A Third of Employers Can’t Access Medical Claims Data from Vendors, Survey Finds

By Marissa Plescia – Many employers cannot get access to their medical claims data from health vendors like PBMs and insurers, a new survey from the National Alliance of Healthcare Purchaser Coalitions shows. A third of employers are struggling to get complete claims data from their vendors, while four in 10 said that their vendors refused to provide access. Employers use this data to analyze healthcare utilization patterns and costs. And this comes as employers combat rising healthcare expenses. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Rising Healthcare Costs as a Competitive Threat: More than half of surveyed employers said healthcare costs limit their ability to compete, and 99% identified drug prices, hospital prices, and high-cost claims as the top threats to affordability. The National Alliance’s Pulse of the Purchaser Survey collected responses from 324 employers in July and August 2024.

2. Access to Claims Data and Employer Strategies: Access to claims data strongly influences employers’ ability to manage costs: 74% of companies with more than 50,000 employees have full access, compared with 52% of employers with fewer than 1,000 employees. Those with access are more likely to implement strategies such as PBM audits, confirming advisor neutrality, direct contracting with providers, and establishing centers of excellence.

3. Policy Priorities and Market Shifts: About two-thirds of employers have switched or are considering switching from the Big Three PBMs (CVS Caremark, Express Scripts, Optum Rx) to more transparent vendors. Roughly 60% disagreed that hospital consolidation improves cost or quality, and top policy priorities include PBM reform, drug price regulation, hospital price transparency, and ERISA pre-emption protections. On GLP-1 coverage, 67% of employers covered branded drugs in 2024 versus 65% in 2025, with cost-control strategies ranging from limiting eligibility to requiring lifestyle programs and, in some cases, covering non-FDA-approved compounded versions.

More than 160 bipartisan lawmakers tell HHS to scrap 340B rebate pilot

By Dave Muoio – A bipartisan group of 163 lawmakers is urging the Department of Health and Human Services (HHS) to cancel an upcoming pilot of after-the-fact rebates for drugs hospitals purchase through the 340B Drug Discount Program—or to at least provide more information on how it intends to shield hospitals and the government itself from additional administrative costs and burdens. Read Full Article...

HVBA Article Summary

1. Controversy Surrounding the 340B Rebate Pilot Program: The HHS and HRSA are launching a one-year pilot program starting January 1 that will require hospitals to buy certain discounted drugs at wholesale cost and then seek rebates from manufacturers. Hospital groups oppose the rebate model, warning it imposes a financial burden—especially on safety-net providers—with an estimated average “float” of $72.2 million per hospital. Drugmakers, supported by PhRMA, argue the model promotes transparency and prevents duplicate discounts.

2. Congressional Pushback Over Financial and Operational Risks: A bipartisan group of lawmakers expressed concern in a letter dated Sept. 8 that the rebate model undermines the 340B program’s original intent to support safety-net providers. They worry manufacturers may use the model to recoup profits lost due to Medicare drug price negotiations. Lawmakers are calling for more transparency from HHS and HRSA about the pilot’s rushed rollout, operational systems, enforcement mechanisms, and long-term plans.

3. CBO Analysis Highlights Rapid 340B Program Growth and Lack of Transparency: A Congressional Budget Office report shows drug spending in the 340B program jumped from $6.6 billion in 2010 to $43.9 billion in 2021—growing 19% annually, far outpacing general industry trends. The growth is attributed to increased hospital and clinic participation, vertical integration, and purchasing of high-cost drugs. However, the CBO noted a lack of data on how hospitals use 340B revenues, fueling calls for reform from pharmaceutical companies and some lawmakers.

