No Surprises, But Plenty of Abuses: How Insurers Are Pulling the Strings on the No Surprises Act

By Wendell Potter – When Congress passed the No Surprises Act (NSA) in 2020, it was rightly hailed as a major consumer protection victory. For decades, patients were blindsided by massive medical bills after doing everything “right” — going to an in-network hospital, only to later learn that the anesthesiologist or radiologist who treated them was not in their insurer’s network. How could a patient possibly know that many insurers often exclude hospital-based physicians from their networks, much less know how much not knowing such a crazy thing could cost them? The NSA addressed that nightmare, eliminating most balance bills and shielding families from financial ruin. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Insurers Manipulate the No Surprises Act's Benchmark: The core issue with the NSA lies in the 'Qualifying Payment Amount' (QPA), a median in-network rate calculated solely by insurers without transparency. This lack of disclosure allows insurers to potentially exclude higher-paying contracts or include artificially low rates, distorting the benchmark. Many physicians report that QPA levels are often below Medicare rates, indicating that the benchmark may not fairly represent market rates.

2. Insurers Delay or Refuse Payments Despite Arbitration Outcomes: Although physicians prevail in approximately 80-85% of arbitration disputes under the NSA, insurers frequently delay payments or refuse to pay arbitration awards altogether. This undermines the law's framework and creates administrative burdens for providers, which can negatively impact their ability to deliver care. Federal data confirm widespread payment delays and unresolved cases, highlighting systemic enforcement issues.

3. Patients Ultimately Bear the Consequences: Insurer tactics such as forcing providers out of networks and delaying payments reduce patient choice and access to care. These practices can lead to higher premiums and diminished healthcare services as providers cut back or close due to financial strain. Policymakers are urged to enforce prompt payment, demand transparency in QPA calculations, and ensure fair benchmarks to protect patients and maintain access to quality care.

Providers believe AI is the key to easing prior auth burdens: survey

By Paige Minemyer – Providers are betting on artificial intelligence to ease the pain point of prior authorization, a new survey shows. Cohere Health, which provides clinical intelligence to insurers and risk-bearing providers, polled 200 clinicians and office administrators and found that 99% of clinicians report confidence in using AI to back prior authorization. Most (96%) office administrators said the same. Two-thirds of those surveyed said a completely digital prior authorization process would significantly improve their workflows. Across the board, the respondents said the process should have real-time tracking baked into the experience, allowing them to track the status of key requests. Read Full Article...

HVBA Article Summary

1. Strong Confidence in AI for Prior Authorization: The survey by Cohere Health reveals that nearly all clinicians (99%) and most office administrators (96%) are confident in using artificial intelligence to support prior authorization processes. This indicates a broad acceptance and trust in AI technology among healthcare providers to potentially streamline and improve these administrative tasks. The enthusiasm for AI suggests providers see it as a viable solution to reduce the complexities and inefficiencies currently associated with prior authorization.

2. Current Challenges and Impact of Prior Authorization Delays: Despite the optimism about AI, the survey highlights significant ongoing issues with prior authorization, including delays that contribute to emergency care or hospitalizations, as reported by over 90% of respondents. More than half of the providers have witnessed patients abandoning treatments due to these delays. Additionally, prior authorization is widely regarded as a significant burden, contributing to clinician burnout, which underscores the urgent need for process improvements.

3. Technology Adoption and Regulatory Changes: Although providers recognize technology as a key to easing prior authorization burdens, actual use of electronic platforms remains limited, with only 16% of administrators and 24% of clinicians submitting 40% or more of requests electronically. The survey also notes that many prior authorization requests are still submitted via fax or phone. New federal requirements effective January 1 will mandate faster insurer responses, but currently, only a small fraction of providers report receiving timely responses, indicating a gap between regulatory expectations and real-world practice.

