House Committee Advances 3 Bills Affecting ERISA Plans

By Emily Boyle – The U.S. House Committee on Education and the Workforce on May 21 advanced a series of bills prohibiting pharmacy benefit managers from providing kickbacks or referral fees to intermediaries, requiring hospitals to adopt accurate billing practices, and extending the deadline for plans to file Form 5500 disclosures. The bills, each affecting plans governed by the Employee Retirement Income Security Act, may now receive consideration from the full House of Representatives. Read Full Article...

HVBA Article Summary

1. Legislative Focus on Transparency and Accountability: The three bills advanced by the House Committee target increased transparency in the healthcare and retirement sectors. By prohibiting pharmacy benefit manager kickbacks, requiring more detailed hospital billing, and simplifying retirement plan disclosures, lawmakers aim to address concerns about opaque practices and administrative burdens. These measures reflect a broader legislative trend toward greater oversight of entities involved in employee benefits.

2. Impact on Employers and Plan Sponsors: If enacted, the legislation would directly affect employers and plan sponsors by changing compliance requirements and potentially reducing paperwork. The Form 5500 Filing Simplification Act, for example, would extend the filing deadline and allow for electronic submissions, easing administrative processes. Such changes are intended to make it easier for employers to provide benefits while maintaining regulatory compliance.

3. Bipartisan Support and Industry Backing: The bills received bipartisan support in committee votes, with some measures passing unanimously. Industry groups, such as the ERISA Industry Committee, have expressed support, citing the potential for increased accountability and reduced complexity in benefit administration. The broad backing suggests momentum for these reforms as they move to the full House for consideration.

Health insurers point fingers over affordability woes

By Peter Sullivan – Health insurers facing growing criticism over rising premiums are trying to shift the narrative by portraying hospitals and drugmakers as the real culprits behind health care's affordability crisis. Why it matters: Health insurance gets more expensive almost every year. But now, more of those added costs are being passed through to workers who are already reeling from inflationary pressures. That's raising the temperature for health plans already getting blamed for coverage denials and other business practices. Read Full Article...

HVBA Article Summary

1. Insurers Shift Blame to Hospitals and Drugmakers: Health insurers are responding to criticism over rising premiums by highlighting the role of hospitals and pharmaceutical companies in driving up health care costs. They are running advertising campaigns that point to hospital monopolies and drugmaker practices as key contributors to the affordability crisis. Insurers argue that their efforts, such as reducing prior authorization requirements, demonstrate a commitment to controlling costs for consumers.

2. Industry Finger-Pointing Amid Congressional Scrutiny: The debate over health care affordability has intensified as Congress investigates the causes of rising costs, with bipartisan interest in addressing industry consolidation and insurance practices. While insurers claim that the cost of health insurance is a symptom of broader health care expenses, lawmakers and other stakeholders are examining the impact of insurer-owned pharmacy benefit managers and prior authorization policies. This scrutiny reflects a broader dissatisfaction with the complexity and opacity of the U.S. health care system.

3. Multiple Stakeholders Contribute to Affordability Issues: Other sectors of the health care industry, including hospitals and drug companies, are also engaging in public campaigns to shift blame for high costs onto insurers. Hospital groups criticize insurers for delays and denials of care, while pharmaceutical companies accuse insurers and pharmacy benefit managers of profiting from drug spending. Experts note that all parties play a role in the system's high costs, and the ongoing blame game underscores the challenges in achieving meaningful reform.

Retatrutide Delivers Unprecedented Weight Loss in Phase 3

By Marilynn Larkin – Retatrutide, Eli Lilly’s first-in-class triple hormone receptor agonist, delivered meaningful weight loss at 80 weeks in all doses in the TRIUMPH-1 phase 3 trial. Retatrutide is an investigational, triple hormone receptor agonist that activates the body's receptors for GIP, GLP-1, and glucagon. It’s given as a once-weekly injection. Trial participants were adults with obesity or overweight and at least one weight-related health condition, but without diabetes. Read Full Article...

HVBA Article Summary

1. Significant Weight Loss Across Doses: The TRIUMPH-1 phase 3 trial showed that retatrutide led to substantial weight loss in adults with obesity or overweight and at least one related health condition. Participants on the highest dose (12 mg) lost an average of 28.3% of their body weight over 80 weeks, with nearly half achieving at least 30% weight loss. Lower doses also resulted in notable reductions, demonstrating a dose-dependent effect.

