Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

FTC Sends Warning Letters to 24 Healthcare Organizations Over Price Transparency

By Marissa Plescia – The Federal Trade Commission sent warning letters to 24 of the “nation’s largest” healthcare services companies, citing concerns that they may be failing to provide transparent price information. The letters were signed by FTC Chairman Andrew N. Ferguson. The agency did not disclose which organizations it sent the letters to. It notes in the letter that the FTC Act requires these organizations to provide patients with “timely, accurate, and complete pricing for healthcare services, especially for non-emergency services that are scheduled in advance.” The agency urged the organizations to conduct a review of their pricing practices and make changes if they find they’re in violation of the FTC Act. Read Full Article...

HVBA Article Summary

1. FTC Emphasizes Healthcare Price Transparency: The FTC identified price transparency as a key consumer protection priority, particularly in healthcare because of the significant financial burden medical services can create. Hospitals and healthcare facilities may charge substantially different prices for the same services, making upfront cost information important for comparison shopping and financial planning. The agency said consumers should receive clear information before committing time, travel, and money to care.

2. CMS Compliance May Not Satisfy FTC Requirements: CMS requires hospitals to publicly disclose pricing information and provide uninsured and self-pay patients with good-faith estimates for scheduled services. However, the FTC noted that compliance with CMS transparency rules does not necessarily mean a healthcare provider is complying with the FTC Act. Because price is considered a “material term,” providers may need to ensure cost disclosures are clear, conspicuous, complete, and not misleading.

3. Incomplete or Inaccurate Pricing Could Raise Concerns: The FTC said healthcare pricing disclosures may be considered deceptive if they omit significant costs, such as physician or facility fees, or present only part of the expected cost of care. Inaccurate information could also mislead patients who reasonably believe the disclosed amount represents their total financial responsibility. The agency clarified that its letters do not conclude that the recipients violated the FTC Act, but instead highlight potential compliance considerations surrounding healthcare price disclosures.

Mark Cuban enters New Jersy's benefits fight

By Kristen Smithberg – New Jersey Gov. Mikie Sherrill welcomed billionaire entrepreneur Mark Cuban's offer to help reduce costs in the state's public employee health benefits system, as her administration and employee unions pursue broader changes to the program. Cuban, co-founder of Cost Plus Drugs, volunteered on X to serve on a committee examining health benefit costs. "I'll volunteer to be on the committee that cuts your health benefits cost. You need someone from the outside that is objective, and can stand up to the big healthcare conglomerates," Cuban wrote. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Cuban offers to join New Jersey’s health benefits cost review: Mark Cuban publicly volunteered to serve on a committee focused on cutting public employee health benefits costs in New Jersey. Gov. Mikie Sherrill responded on X by welcoming his involvement and emphasizing a push for accountability and results. The exchange frames Cuban as an outside participant offering to challenge entrenched health care interests. It also signals that the administration is open to high-profile voices as it evaluates reforms.

2. State lawmakers and coverage link Cuban’s model to lower drug prices: Republican state Sen. Declan O’Scanlon backed Cuban’s participation and cited his experience as a Cost Plus Drugs customer, according to the Press of Atlantic City. O’Scanlon argued that Cuban’s approach delivers medications at much lower costs than the existing state system and suggested refusing his help would undercut reform credibility. Cuban’s comments, as reported, emphasized prescription pricing transparency and the complexity of the current market. The episode highlights how drug pricing and PBM-style opacity are central to the policy debate.

3. Broader reform process includes unions and structural program changes: The effort follows a Sept. 2 agreement between Sherrill’s administration and 17 state employee unions that pauses increases in employee contribution rates for 2027 while initiating a review of the State Health Benefits Program. The article states New Jersey’s public employee health plans cover approximately 690,000 members across state, local government and education plans. A working group is tasked with advising on vendor contracting, claims review, eligibility verification, provider networks, benefit design, and premium contribution structures, as well as governance and data access. The administration argues the system’s structure has constrained flexibility, transparency, and accountability as costs rise, and the stated goal is to maintain benefit quality while improving long-term sustainability.