AHIP launches campaign to protect $231B employer health tax break

By Allison Bell – How confident are U.S. health insurers about the idea that Congress will avoid touching the federal income tax exclusion for employer-sponsored health benefits? Not very. America's Health Insurance Plans, a group for health insurers, hinted at its concern Monday by posting a new primer with the title, "5 Things You Need to Know About Employer-Provided Coverage." The colorful infographic starts with the message that "Over 180 million Americans rely on employer-provided coverage for affordable access to care, effective ways to improve health, and financial security." Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. AHIP's Campaign to Protect Employer Health Tax Break: America's Health Insurance Plans (AHIP) has launched the Coverage@Work campaign, including an infographic titled "5 Things You Need to Know About Employer-Provided Coverage," to advocate for maintaining the current federal income tax exclusion for employer-sponsored health benefits. The campaign targets policymakers and the public to emphasize the importance of this tax exclusion in providing affordable health coverage to over 180 million Americans. AHIP's efforts reflect concerns that some lawmakers may propose changes to this tax treatment.

2. Significant Fiscal Impact of the Tax Exclusion: The federal health benefits tax exclusion reduced government tax revenue by $231 billion in 2024, making it the largest income tax expenditure according to federal budget analysts. Despite the substantial cost to the federal budget, health insurers and employers argue that this exclusion is a cost-effective way to encourage employers to offer high-quality health coverage to most full-time workers and their families. The U.S. faced a $1.8 trillion budget deficit in 2024, highlighting the fiscal pressures surrounding tax expenditures like this one.

3. Public Support and Political Context: The AHIP infographic highlights that a strong majority of voters (63%) support the current tax treatment of employer-provided health coverage, while only 28% support taxing employee health benefits. This public opinion data is used to bolster the campaign's message to protect the tax exclusion amid ongoing political debates. The campaign underscores the uncertainty among health insurers about whether Congress will maintain the tax exclusion, especially given recent legislative proposals and budgetary challenges.

Pharma companies scramble to make deals with Trump after Pfizer scored White House praise

By Daniel Payne – The agreement between Pfizer and the Trump administration to lower drug prices has sent other companies scrambling to make a deal. Several major pharmaceutical firms that received letters from President Trump demanding lower prices have been hustling to show progress, with some hoping to announce a deal with the White House as soon as this week, according to five Washington representatives and lobbyists for the companies, granted anonymity to speak about private deliberations. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Pharmaceutical Companies Facing Government Pressure: The Trump administration is intensifying its campaign to push pharmaceutical companies to reduce U.S. drug prices by matching them to prices in other countries. Pfizer's public agreement to lower prices for its Medicaid portfolio has heightened the pressure on other drugmakers to follow suit. However, lobbyists and insiders caution that many negotiations are still unresolved, and potential delays—such as a government shutdown—could stall any official announcements.

2. Lack of Transparency and Uncertainty in Effectiveness: While the administration is touting the Pfizer agreement as a policy success, the absence of publicly available details raises significant questions. Without transparency around how price cuts are calculated or which drugs are affected, experts say it's difficult to gauge the real impact on drug affordability. There is also widespread skepticism that companies will willingly accept arrangements that substantially erode their profit margins, unless compelled or incentivized to do so.

3. Momentum Building Among Drugmakers Despite Concerns: Despite lingering doubts, momentum appears to be growing as additional pharmaceutical companies engage with the administration. Trump has publicly named firms like Eli Lilly as being close to deals, though some industry representatives were surprised by these announcements. Ongoing negotiations include broader policy considerations, such as expanding Medicare coverage for weight-loss drugs and setting global benchmark prices for new medications. These discussions reflect a larger effort to reshape pricing structures in the U.S. pharmaceutical market.

Large nonprofits net billions from untaxed debt, investments

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. Indirect Tax Arbitrage Benefits Large Nonprofits: Large nonprofit hospitals use low-interest tax-exempt debt to indirectly fund healthcare projects while maintaining large portfolios of tax-free investments. This strategy, known as indirect tax arbitrage, generated an estimated $9.4 billion in profit for nonprofit hospitals in 2022, with the largest 1% of hospitals accounting for $2.9 billion of that total. This practice gives large nonprofits a competitive advantage over smaller or for-profit hospitals.

2. Concentration of Investment Assets and Debt: The top 1% of nonprofit hospitals hold a disproportionately large share of investment assets and tax-exempt debt, with an average of $8.2 billion in investments and $1.8 billion in debt per hospital. In contrast, the remaining 90% hold significantly less, averaging $40 million in investments and $32.3 million in debt. This concentration raises concerns about the equity and distribution of tax benefits within the hospital market.

