When Even Celebrities Turn to GoFundMe to Raise Money for What Insurers Won’t Cover

By Wendell Potter – Known for his good looks and charisma that led to the starring roles in TV’s Dawson’s Creek and the film Varsity Blues that made him an idol to Generation X teens, James Van Der Beek seemed to his fans like someone who had it all, the American Dream. But when Van Der Beek neared middle age and was diagnosed with advanced colorectal cancer, the married actor with six kids made it clear to the public what he did not have: Enough funds to pay for the costly treatments he sought out in an effort to prolong his life. Read Full Article...

HVBA Article Summary

1. Medical Crowdfunding Reflects Systemic Gaps: The article highlights how even well-known individuals like James Van Der Beek have had to rely on crowdfunding platforms such as GoFundMe to cover medical expenses not paid by insurance. This trend underscores the growing prevalence of high out-of-pocket costs and insurance denials in the U.S. healthcare system. The normalization of crowdfunding for medical needs points to significant shortcomings in coverage and affordability, affecting people across socioeconomic backgrounds.

2. Crowdfunding Success Is Marked by Inequality: While some high-profile campaigns raise substantial sums, most medical crowdfunding efforts fall short of their financial goals. Research cited in the article shows that the median amount raised is only $2,000, and fewer than 12% of campaigns reach their targets. Factors such as race, community wealth, digital literacy, and social networks contribute to disparities in outcomes, meaning those with more resources or visibility are more likely to succeed.

3. Reliance on Philanthropy Is Not a Substitute for Health Care Reform: The article argues that the widespread use of crowdfunding to pay for medical care is a symptom of deeper systemic issues. It points out that while successful campaigns are sometimes celebrated, the reality is that many Americans are left without adequate support, and the process reinforces existing inequalities. The author suggests that depending on charitable giving for essential health needs is an inadequate solution and calls for broader reforms to treat health care as a public good.

Congress plans new response to health cyberattacks

By Peter Sullivan – Two years after the seismic Change Healthcare cyberattack, Congress is advancing a plan to safeguard against the kind of hacks that can expose millions of people's private data and cripple health systems. Why it matters: The bipartisan plan puts the burden on the government and providers to prevent the kind of breach that reverberates across the entire industry, jeopardizing patient access to needed treatments and costing hospitals billions. Read Full Article...

HVBA Article Summary

1. Senate Advances Health Care Cybersecurity Legislation: The Senate Health Committee approved a bill aimed at strengthening cybersecurity protections across the U.S. health care system with a 22–1 vote. The legislation would require the Department of Health and Human Services to develop a coordinated incident response plan and improve collaboration among government agencies during cyber incidents. It also establishes grant programs to help health organizations prepare for and respond to cyberattacks.

2. New Security Requirements for Health Organizations: The bill would require health entities to implement stronger cybersecurity measures, including multi-factor authentication and encryption. These requirements respond to vulnerabilities highlighted by the 2024 Change Healthcare cyberattack, which disrupted patient care and exposed weaknesses in existing protections. Policymakers and cybersecurity experts say the health sector faces persistent threats because medical data is highly valuable and breaches can be costly.

3. Legislative Compromise Faces Political and Timing Challenges: The proposal is considered a middle-ground approach compared with earlier Democratic legislation that included stricter mandates and penalties. While the bill has support from several health industry groups, hospitals may still raise concerns about some of the requirements. Its path forward may depend on being attached to a larger legislative package, as Congress faces a crowded agenda and political tensions that could affect its passage.

Express Scripts hit with $1.5M penalty in West Virginia over pharmacy violations

By Alan Goforth – Express Scripts will pay a $1.5 million administrative penalty following an investigation by the West Virginia Offices of the Insurance Commissioner. The agency's probe included a review of the pharmacy benefit manager's reimbursement practices, pharmacy audits, consumer appeals and network adequacy from early 2023 to mid-2024. Failure to reimburse West Virginia pharmacies at the minimum required rates and improper recoupment of funds from pharmacies were among the 28 violations cited. More than 20,500 claims and 191 instances in which reimbursement for a 30-day supply fell below the state-mandated $35 minimum were identified in the report. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Regulatory Action and Violations: The West Virginia Offices of the Insurance Commissioner found Express Scripts in violation of 28 state regulations, including inadequate reimbursement rates and improper fund recoupment from pharmacies. The investigation also uncovered delays in responding to consumer appeals and information requests. These findings highlight the state's increased scrutiny of pharmacy benefit managers' (PBMs) business practices.