The Hidden Cost of Healthcare AI: Why Premium Prices Don’t Equal Premium Results

By Andy Flanagan – I has made an undeniable impact throughout the healthcare industry: from a nurse navigator using an AI triage assistant to prioritize cases and respond faster, to tools to help providers document visits, to systems that automate repetitive, resource-intensive administrative tasks. As the use cases have added up, so too has the investment in AI. But healthcare systems are starting to look more closely at whether they are actually getting their money’s worth. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Disproportionate Costs and Minimal Returns: Many health systems are paying thousands of dollars per user annually for AI tools that save only five minutes per day, making the return on investment (ROI) highly questionable. According to the 2024 Healthcare IT Spending Report by Bain & Company and KLAS Research, nearly half of healthcare providers cite cost as the biggest pain point in their current tech stack. The widespread adoption of expensive tools with limited measurable benefit highlights a growing disconnect between AI pricing and its actual utility.

2. Integration Challenges and Vendor Fatigue: While some AI tools perform well in pilot programs, they often fail when deployed system-wide due to the complexity of integrating with existing workflows. In some cases, vendors claim widespread use, but their tools may only be used by a single researcher in one department, exposing a lack of scalability. This disconnect, combined with the overhead of managing multiple point solutions (e.g., separate tools for documentation, billing, and follow-ups), has led to mounting vendor fatigue and a shift back toward trusted, established platforms with integrated AI capabilities.

3. Need for Evidence-Based, Strategic Adoption: With regulatory and legal concerns cited by 38–43% of healthcare providers as top barriers to adoption, many health systems are becoming more cautious. Leaders are now being urged to ask foundational questions about each AI tool’s problem-solving ability, time/money savings, scalability, and workflow compatibility. Rather than chasing flashy new startups, many systems are evaluating how AI can be incorporated into the platforms they already use—seeking proven, governed, and clinically aligned solutions, as exemplified by Kaiser Permanente's thoughtful, system-wide AI oversight approach.

Employers face 6.5% benefit cost surge in 2026 — how benefit leaders can prepare

By Alyssa Place – Employers are preparing for the steepest rise in health benefit costs in more than a decade. According to Mercer's 2025 National Survey of Employer-Sponsored Health Plans, total health benefit costs per employee are projected to increase by 6.5% in 2026 — the highest jump since 2010. Without employer interventions, the increase could reach nearly 9%. This marks the fourth consecutive year of accelerated cost growth following a decade of moderate 3% increases, signaling intensifying pressure on employer budgets. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Multiple Factors Driving Cost Increases: Health benefit costs are climbing due to a convergence of pressures: the expense of cancer treatments and weight loss drugs, healthcare provider consolidation into fewer large systems, and inflation. Utilization is also up as patients return for delayed care and virtual health expands access. According to Mercer, both healthcare price and utilization — the two primary drivers of cost — are currently rising in tandem.

2. Employers Shifting Strategies to Manage Costs: Nearly 60% of employers plan to make cost-cutting changes by 2026, a sharp increase from previous years. While traditional strategies like raising deductibles remain common, employers are increasingly focusing on value-based approaches. These include enhancing management of high-cost claims, improving health program performance metrics, and expanding behavioral health services — with nearly two-thirds of large employers planning to enhance behavioral health offerings.

3. Open Enrollment as a Strategic Opportunity: With average employee paycheck deductions for health coverage projected to rise by 6–7% in 2026, open enrollment is becoming more critical. Employers are urged to use analytics to address high-cost claims, invest in navigation tools, and measure outcomes to ensure ROI. This data-driven approach helps avoid excessive cost-sharing, which could otherwise deter necessary care and drive higher long-term costs.

Pill vs Pen: Can Oral GLP-1s Transform the Obesity Treatment Landscape?

By Jennifer Larson – Only a fraction of the people who could benefit from taking obesity medications are currently doing so. A wider array of affordable, effective treatment options could help more people. Could oral GLP-1s be one of them? Yes, experts say, but there are some caveats. More than 42% of the adult population in the US is considered obese, and nearly 31% is overweight. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Emerging Oral GLP-1 Drugs: Currently, only about 2% of adults are using GLP-1 medications for obesity or overweight, but drugmakers are racing to expand the market with oral formulations. Novo Nordisk has submitted an application for an oral version of Wegovy, while Eli Lilly has reported positive late-stage trial results for its oral candidate, orforglipron. If approved, these daily pills could give patients an alternative to injections, broadening treatment choices and potentially drawing in people who were hesitant about injectables.