Highmark taps Karen Hanlon as CEO, David Holmberg to transition to executive chairperson

By Paige Minemyer – Highmark is making a change at the top, with Karen Hanlon stepping to the role of CEO on Jan. 1. The Pittsburgh-based insurer announced Tuesday that current CEO David Holmberg, who has held the title since 2014, will transition to executive chairperson at Highmark. Hanlon, who is currently Highmark's president, will become the company's first female CEO. At the helm of Highmark, Hanlon will spearhead strategy, operations and performance across Highmark's health plans, diversified businesses and Allegheny Health Network. She's spent nearly three decades at Highmark, during which the organization grew from a $17 billion revenue business in 2014 to a projected $35 billion at the end of this year. Read Full Article...

HVBA Article Summary

1. Leadership transition and timing: Highmark plans to install Karen Hanlon as CEO effective Jan. 1, while David Holmberg moves into an executive chairperson role after serving as CEO since 2014. The company framed the shift as a board-backed transition rather than an abrupt change. Holmberg is expected to remain involved and work closely with Hanlon and the board during the handoff. The announcement also notes that Hanlon will be the organization’s first female CEO.

2. Scope of responsibilities and strategic focus: As CEO, Hanlon will oversee strategy, operations and performance across Highmark’s health plans, diversified businesses and the Allegheny Health Network. In the statement included in the article, she emphasized priorities of affordability, simplicity and effectiveness for members and communities. She also said the organization will continue pursuing its “Living Health strategy.” The leadership messaging suggests continuity of the current strategic direction under new executive leadership.

3. Hanlon’s background and prior initiatives: The article describes Hanlon as a long-tenured executive who joined Highmark after working in public accounting at KPMG and moved through finance leadership roles. She became chief financial officer in 2014, chief operating officer in 2018 and president in 2025. It also says she worked alongside Holmberg on major initiatives, including integrations with HealthNow and Blue KC and the acquisition of Gateway Health. The announcement further credits her with playing a key role in the formation of AHN.

Member engagement influences digital health spending, report shows

By Anuja Vaidya – Most healthcare providers, payers and employers plan to maintain or increase their spending on digital health tools in the coming year, but they increasingly want proof of strong member engagement, a new survey revealed. In fact, poor engagement is one of the top reasons for switching digital health vendors. Read Full Article...

HVBA Article Summary

1. Budgets are steady or rising, with engagement a key decision factor: The survey found that 64% of organizations increased digital health spending in 2026 compared to the prior two years, while 35% kept spending flat. Looking ahead, 56% plan to maintain their budgets and 38% plan to increase them. Organizations most commonly pointed to strong member engagement as the primary reason for raising investment, indicating that utilization is central to purchasing decisions.

2. Enrollment and meaningful use remain major hurdles for digital health programs: Respondents most often defined engagement as active use of a platform, alongside completing clinical interactions and registering or enrolling. Even so, nearly half of purchasers (47%) said that fewer than 25% of eligible members enroll in their digital health offerings. The findings suggest that buyers may be willing to fund tools, but adoption at the member level is frequently below expectations.

3. Performance-based contracts and AI tools are growing, but operational frictions persist: More than half of purchasers (57%) reported using performance-based contracts, and most said about half of contract value is at risk (67%), with health systems most likely to put more than half at risk (45%). Purchasers cited misalignment on performance metric definitions (41%), limited internal resources for negotiations (35%), and insufficient access to evaluation data (34%) as leading barriers, with data integration (45%) and opaque measurement methods (42%) contributing to those challenges. On AI, buyers reported more enterprise-scale activity in administrative and documentation-oriented deployments than in clinical decision support, though many health systems still reported limited, case-specific use of AI for clinical decision support (44%).

What patients and payers pay for 340B drugs: 6 study notes

By Ella Jeffries – An October report from Berkeley Research Group estimates how much patients and payers spend on 340B drugs, beyond what covered entities pay to acquire them. Read Full Article...