2. Corrective Measures and Compliance: Although Express Scripts did not admit liability, the company agreed to reimburse affected pharmacies with interest and update its internal policies to align with West Virginia law. The PBM is required to submit a corrective action plan and report its progress to state regulators within 90 days. This demonstrates a regulatory push for greater accountability and transparency in PBM operations.

3. Broader Industry Implications: The penalty comes shortly after Express Scripts reached a settlement with the Federal Trade Commission (FTC) regarding allegations of inflating insulin prices. The FTC settlement included significant reforms to Express Scripts' business practices and may influence other major PBMs to consider similar changes. These developments reflect ongoing national efforts to address concerns about drug pricing and PBM practices.

How Employers Can Reduce, Stabilize GLP-1 Costs

By Emily Boyle – It is no secret that plan sponsors’ health care budgets are stretched thin covering rising costs, including weight loss drugs, but providers are offering new tools to help rein in the spend. Glucagon-like peptide-1 medications, widely known as GLP-1s, were originally developed to help control blood glucose levels in people with type 2 diabetes but have since gained Food and Drug Administration approval for treating a variety of conditions—perhaps most notably, obesity. Read Full Article...

HVBA Article Summary

1. Obesity Prevalence and Employer Costs: More than 40% of U.S. adults were classified as obese between 2021 and 2023, with the highest prevalence among working-age adults, according to data from the Centers for Disease Control and Prevention. Research published in Nutrition & Diabetes estimates that excess body weight among 158 million civilian non-farm employees generated approximately $425.5 billion in costs for employers in 2023. These expenses are associated with higher medical claims, disability payments, workers’ compensation, absenteeism, and reduced productivity.

2. Rising Employer Coverage of GLP-1 Medications and Claims Impact: Employer coverage of GLP-1 medications has expanded, with 36% of employers covering them for both diabetes and weight loss in 2025, while 57% cover them only for diabetes treatment. GLP-1 medications used for weight loss accounted for an average of 10.5% of employers’ annual claims in 2025, increasing from 8.9% in 2024 and 6.9% in 2023. Additionally, 27% of surveyed employers reported that GLP-1 costs represented more than 15% of their annual claims.

3. Employer Strategies to Manage GLP-1 Coverage Costs: Employers are exploring several approaches to control the rising costs associated with GLP-1 medications. These strategies include negotiating direct-to-employer pricing through pharmacy benefit managers, implementing holistic wellness and lifestyle programs alongside medication use, and requiring participation in coaching or behavioral programs. Employers are also using utilization management tools such as prior authorization, step therapy, eligibility requirements, and cost-sharing measures to help manage spending.

One in three brand-name drugs now missing from employer health menus

By Allison Bell – Employers' health plans really are getting tougher about which brand-name prescription drugs they cover. A team at Avalere Health, a health care consulting firm, has published numbers documenting that trend in a new analysis of commercial health plan "formularies," or prescription drug menus. The Avalere looked at how likely formularies at all types of U.S. commercial plans were to include the available brand-name drugs for six serious conditions: depression, migraines, multiple sclerosis, multiple myeloma, psoriasis and rheumatoid arthritis. The team also looked at formulary entries for GLP-1 agonist drugs, which can treat diabetes, obesity and other conditions, and SLGT-2 inhibitors like Jardiance, which can also help people control diabetes. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Significant Decline in Brand-Name Drug Coverage: The analysis by Avalere Health reveals a notable reduction in the percentage of brand-name drugs included in employer health plan formularies over the past decade. This trend suggests that employers are increasingly selective about which medications are covered, likely in response to rising drug costs and the need for cost containment. The narrowing of formularies may impact employee access to certain treatments, especially for complex or chronic conditions.