2. Improvements in Cardiometabolic Health and Safety Profile: In addition to weight loss, retatrutide was associated with improvements in several cardiovascular risk factors, such as waist circumference, cholesterol, triglycerides, blood pressure, and inflammation markers. The most common side effects were gastrointestinal, including nausea, diarrhea, constipation, and vomiting, which were more frequent at higher doses. Most adverse events were mild to moderate, and discontinuation rates due to side effects were relatively low and comparable to placebo.

3. Expert Caution and Need for Peer Review: While early expert commentary is optimistic about the magnitude of weight loss observed, there is caution due to the results being company-reported topline data rather than a full peer-reviewed publication. Experts emphasize the importance of awaiting the complete dataset to assess factors like adherence, subgroup responses, durability after discontinuation, and long-term safety. The findings, if confirmed in future peer-reviewed studies, could represent a major advance in pharmacological obesity treatment.

The $35 prescription cliff: Fill rates collapse as costs rise

By Kristen Smithberg – A new consumer survey suggests prescription affordability may hinge on a surprisingly narrow threshold. Once out-of-pocket costs reach about $35, patients become dramatically less likely to fill their medications. The survey from health care technology company Buzz Health found prescription fill rates fell sharply between the $15 and $35 price range, revealing what researchers described as a key behavioral tipping point for consumers navigating rising health care costs. At a $15 out-of-pocket cost, 89% of respondents said they would fill their prescription. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Behavioral Tipping Point for Prescription Fills: The survey identifies a significant behavioral threshold at the $35 out-of-pocket cost mark, where prescription fill rates drop sharply. This suggests that even insured patients are highly sensitive to relatively modest increases in medication costs. The data highlights how small changes in price can have a large impact on whether patients adhere to prescribed therapies.

2. Impact on Patients with Chronic Conditions and High-Deductible Plans: Patients managing chronic conditions are somewhat more likely to fill prescriptions at higher price points, but they are still affected by rising costs. Those enrolled in high-deductible health plans or who have previously paid full price before meeting their deductible are less likely to fill expensive prescriptions. This trend underscores the ongoing financial strain faced by individuals with ongoing health needs, even when they have insurance coverage.

3. Convenience and Provider Guidance Influence Pharmacy Choices: While some consumers are willing to switch pharmacies for small savings, many prioritize convenience, such as proximity to home, over lower prices. Additionally, when faced with high medication costs, most patients seek help directly from their health care providers or pharmacists rather than searching online for discounts. This indicates that embedding pricing information and affordable alternatives into the prescribing process could be an effective way to support medication adherence.

Could Cigna Exiting the Individual Market be an Indictment of ICHRA?

By Marissa Plescia – This month, Cigna announced during its first quarter earnings call that it is exiting its individual exchange business or the Obamacare exchanges at the end of the year, affecting 369,000 Americans in 11 states. With this exit, combined with the sale of its Medicare Advantage business in 2025, it appears Cigna is shifting its focus entirely to employer-sponsored insurance and pharmacy services. In exiting that business, one healthcare expert believes Cigna is doing something that is contrary to its core insurance strength: mid-market employers (50-250 employees) and alternative funding arrangements. Read Full Article...

HVBA Article Summary

1. Cigna's Strategic Shift Away from Individual Markets: Cigna's decision to exit both the ACA individual exchanges and its Medicare Advantage business signals a clear pivot toward employer-sponsored insurance and pharmacy benefit services. Company leadership cited the inability to scale the individual exchange business and a desire to focus management attention on core growth areas as primary reasons for the move. This reflects a broader industry trend where insurers are prioritizing segments that offer greater scale and profitability.

2. Implications for ICHRA Adoption and Insurer Interest: The exit raises questions about the future of Individual Coverage Health Reimbursement Arrangements (ICHRAs), which some have touted as a flexible solution for employers and employees. Experts quoted in the article suggest that Cigna's lack of enthusiasm for ICHRAs, combined with its withdrawal from the individual market, indicates skepticism about ICHRA's near-term potential as a significant revenue stream for traditional insurers. Unless larger insurers embrace ICHRAs, widespread adoption may remain limited.

3. Broader Industry Trends and Market Volatility: Other major insurers, such as Aetna and Baylor Scott & White Health Plan, are also leaving or scaling back their presence in the ACA marketplace, citing factors like expiring subsidies and rising premiums. The volatility and shrinking enrollment in the individual market have made it less attractive for insurers seeking sustainable growth. Industry analysts predict that ongoing uncertainty around subsidies, utilization, and margins may prompt further exits and a continued focus on core, profitable business lines.

