5 compliance areas where brokers should build expertise

By Brooke Salazar, JD – There's a lot up in the air right now around healthcare policies and evolving regulations, and this has HR teams concerned about how to balance this in with the broader employee experience. As long as turmoil over public health decisions continues to make news, they will be looking to their brokers for real-world, practical and apolitical guidance. As one example, preventive care guidance is up in the air, causing concern among many wellness-oriented employers — particularly those that have achieved measurable outcomes from connecting workers with early intervention programs and services. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Importance of Understanding PBM Contracts: Brokers need to develop expertise in transparent pharmacy benefit manager (PBM) contracts as these agreements are becoming increasingly complex due to state-level reforms. Being able to review and negotiate these contracts on behalf of clients will help employers manage volatility in pharmacy benefits and ensure better access and affordability for employees. This knowledge will differentiate brokers in a competitive market.

2. Navigating Claims Coding and State Mandates: Brokers should become proficient in claims coding, especially for sensitive benefits like reproductive healthcare and hormone treatments, as coverage decisions can vary significantly by state law. Understanding how claims are coded and the legal implications can help brokers guide employers in structuring compliant and consistent benefits plans. This expertise is crucial for managing federal pre-tax payroll deductions and avoiding legal pitfalls.

3. Leveraging Data for Strategic Benefits Decisions: Brokers are encouraged to use claims data and multiple data sources to help employers make informed decisions about coverage changes, especially when clinical recommendations evolve. They should caution clients against superficial interpretations of data and emphasize the importance of benefits literacy and employee communication. Additionally, expanding the scope of benefits to include policies like paid parental leave can improve health outcomes and overall plan value, demonstrating a holistic approach to employee well-being.

Big Health Insurance Front Groups Are Attacking the No UPCODE Act

By Wendell Potter – HEALTH CARE un-covered readers were the first to tip me off to television attack ads against the bipartisan No UPCODE Act, sponsored by Senators Bill Cassidy (R-LA) and ​​Jeff Merkley (D-OR). The ads in question, airing in the Washington D.C. media market, were paid for by Medicare Advantage Majority (MAM), which bills itself as a patient and provider coalition but has all the markings of a front group funded by the nation’s largest health insurers. Read Full Article...

HVBA Article Summary

1. Industry Front Groups Oppose No UPCODE Act: Medicare Advantage Majority (MAM) and Better Medicare Alliance (BMA) are front groups funded by major health insurers that are actively campaigning against the bipartisan No UPCODE Act. These groups use advertising and lobbying efforts to influence public opinion and lawmakers to protect Medicare Advantage plans, which benefit from current overpayment practices. Their campaigns often omit critical information about the drawbacks of Medicare Advantage plans, such as hidden fees and limited provider networks.

2. Purpose and Impact of the No UPCODE Act: The No UPCODE Act, sponsored by Senators Bill Cassidy and Jeff Merkley, aims to curb the practice of 'upcoding' by Medicare Advantage insurers, which inflates payments by exaggerating patient illness severity. This legislation is designed to reduce tens of billions of dollars in overpayments, potentially saving taxpayers up to $124 billion over the next decade and extending the solvency of the Medicare Trust Fund. The act represents a significant bipartisan effort to address wasteful and fraudulent billing practices in Medicare Advantage.

3. Lobbying and Political Influence Tactics: The health insurance industry employs sophisticated lobbying and public relations strategies, including text message campaigns and television ads, to oppose reforms like the No UPCODE Act. These efforts are part of a broader strategy to maintain the profitability of Medicare Advantage plans funded by taxpayer dollars. The article highlights the industry's use of well-funded intimidation campaigns to sway Congressional decisions and public perception, underscoring the political power wielded by Big Insurance.

BCBS of Massachusetts offers buyouts to 18% of workforce

By Alan Goforth – Blue Cross Blue Shield of Massachusetts is offering voluntary buyouts to 750 employees, or about 18% of its workforce. The initiative targets employees aged 55 and older with at least a decade of service. The decision comes as the company reported a net loss of $223.6 million and an operating margin of a negative 4.3% last year. “We recognize that at this moment of unprecedented growth in the cost of health care, all of us have to do everything we can to make care more affordable for employers and families,” a spokesperson told Becker’s Payer Issues. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Significant Workforce Reduction Initiative: Blue Cross Blue Shield of Massachusetts is offering voluntary buyouts to approximately 750 employees, which represents about 18% of its total workforce. This program specifically targets employees aged 55 and older who have at least ten years of service, indicating a focus on experienced staff as part of cost-control measures during financial difficulties.