2. Variation Across Drug Classes and Plan Types: The study highlights that the inclusion rates for brand-name drugs vary widely depending on the drug class and the type of health plan. For example, drugs for conditions like rheumatoid arthritis and GLP-1 agonists have higher inclusion rates compared to those for multiple myeloma or migraines. Additionally, plans sold through the Affordable Care Act exchanges show even lower inclusion rates, indicating that access disparities may exist based on the type of insurance coverage.

3. Implications for Patients and Employers: As formularies become more restrictive, patients may face increased challenges in obtaining prescribed brand-name medications, potentially leading to higher out-of-pocket costs or the need to switch to alternative therapies. Employers must balance the financial pressures of providing comprehensive drug coverage with the health needs and satisfaction of their workforce. This evolving landscape underscores the importance for both employers and employees to stay informed about formulary changes and advocate for access to necessary treatments.

The TPA’s role in avoiding unnecessary ERISA litigation

By Win Rawson – Now is a good time for third-party administrators (TPA) to make sure that critical but frequently overlooked health plan documentation is complete and error-free. This isn’t about perfectionism; it’s about protecting themselves and their clients from unnecessary litigation. The TPA plays a vital role in ensuring self-funded plan sponsors and their members have frictionless experiences, especially when they need to file a claim or subrogate one. And TPAs are known for being efficient and responsive with an enviable knowledge of self-funded plans and subrogation. Read Full Article...

HVBA Article Summary

1. Importance of Accurate Documentation: Third-party administrators (TPAs) must ensure that all health plan documents, especially the formal plan document and the summary plan description (SPD), are complete, accurate, and aligned. Incomplete or misaligned documents can expose both TPAs and plan sponsors to significant legal risks under ERISA. Even minor oversights, such as missing clauses or unclear document references, can result in costly and prolonged litigation.

2. Shared Responsibility and Common Pitfalls: Many TPAs and plan sponsors mistakenly assume that someone else is managing compliance, leading to gaps in oversight. The article highlights that as many as one-third to one-half of TPAs may lack full control over document alignment, often due to unclear roles or assumptions about legal counsel’s involvement. Clear delineation of responsibilities and proactive verification are essential to avoid these common pitfalls.

3. Proactive Steps to Mitigate Risk: TPAs are advised to immediately review all plan documents, paying special attention to provisions related to subrogation, reimbursement, and recovery. It is crucial that the SPD is properly incorporated by reference into the legally binding plan document, and that legal counsel with ERISA expertise verifies the documentation. Taking these steps upfront can prevent expensive legal disputes and protect both the TPA’s and the plan sponsor’s interests.

Optum teams with Microsoft to expand AI-powered claims platform

By Paige Minemyer – Optum is building out its claims management platform, Real, with new provider-focused capabilities built in partnership with Microsoft. The companies announced Thursday that they are expanding their collaboration to bring generative AI tools to Real, which is designed to streamline claims processing and prior authorization for providers. The new features aim to reduce administrative burden and improve efficiency for healthcare organizations. Optum said the enhancements will leverage Microsoft’s Azure OpenAI Service to enable more automated and accurate claims management. Read Full Article...

HVBA Article Summary

1. Expansion of AI Capabilities in Healthcare Claims: Optum and Microsoft are deepening their partnership to enhance Optum's Real platform with generative AI features. This move is intended to automate and improve the accuracy of claims processing and prior authorization, which are traditionally time-consuming tasks for healthcare providers. By integrating Microsoft's Azure OpenAI Service, the platform aims to deliver more advanced and reliable automation.

2. Focus on Reducing Administrative Burden: The collaboration specifically targets the reduction of administrative workload for healthcare organizations. By streamlining claims management processes, providers may be able to allocate more resources to patient care rather than paperwork. This could lead to increased operational efficiency and potentially faster turnaround times for claims and authorizations.

3. Strategic Use of Cloud and AI Technologies: Leveraging Microsoft's cloud-based AI infrastructure allows Optum to scale its solutions and offer more robust services to its clients. The partnership highlights a growing trend in healthcare technology, where major players are investing in artificial intelligence to solve longstanding industry challenges. This approach may set a precedent for further innovation and collaboration between technology and healthcare companies.