HVBA Article Summary

1. Estimated 340B-related spending has increased sharply: Berkeley Research Group estimates patients and payers spent $244.3 billion in 2025 on drugs purchased through the 340B program, compared with $108.4 billion in 2021. The article frames this as spending beyond what covered entities pay at discounted acquisition prices. The figures suggest that the program’s footprint in drug purchasing has expanded substantially over a four-year period.

2. Reported sales totals and downstream charges measure different things: The article says HRSA reported 340B sales of $100 billion for 2025, which reflects what covered entities paid to acquire drugs at the 340B price. It contrasts that with BRG’s estimate of what patients and payers were charged, which is higher because it incorporates reimbursement amounts rather than acquisition costs. The gap between those two measures is labeled by BRG as the “340B drug margin,” estimated at $142.2 billion in 2025 versus $63.6 billion in 2021.

3. Payers and program structure are linked to where margins arise and why the program is growing: The article attributes 63% of the 2025 margin to private and commercial insurers, followed by Medicare at 25% and Medicaid managed care at 7%, while noting Medicaid fee-for-service generates no margin due to acquisition-cost reimbursement. It also states 340B prescriptions account for 27% of net U.S. pharmaceutical spending, up from about 18% in 2021, and ties growth to hospital acquisition of off-site clinics, expanded hospital participation after the Affordable Care Act, and increased use of contract pharmacies. As additional context on growth, it cites a separate CBO analysis finding 340B spending rose 565% from 2010 to 2021, with increases concentrated heavily in cancer drugs.

Small businesses see big value in benefits, but need help with rising cost, complexity

By Jimmy Nesbitt – Small-business owners overwhelmingly see the value of employee benefits, according to a new survey, but many say they need outside help navigating the complexities of offering them. New data from the Q3 Justworks and U.S. Chamber Small Business Index shows just how much benefits can influence the workplace: 95% of small business owners say they boost productivity and engagement, 94% say they help retain employees, and 89% say they help attract talent. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Small Businesses Face Cost and Resource Barriers: Small employers continue to view benefits as important for attracting and retaining workers, but affordability remains a significant challenge. About 67% of small business owners say they would like outside help offering benefits, while 35% cite rising costs and 34% point to limited budgets as barriers. Health insurance remains the most desired benefit, with 71% saying they would offer it if resources were unlimited, although the share currently providing health coverage increased from 41% to 46%.

2. Benefits Can Influence Recruitment and Retention: Nearly half (49%) of small-business decision-makers are concerned that their current benefits could make it more difficult to recruit or retain employees. At the same time, 58% report difficulty keeping pace with employee pay expectations, and 53% are concerned about retention challenges related to stress or burnout. Rather than competing with larger employers primarily on spending, small businesses may benefit from identifying which benefits employees value most and tailoring their offerings accordingly.

3. Targeted Benefits and Better Support May Improve Value: Small employers may be able to strengthen their benefits packages without substantially increasing costs by focusing on benefits employees are most likely to use and providing year-round education to improve understanding and engagement. Outside partners can also help employers evaluate options that fit their workforce, budget and long-term financial needs while reducing the administrative burden of managing benefits. Alternative coverage approaches may offer greater cost predictability or employee flexibility for some businesses, making it important for employers to compare available models before determining the best fit.

The top cancer success stories of the past 50 years, by the numbers

By Heidi Ledford – An analysis showcases the past half-century’s biggest cancer success stories — but also highlights the recalcitrant malignancies that continue to vex researchers. The report, released last month by the American Association for Cancer Research1 in Philadelphia, Pennsylvania, finds that 71% of people with cancer in the United States will live for at least five years after diagnosis, up from 49% in the late 1970s (see ‘Uneven progress’). Read Full Article...

HVBA Article Summary

1. Lung-cancer survival has improved, but remains low: The article highlights lung cancer as a standout example of progress, with five-year survival rising from 13% (1975–1979 diagnoses) to 29% (2016–2022 diagnoses). It attributes the gains to advances in surgery and radiation, alongside newer drug approaches such as immunotherapies and mutation-targeted medicines. Experts quoted in the story emphasize that, despite the improvement, lung cancer outcomes still reflect substantial unmet need.