3. Policy and Market Implications: The researchers highlight that the ability to engage in indirect tax arbitrage incentivizes large nonprofit hospitals to issue tax-exempt debt even when they have sufficient investment assets, potentially contributing to hospital consolidation and affecting affordability. The findings call for policymakers to scrutinize the taxpayer subsidies granted to nonprofit hospitals, especially as these tax exemptions are intended to ensure community benefits that some critics argue are not always realized.

Global health plan costs projected to rise nearly 10% in 2026

By Alan Goforth – The United States is not alone in anticipating a substantial increase in health plan costs next year. In its latest report, Aon projects a worldwide price hike of nearly 10%, including an 8.8% rise in North America. “The 2026 Global Medical Trend Rates Report arrives at a time of economic and geopolitical uncertainty, including global tariffs,” said Kathryn Davis, a global benefits vice president for the professional services firm. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Projected Global Increase in Health Plan Costs: Aon's latest report forecasts a nearly 10% rise in global health plan costs for 2026, with North America expected to see an 8.8% increase. This projection reflects ongoing economic and geopolitical uncertainties, including global tariffs, which continue to exert pressure on healthcare expenses worldwide. Organizations are urged to adopt proactive planning and innovative cost-management strategies to address these challenges effectively.

2. Primary Medical Conditions Driving Cost Increases: The report identifies cardiovascular disease as the leading condition influencing rising health plan costs across more than 20 countries. Cancer and tumor growth are also significant contributors, ranking among the top five cost-driving conditions globally, with lung, breast, colorectal, and prostate cancers being the most commonly diagnosed. Additionally, high blood pressure and hypertension remain critical risk factors, cited by eighteen countries as major drivers of medical claims.

3. Employer Strategies to Manage Rising Costs: In response to escalating healthcare expenses, employers are increasingly focusing on cost containment measures such as negotiating with insurance carriers, implementing wellbeing initiatives, offering flexible benefits, and raising employee cost sharing. Wellbeing initiatives are the most widely adopted, reported by 86% of countries. Leveraging data analytics and targeted interventions can help employers sustain workforce wellbeing, enhance engagement, and achieve long-term cost sustainability amid evolving healthcare demands.

Healthy Diet Offers Pain Relief, Not From Weight Loss Alone

By Stephanie Brown – Many people with obesity have chronic pain due to joint stress and inflammation. Speaking to these patients about modifiable lifestyle factors — like diet and exercise — can help improve their pain severity and quality of life. In a new study published in the European Journal of Nutrition, patients with overweight or obesity who followed a 3-month weight-loss dietary intervention cut chronic musculoskeletal pain scores in half — independent of adiposity changes. Specifically: 1. Diet quality improved 22% 2. Presence of chronic musculoskeletal pain dropped from 50% to 24% Read Full Article...

HVBA Article Summary

1. Diet Quality Impacts Pain Relief Beyond Weight Loss: The study highlighted that improvements in diet quality, such as increased intake of fruits, vegetables, whole grains, and lean meats, significantly reduced chronic musculoskeletal pain independent of weight loss. This suggests that focusing on the types of foods consumed is crucial for pain management, not just the amount of weight lost. Clinicians should emphasize diet quality when advising patients with obesity-related chronic pain.

2. Anti-Inflammatory Diets May Reduce Chronic Pain: Chronic pain is linked to inflammation, which can be exacerbated by diets high in saturated fats, processed foods, and sugars. Diets rich in anti-inflammatory nutrients, like the Mediterranean diet, which emphasizes fruits, vegetables, whole grains, and healthy fats, may help reduce low-grade inflammation and improve pain symptoms. Such dietary patterns can also benefit overall health and reduce risks for chronic diseases associated with inflammation.

3. Addressing Nutritional Deficiencies is Important in Pain Management: Some patients with severe chronic pain may have deficiencies in micronutrients such as vitamin D, B12, magnesium, and folate. Screening for these deficiencies and addressing them through diet or targeted supplementation can enhance pain management outcomes. Additionally, healthcare providers should consider the challenges chronic pain patients face in maintaining proper nutrition and support them with practical strategies and involvement of caregivers.