2. Financial Challenges Driving the Buyouts: The company reported a net loss of $223.6 million and an operating margin of negative 4.3% in the previous year. These losses are attributed primarily to rapidly escalating medical care and medication costs, including a significant impact from new GLP-1 weight-loss drugs, which now account for nearly 20% of pharmacy spending, totaling over $300 million in 2024.

3. Strategic Responses to Cost Pressures: BCBS of Massachusetts is addressing its financial challenges by pricing benefit plans to reflect higher costs and collaborating with physicians and hospitals to moderate price growth. The company is also focusing on administrative spending control and plans to become more efficient in its operations while working to slow the growth in spending for medical and pharmacy services in the future.

Semaglutide, Tirzepatide Named First-Line Drugs for Obesity

By Marilynn Larkin – Semaglutide or tirzepatide should be first-line drugs for obesity and most of its related complications, new guidance from the European Association for the Study of Obesity recommended. The authors of the new framework for the pharmacological treatment of obesity and its complications proposed an algorithm to assist clinicians “by aligning each patient’s health background with the action profiles of the available medications.” The algorithm was published online in Nature Medicine. Read Full Article...

HVBA Article Summary

1. First-Line Drug Recommendations: The European Association for the Study of Obesity recommends semaglutide and tirzepatide as the first-line pharmacological treatments for obesity and most related complications. These drugs were identified as the 'medications of choice' due to their superior effectiveness in promoting substantial total body weight loss and their favorable safety profiles, based on clinical trial data up to January 2025. Other medications may be considered when a lesser degree of weight loss is targeted.

2. Tailored Treatment Based on Obesity-Related Complications: The guidance proposes an algorithm that aligns patient health backgrounds with drug action profiles, distinguishing between fat mass diseases (such as obstructive sleep apnea and knee osteoarthritis) and sick fat diseases (including prediabetes, type 2 diabetes, cardiovascular disease, heart failure, and metabolic dysfunction-associated steatohepatitis). For example, tirzepatide is recommended for obesity with obstructive sleep apnea, while semaglutide is preferred for knee osteoarthritis and cardiovascular disease. The recommendations are based on available randomized controlled trials and meta-analyses.

3. Emphasis on Lifestyle and Individualized Care: Despite the strong endorsement of semaglutide and tirzepatide, the authors stress that medication should not be the first-line intervention for weight management. Lifestyle approaches remain the initial focus for most patients. Pharmacotherapy is recommended as an adjunct when lifestyle interventions are insufficient, with treatment decisions made through comprehensive evaluation and shared decision-making to tailor therapy to individual patient needs and tolerability.

Large nonprofit hospitals taking full advantage of low-interest debt, untaxed investments, researchers say

By Dave Muoio – Larger nonprofit hospitals and health systems are using their low-interest debt to indirectly offset billions of nontaxable investments, giving this portion of the hospital market a competitive advantage over their smaller or for-profit peers, researchers wrote in an analysis published Monday. Such practices, referred to as indirect tax arbitrage, generated nonprofit hospitals and health systems an estimated of $9.4 billion in profit during 2022, accounting and policy researchers found. Read Full Article...

HVBA Article Summary

1. Tax Arbitrage is Heavily Concentrated Among the Largest Nonprofit Hospitals: A small subset—the top 1% of nonprofit hospitals (just 23 out of over 2,200)—generated approximately $2.9 billion of the estimated $9.4 billion in profits from tax arbitrage in 2022. These hospitals, with significantly larger investment portfolios and access to low-cost, tax-exempt debt, are uniquely positioned to benefit from this financial strategy, highlighting disparities in how tax advantages are distributed across the nonprofit sector.

2. Indirect Use of Tax-Exempt Debt Raises Concerns About Market Fairness: Although nonprofit hospitals are legally barred from directly using tax-exempt debt to buy tax-free investment assets, current laws allow them to benefit indirectly by using debt for operations while retaining investments. Researchers suggest this practice encourages the issuance of unnecessary tax-exempt debt, potentially distorting competition in the hospital market and raising questions about fairness, especially in relation to hospital consolidation and pricing power.