2. Childhood leukaemia gains came from optimization, not a single breakthrough: For lymphoid leukaemia in people up to age 19, the five-year survival rate increased from 57% to 90%. The piece notes this success was driven largely by collaborative refinement of how existing treatments are delivered, including adjustments to dosage and timing. This underscores how incremental, system-wide clinical improvements can produce large real-world survival gains.

3. Progress is uneven across cancers, with some notable advances: The story points to liver cancer as another area of improvement, with five-year survival tripling to 22% since the mid-1990s. It also cites major gains for multiple myeloma, partly linked to drugs that harness the immune system. At the same time, the framing of the analysis stresses that some malignancies remain difficult to treat, reinforcing that overall gains mask wide variation by cancer type.

The Power of Personalization: Why Financial Wellbeing Isn't One-Size-Fits-All

By Michael Clark – As Michael Clark, senior vice president at Gallagher, notes, best-in-class financial wellbeing isn't a collection of disconnected benefits. Rather, "it's a strategy that connects short-term stability, long-term savings, education and measurable outcomes." More employers are waking up to this reality. According to Gallagher's 2026 US Workforce Trends Report: Financial Benchmarks, almost half (45%) reported an increased focus on financial wellbeing. Read Full Article...

HVBA Article Summary

1. Financial wellbeing is positioned as an integrated strategy: The article argues that effective programs connect near-term stability with longer-term savings, education, and measurable outcomes rather than offering scattered benefits. It frames this as a shift from adding more perks to building a coherent approach that helps employees make decisions. The emphasis is on aligning tools and resources to real employee needs so they are used and have impact.

2. Employee needs vary by career stage, shaping what support is most relevant: It outlines three broad stages—early, mid-, and late career—each with different dominant concerns, from managing student debt and day-to-day expenses to juggling family-related costs and planning for retirement. The point is that “more benefits” alone may not help if employees can’t see what applies to their situation. Personalization is presented as a way to reduce friction and help employees focus on the resources that match their current trade-offs.

3. Employers can use plan design, guidance, and tools (including AI) to improve decisions and outcomes: The article highlights flexible benefit options and references US policy changes (SECURE and SECURE 2.0) that can expand ways to support different needs, such as student-loan-related features and emergency savings approaches. It also suggests employers provide guidance, adviser access, educational resources, and decision-support tools so choices become easier to navigate. Success is framed as broader than utilization, encouraging employers to track engagement, financial behaviors (like savings and match usage), and workforce indicators such as absenteeism and turnover.

Dear Valued Clients and Partners,

Celebrate America’s 250th anniversary with new connections, new opportunities, and a meaningful way to give back! 🇺🇸

Join us as a sponsor of the 19th Annual HVBA Conference on Thursday, November 19, 2026, at the historic Logan Inn located in the quaint town of New Hope, Pennsylvania.

With its charm and welcoming atmosphere, New Hope offers a beautiful setting to celebrate our nation’s milestone. Together, we’ll honor the American spirit of innovation, service, and community while building relationships that help our industry move forward.

HVBA Innovation Summit New Hope, PA Thursday, November 19 Logan Inn A curated gathering of industry leaders focused on innovation, partnerships, and the future of benefits.

Join the Leaders Shaping the Future of Benefits & Healthcare

This intimate event brings together Brokers, PBMs, TPAs, Carriers, and Insurance Professionals, with only 130 seats available.

Our goal: Help you leave with business and partnerships—not just business cards!

The day offers several opportunities to connect and share your expertise:

• 8:00 AM–11:30 AM | HVBA Board Meeting: Up to five speaking spots, offering an opportunity to present your solutions to HVBA’s Executive and Advisory Board members.

• 11:30 AM–12:50 PM | HVBA Young Professionals & First-Time Attendees Board Luncheon: Following the board meeting, connect with emerging leaders and build relationships with the next generation of benefits professionals. (Invitation Only)

• 1:00 PM–8:00 PM | Innovation Sessions & Networking: Up to five speaking sessions, featuring fresh ideas, industry insights, emerging trends, and opportunities for collaboration. Conference registration for general attendees opens at noon.

