health care services already performed, in the face of efforts by the new Department of Government Efficiency to cut off funding for those types of services on short notice. Read Full Article…  ^{_{(Subscription required)}}

HVBA Article Summary

1. Supreme Court Decision on Payment Obligations: The Supreme Court ruled 5-4 that the State Department must continue making payments for completed work while litigation over a preliminary funding injunction is ongoing. Chief Justice John Roberts joined Justices Sotomayor, Kagan, Barrett, and Jackson in the majority, while Justice Alito, joined by Thomas, Gorsuch, and Kavanaugh, dissented.

2. Dissenting Opinion and Sovereign Immunity Argument: Justice Alito's dissent strongly objected to the ruling, arguing that a single district judge should not have the authority to compel the federal government to pay $2 billion in taxpayer funds, particularly when sovereign immunity protections may prevent such enforcement.

3. Implications for Private-Sector Entities: The ruling suggests that the Supreme Court may be receptive to arguments from private-sector companies and nonprofits seeking to prevent abrupt federal funding changes. This could have broader implications for industries such as health insurance, where government funding decisions impact financial stability and long-term commitments.

Older, self-employed enrollees more likely to lose ACA subsidies if enhanced tax credits lapse: KFF

By Emily Olsen - The enhanced subsidies, first enacted in 2021, provide higher premium tax credits to most enrollees in ACA plans, and allow beneficiaries with higher incomes to receive financial assistance when they were previously ineligible. Higher-income beneficiaries on the exchanges are a relatively small group. Only 7% of ACA marketplace enrollees reported an income over four times the federal poverty level last year, according to administrative data reviewed by KFF. Read Full Article…

HVBA Article Summary

1. Increased Costs for Enrollees: If the enhanced subsidies expire at the end of the year, higher-income ACA enrollees could face steep premium hikes, potentially making coverage unaffordable. For instance, a 60-year-old couple earning $85,000 annually could see their premiums rise by over $1,500 per month.

2. Disproportionate Impact on Certain Groups: Self-employed individuals and rural residents are more likely to be affected by the subsidy lapse. Nearly 40% of higher-income ACA enrollees are self-employed, and 15% of those at risk of losing subsidies live outside metropolitan areas, making them particularly vulnerable to cost increases.

3. Economic and Political Consequences: Ending the enhanced financial assistance could lead to job losses, particularly in the 10 states that have not expanded Medicaid. A report estimates that 286,000 jobs could be lost nationwide, with about 194,000 of them in non-expansion states. Politically, removing subsidies is challenging, as it directly impacts constituents and could provoke backlash.