3. Policymakers Are Reassessing the Distribution and Impact of Tax Benefits: This new analysis, which complements prior studies on nonprofit hospitals’ tax exemptions, shows that the total value of tax-related benefits could be about 20% higher when tax arbitrage is factored in—rising from $37.4 billion to $44 billion. These findings are fueling policy debates in Washington about whether nonprofit hospitals are delivering sufficient community benefit to justify their tax-exempt status, especially given the concentration of financial advantages among the largest institutions.

IQVIA Analyst: Biosimilar Uptake Remains Uneven Across Molecules

By Gina Shaw – “Generics rapidly displace brands once exclusivity is lost,” Mr. Biggs said. “If biosimilars followed a similar trajectory, the savings for patients and the healthcare system would be enormous. But the reality is much more complicated.” IQVIA data show that biosimilars launched to date account for 24% of competitive molecule volume overall. But adoption rates by molecule tell a story of stark contrasts. “Three years after launch, insulin lispro biosimilars captured just 8% of the market, [and] infliximab 13%,” Mr. Biggs reported. Read Full Article...

HVBA Article Summary

1. Biosimilar Uptake Varies Widely by Drug and Channel: While some oncology biosimilars like bevacizumab and trastuzumab have seen strong adoption (82% and 80% respectively), others like rituximab have lagged. Adoption is also influenced by the dispensing channel—clinic-administered biosimilars are gaining share more quickly than those distributed via mail-order pharmacies, where drugs like Humira have remained dominant despite biosimilar availability. These variations highlight how factors such as molecule type, provider preferences, and contracting arrangements significantly affect biosimilar success.

2. Humira’s Case Shows Slow Transition Despite High Expectations: The launch of multiple adalimumab (Humira) biosimilars in 2023 was anticipated to be a turning point. However, the transition has been slower than predicted, particularly in mail-order settings. This slower-than-expected switch suggests that behavioral and logistical barriers, such as prescriber comfort and patient inertia, may limit biosimilar uptake even when cost savings are available.

3. Biosimilars Have Delivered Savings, But Impact Is Uneven: From 2019 to 2024, biosimilars contributed to $44.7 billion in brand revenue losses—part of a $77.5 billion total across all drug types—demonstrating significant cost-saving potential. However, this financial impact has been concentrated in a few therapeutic areas, suggesting that broader adoption remains a challenge. Achieving consistent savings across the healthcare system will likely depend on overcoming resistance in underperforming markets and channels.

Physician Consolidation is Growing, Driving Up Costs

By Jay Asser – Physician consolidation has accelerated over the past decade, resulting in increased spending and prices, according to a new Government Accountability Office (GAO) report. The analysis, which examined published studies and stakeholder perspectives on physician consolidation involving hospitals, insurers, corporate entities, and private equity, found that physician independence continues to shrink as hospitals, payers, and investors expand their ownership. Read Full Article...

HVBA Article Summary

1. Rising Physician Employment and Consolidation: By 2024, at least 47% of U.S. physicians were employed by or affiliated with hospitals, a significant rise from under 30% in 2012. At the same time, private equity ownership reached an estimated 6.5%, and employment by corporate entities grew from 15% in 2019 to 23% in 2024. These shifts reflect a broader and accelerating trend toward consolidation in healthcare, altering the traditional model of physician-led private practices.

2. Financial Pressures and Market Effects: Stakeholders representing physicians emphasized that maintaining an independent practice has become increasingly difficult, with practice costs rising faster than revenues. This has led to more physicians joining larger organizations. Consolidation, especially when hospitals acquire physician practices, is associated with higher healthcare spending, including increased Medicare payments and notable commercial price hikes for outpatient and office visits in certain markets.

3. Uncertain Impacts on Patient Care and Oversight: While the financial consequences of consolidation are well documented, its effects on patient care remain ambiguous. Most studies show little to no improvement in care quality, and in some cases, modest declines. Access to care is also inconclusive, with stakeholders divided on whether consolidation enhances or restricts it. Additionally, many physician acquisitions fall below federal reporting thresholds, creating significant gaps in regulatory oversight and limiting transparency into the full scope of market changes.