Attendees will enjoy complimentary attendance, top industry speakers, butlered hors d’oeuvres, food stations, a premium open bar, and the opportunity to celebrate excellence through HVBA’s Annual Hall of Fame & Leadership Awards.

🇺🇸 Celebrate Our Nation. Honor Service. Give Back.

As we celebrate 250 years of American independence, we’re bringing the spirit of generosity into our gathering through a charity raffle & auction benefiting Trinity Oaks.

Trinity Oaks uses outdoor experiences to make a difference in the lives of veterans, first responders, youth, and people facing life-threatening illnesses. Participating in the raffle and live auction offers a meaningful way to honor those who serve and support experiences that bring hope and connection to others.

Sponsorship opportunities include:

• Conference Title Sponsor — $15,000: Prominent branding and a 15-minute main-event speaking opportunity.

• Board Meeting Sponsor — $5,000: Sponsor the board meeting and breakfast, including a 15-minute presentation to board members.

• Networking Cocktail Reception Sponsor — $5,000: Showcase your brand as attendees connect and build relationships.

• Innovation Session Sponsor — $3,500: Share your expertise through a 15-minute presentation.

• General Event Sponsor / Event Table — $1,500: Showcase your organization with a dedicated table and recognition in the Digital Event Guide.

• HVBA’s Hall of Fame Leadership Awards— $3,500: Showcase your organization’s name in light while we honor top industry professionals who were extraordinary!

Additional opportunities include media and photography, Hall of Fame & Leadership Awards, attendee gifts, special events, and a signature drink.

Depending on your selected package, sponsor benefits include logo visibility, event signage, press release recognition, Event Guide advertising, live acknowledgment, broker invitations, and an optional exhibit table.

Whether you want to introduce a solution, share your expertise, or develop new distribution and referral partnerships, we would love to help you find the right sponsorship.

Seats and speaking spots are limited! Discounted hotel rooms are available with booking by October 19, 2026.

Join us in charming New Hope as we celebrate 250 years of America, the promise of innovation, and the power of giving back. 🇺🇸

Partner with HVBA as Sponsorships are going fast

Contact Jenny Jenkins, Global Brand Ambassador, to explore sponsor or speaker opportunities at JJenkins@vbassociation.com.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

Texas AG Ken Paxton launches investigations into UnitedHealth Group, BCBSTX

By Paige Minemyer – Texas Attorney General Ken Paxton announced on Monday that he would launch an investigation into industry giant UnitedHealth Group for "engaging in deceptive and unlawful practices" that may have denied care to Texans. In the announcement, Paxton said he issued investigative demands to the company for any evidence that it violated Lone Star State laws, including the Deceptive Trade Practices Act (DTPA). He points to multiple reports that indicate UHG "has engaged in numerous unlawful practices in administering health insurance benefits and making patient-care decisions." Read Full Article...

HVBA Article Summary

1. UnitedHealth investigation centers on alleged coverage and decision-making practices: Texas Attorney General Ken Paxton said his office is seeking documents and information from UnitedHealth Group to assess whether the company violated Texas laws, including the Deceptive Trade Practices Act. The announcement frames the probe around claims that insurer administration of benefits and patient-care decisions may have improperly limited access to care. Paxton also suggested certain insurer coverage determinations, including prior authorization, could cross into the “corporate practice of medicine” by overriding clinicians. UnitedHealth Group did not respond to Fierce Healthcare’s request for comment before publication.

2. Allegations reference prior reporting and disputed claims: Paxton cited reporting, including a Guardian story alleging UnitedHealth paid kickbacks to skilled nursing facilities to reduce hospital transfers. The article notes that UnitedHealth has consistently denied those allegations. This indicates the investigation is being justified, at least in part, by external reporting rather than findings already made public by the attorney general’s office. The piece does not describe any conclusions or enforcement action at this stage, only investigative demands and stated concerns.