2. Patient Preferences Vary: While some experts highlight that oral GLP-1s could be attractive for individuals who dislike injections or want a more discreet option, many patients seem comfortable with — or even favor — the convenience of weekly injections. Doctors note that injections are easy to administer, rarely deter patients, and have proven highly effective, particularly newer drugs like tirzepatide. For some, a weekly shot is easier to remember than a daily pill, and many are motivated to stick with what has already delivered strong results.

3. Cost and Access Are Major Barriers: One of the biggest obstacles to broader use of GLP-1s remains affordability and limited insurance coverage for weight-loss indications. Even with recent price-lowering programs, monthly costs of several hundred dollars can be prohibitive, especially since these medications must be taken long-term to sustain benefits. Experts suggest that a lower-cost oral version could help expand access and might even drive down the cost of injectables. However, unless a meaningful price difference exists, most patients already stable on injectables are unlikely to switch.

FTC issues noncompete warning letters to healthcare employers

By Madeline Ashley – Federal Trade Commission Chairman Andrew Ferguson sent warning letters on Sept. 10 to multiple large healthcare staffing firms and employers, urging them to review employment agreements for possible unlawful noncompetes or restrictive terms. Read Full Article...

HVBA Article Summary

1. Concerns Over Noncompete Agreements in Healthcare: The Federal Trade Commission (FTC) has raised concerns that noncompete agreements—commonly used in healthcare roles such as nurses, physicians, and other medical professionals—can have harmful effects. These agreements may unfairly restrict job mobility for workers and reduce patient access to preferred providers. This issue is particularly acute in rural areas, where limited access to care is already a significant challenge, making these restrictions even more impactful on community health.

2. FTC's Enforcement Priorities: The FTC reiterated that cracking down on unlawful or unreasonable noncompete agreements remains a high priority. Under Section 5 of the FTC Act, the agency has the authority to investigate and challenge unfair methods of competition. Employers—whether or not they were directly contacted—are strongly encouraged to review their employee contracts to ensure any mobility restrictions comply with the law and are not overly broad or unjustified.

3. Shift in Regulatory Strategy Following Legal Challenges: After the courts blocked the Biden administration’s proposed nationwide ban on noncompete clauses, the FTC withdrew from defending the rule. However, this does not mark a retreat from enforcement. Regulators emphasized that existing antitrust laws are still in effect and will continue to be used to take action against anticompetitive conduct, particularly practices that threaten fair labor competition or employee freedom within the job market.

Shareholders sue over hospital firm's use of 'fraudulent' billing strategy

By Allison Bell – Some health care providers have been trying to fight much harder against health insurer and health plan claim administration teams. Now, those providers face a new kind of counterattack: shareholder derivative suits. Juan Camilo Jimenez, an investor in Nutex Health, a publicly traded health care provider, has filed a shareholder derivative complaint against Nutex in the U.S. District Court for the Southern District of Texas. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Allegations of Fraud and Mismanagement: Shareholder Jimenez has brought a derivative lawsuit against Nutex executives, arguing that they failed to maintain proper internal controls when the company hired HaloMD. According to the complaint, HaloMD allegedly inflated revenues by submitting thousands of ineligible claims through the No Surprises Act arbitration system, which Jimenez contends created short-term gains that were ultimately unsustainable.

2. Claims of Securities and Fiduciary Violations: The lawsuit accuses Nutex executives of violating federal securities laws, breaching fiduciary duties, engaging in gross mismanagement, and abusing their control of the company. Jimenez is asking the court not only to award damages against the executives but also to impose structural reforms at Nutex, such as improving oversight practices and allowing shareholders to nominate at least four candidates for the company’s board of directors.

3. Conflicting Perspectives: The complaint leans heavily on a report by Blue Orca Capital that criticizes HaloMD’s billing practices, but HaloMD has publicly rejected the allegations. A HaloMD representative characterized the lawsuit as part of ongoing efforts by insurers to weaken the No Surprises Act protections, asserting that HaloMD is focused on defending fair reimbursement for physicians and intends to contest the claims fully in court.