Caregiving as a business risk

By Elle Lebourg – Most organizations I talk to right now have the same mandate: do more, produce more, hit bigger goals, with fewer resources and less margin for error. Most of those same organizations are absorbing a significant, recurring performance drag: It's caregiving, and it's hiding in plain sight. A high performer whose output has been inconsistent for eight months. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Hidden Impact of Caregiving on Performance: Caregiving responsibilities often go unnoticed in the workplace, manifesting as inconsistent output, missed opportunities, or unexplained absences. These issues are frequently misattributed to other causes, such as lack of motivation or engagement, rather than being recognized as symptoms of caregiving strain. This misdiagnosis can lead to ineffective interventions and missed opportunities to support valuable employees.

2. Presenteeism and Attrition Costs: While absenteeism due to caregiving is tracked and estimated to cost U.S. businesses billions annually, the larger issue is presenteeism—when employees are physically present but less productive due to caregiving demands. This hidden productivity loss can persist for months and often culminates in employee attrition, which carries significant replacement costs for organizations. Salaried employees, in particular, may quietly reduce their engagement or exit without their caregiving challenges ever being identified.

3. Need for Systemic Recognition and Support: Caregiving affects employees throughout their career lifecycle, influencing decisions at recruitment, onboarding, development, and exit. Organizations typically treat each instance as a separate HR event, failing to recognize the ongoing nature of caregiving challenges. By connecting the dots and proactively addressing caregiving as a business risk, employers can better retain talent and unlock hidden performance capacity.

The Medicare rules agents would repeal tomorrow

By Theo Morrill – Medicare's regulatory framework was built for a version of retirement that no longer exists. The rules assume seniors stop working at age 65, understand their enrollment windows and can absorb unlimited cost exposure. The gap between those assumptions and reality is widening. And the people who see it most clearly are the agents sitting across kitchen tables from confused beneficiaries every day. Read Full Article...

HVBA Article Summary

1. Outdated Rules Create Financial and Practical Challenges: Medicare agents report that several longstanding rules, such as the three-day inpatient hospital stay requirement for skilled nursing coverage, no longer reflect current healthcare practices. Changes in hospital admission classifications, like increased use of observation status, can leave beneficiaries unexpectedly ineligible for certain benefits. These outdated policies often result in higher out-of-pocket costs and confusion for seniors navigating the system.

2. Penalties and Lack of Guidance Lead to Lasting Consequences: The article highlights that permanent premium surcharges for late enrollment in Medicare Part B or Part D disproportionately penalize seniors who are confused or uninformed, rather than those who intentionally delay enrollment. Agents note that many beneficiaries are not given adequate guidance about enrollment deadlines, leading to lifelong financial penalties. This suggests a need for clearer communication and more lenient penalty structures to better support seniors.

3. Complexity and Lack of Standardization Drive Risk-Averse Choices: Unlike other major insurance products, Original Medicare lacks a maximum out-of-pocket limit, exposing beneficiaries to potentially unlimited costs unless they purchase supplemental coverage. Additionally, the wide variation in Medicare Advantage plan designs makes it difficult for seniors to compare options, often pushing them toward plans that cap expenses rather than those that best fit their needs. Agents advocate for standardizing benefits and simplifying rules to help beneficiaries make more informed, preference-based decisions.

Brokers face a new reality in voluntary benefits

By Christin Kuretich – Employer expectations around voluntary benefits are changing. Tight budgets, increased legal scrutiny on these products and evolving product designs are causing employers to raise new questions about voluntary benefits — challenging the long-held belief that these plans carry minimal risk because employees fund the premiums. At the center of this heightened scrutiny is a simple but important issue: Are employees paying for benefits they don’t fully use — or don’t fully understand? Read Full Article...

HVBA Article Summary

1. Shift Toward Utilization-Focused Benefits: Employers are moving away from evaluating voluntary benefits solely on price or the breadth of coverage. Instead, they are increasingly prioritizing whether employees actually use and understand the benefits provided. This shift means that benefits must be designed for real-world relevance and ease of use, rather than just appearing attractive on paper.

2. Evolving Product Design and Employee Expectations: Modern voluntary benefits are being restructured to focus on common, high-impact conditions and to provide support earlier in the care journey. There is also a growing emphasis on human-centered coverage, such as mental health support and family caregiving, to better align with the needs of today’s workforce. These changes aim to make benefits more accessible and meaningful, increasing employee engagement and satisfaction.

3. Increased Accountability for Brokers: Brokers now face greater responsibility to ensure that the voluntary benefits they recommend deliver tangible value to employees. This involves asking deeper questions about claims processes, utilization rates, and workforce alignment, rather than simply comparing plan features or costs. Brokers are expected to educate employers and employees alike, helping them understand and maximize the value of their benefits in a more legally and financially scrutinized environment.