3. A parallel probe targets Blue Cross Blue Shield of Texas over denials, delays, and prior authorization: The attorney general also opened an investigation into Blue Cross Blue Shield of Texas and its parent company, Health Care Service Corporation, focusing on processes that may deny or delay urgent and medically necessary care. Paxton’s office referenced reports including a case involving a newborn whose transfer to an appropriate facility was allegedly delayed due to administrative denials and utilization review procedures. The office sent letters seeking evidence of potential Texas law violations, again including the Deceptive Trade Practices Act. BCBSTX told Fierce Healthcare it does not comment on investigations, and the article adds that Paxton is running for a Texas Senate seat in a closely watched race.

5 GLP-1 updates to know

By Ella Jeffries – Medicare uptake, off-label prescribing and new safety questions are shaping the GLP-1 landscape. Here are five GLP-1 updates to know. People taking GLP-1s are more than four times as likely to report nail detachment as similar patients who do not take the drugs. In the first controlled study of GLP-1s and nail health, 39% of 575 users reported nail detachment, compared with 9% of 1,329 controls across the U.S., France, Brazil and Mexico. The gaps held among participants who had lost weight. Read Full Article...

HVBA Article Summary

1. Safety signals are expanding beyond commonly discussed side effects: The roundup highlights a controlled study linking GLP-1 use with higher reported rates of nail detachment versus controls. It also notes ongoing litigation alleging vision-related harms tied to several major GLP-1 brands, alongside differing label actions between Europe and the U.S. Together, these developments suggest safety monitoring for GLP-1s continues to evolve and may influence how clinicians counsel patients and watch for adverse events.

2. Care delivery models may affect persistence on injectable therapy: Data summarized from NYU Langone Health Specialty Pharmacy points to low discontinuation among treatment-naive adults receiving structured pharmacist onboarding and follow-up touchpoints. The item also reports different discontinuation rates between tirzepatide and semaglutide within that cohort. This suggests that both medication choice and the intensity of pharmacy support could play roles in keeping patients on therapy.

3. Utilization patterns show both broader access and growing off-label use: The update cites a sharp rise in off-label GLP-1 use over several years, including use among people without documented qualifying conditions and among some with normal BMI. Separately, it reports substantial new Medicare starts since the launch of the Medicare GLP-1 Bridge, with one manufacturer capturing a large share of new beneficiaries and notable uptake of an oral option. These trends indicate rising demand across payer types and formulations, while also raising questions about appropriateness and documentation in prescribing.

Navigating the total rewards crunch to deliver real value to employees

By Andrew Brandman – HR leaders are being asked to solve a difficult operational equation right now: Between adapting to AI, managing market competition, and tightening corporate expense controls, teams are being forced to do more with less. Finance is under significant pressure to cut costs, while business leaders still expect HR to improve retention, support recruiting, and keep teams productive. The goals haven’t changed, but the resources available to achieve them have. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Use Employee Data to Determine Which Benefits Deliver Value: Employers planning for 2027 are encouraged to evaluate benefits based on actual employee needs and utilization rather than assumptions or cost alone. The 2026 NFP U.S. Annual Benefits Trend Report found that only 28% of employees fully use their supplemental benefits as intended, while 13% forget they have them altogether, highlighting potential gaps in relevance, awareness, or accessibility. Reviewing utilization data alongside employee surveys and HR service requests can help employers determine whether an underused benefit should be improved, communicated differently, or reconsidered.

2. Measure Benefits by Employee and Business Outcomes, Not Just Price: Benefits represent a significant portion of compensation, with Bureau of Labor Statistics data showing employers spend an average of $14.01 per hour on benefits, or roughly 30% of total compensation. Employers can assess that investment by considering a benefit’s relevance, utilization, accessibility, and impact on goals such as recruitment, retention, productivity, and employee well-being. This approach can provide HR and finance teams with a more consistent framework for comparing programs while recognizing that different benefits may be intended to achieve different outcomes.

3. Improve Access, Communication, and Integration With Business Strategy: Even potentially valuable benefits may produce limited results when employees do not understand them or cannot easily access them, with research showing 84% of employees who receive engaging benefits communications understand their benefits’ value, compared with 33% who do not. Employers can improve the employee experience by creating a clear access point, communicating throughout the year, tracking activation and repeat use, and addressing points where employees encounter difficulty. Incorporating these measures into quarterly scorecards and broader workforce planning can help organizations evaluate benefits as strategic investments while avoiding claims of direct business impact when the available data only demonstrates trends or associations.

It’s Time We Reframe Healthcare Organizational Culture Using Behavioral Science

By Lisa Miller – Healthcare business leaders often treat clinician well-being, patient outcomes, and company performance as distinct (or even competing) priorities rather than interconnected pieces that feed each other. The data says this approach is wrong. For one example, clinicians suffering from burnout are less able to provide the empathy and support their patients need, and patient outcomes suffer as a result. On the other hand, positive workplace cultures decrease the risk of clinician burnout and are consistently linked to benefits for patients, like reduced mortality and greater satisfaction. Read Full Article...

HVBA Article Summary

1. Culture framed as a testable system, not an abstract ideal: The piece argues leaders can treat company culture like a design and operations challenge that can be continuously improved by observing behaviors and running data-informed experiments. It positions intuition as a common but weaker fallback compared with using behavioral insights to understand stress, trust, and motivation. The intended outcome is a culture strategy that serves clinicians, patients, and organizational performance simultaneously rather than forcing tradeoffs.

2. Psychological safety is presented as foundational to clinician resilience and teamwork: The author describes psychological safety as a prerequisite for clinicians to debrief after heavy sessions, collaborate on solving problems, and recover before seeing the next patient. Examples given include creating structured time for shared problem-solving, shared in-office days to strengthen connection in hybrid settings, and clear channels for questions and feedback. The claim is that when clinicians feel safe, their well-being improves, teams function more effectively, and patient care benefits in turn.

3. Individuality and purpose are positioned as levers for better care and sustainable operations: The article contends that allowing clinicians to show up authentically reduces the energy spent on self-monitoring and frees more capacity for patient care. It also argues leaders should connect workflows—such as clinician availability—to purpose (patient access and outcomes) rather than presenting them mainly as productivity targets. The overall message is that aligning day-to-day operations with meaning can support patient health while also helping organizations address practical constraints like volume and overhead.

Idaho self-funded health trust fails after claims costs outpace expectations

By Allison Bell – An Idaho state court judge has appointed Dean Cameron, the director of the Idaho Department of Insurance, to serve as the rehabilitator for the Idaho School Benefit Trust. The self-funded trust has provided health benefits for about 16,500 school district employees and dependents at about 100 school districts and charter schools in Idaho. The trust used stop-loss insurance from Blue Cross of Idaho, which is also the trust plan's third-party administrator, to protect itself against catastrophic claims, but the cost of ordinary claims was much higher than the trustees had expected, and the trustees warned in June that the fund likely would not be able to meet its obligations for 2026. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Financial deterioration led to rehabilitation oversight: The trust’s reported financial position moved from a small surplus at the start of the fiscal year to a sizable deficit by the end of the nine-month period ending May 31, 2026. State court action resulted in the Idaho Department of Insurance director being appointed to oversee rehabilitation, indicating formal concerns about the trust’s ability to meet obligations. The situation illustrates how claim-cost assumptions can destabilize self-funded arrangements even when catastrophic risk is separately insured. It also highlights the role of state insurance regulators and courts when a collective benefits vehicle becomes insolvent or near-insolvent.

2. Member assessments and claim-payment consequences: To address the 2026 funding gap, the rehabilitator imposed a per-member assessment and offered districts an alternative monthly payment option. Some districts declined to pay, and the trust responded by suspending claim payments for employees and dependents in those nonpaying districts. Officials emphasized that the rehabilitator must follow the law and the contractual terms agreed to by districts, limiting flexibility in handling delinquent payments. The dispute underscores how funding remediation measures can directly affect enrollees’ access to timely claims reimbursement.

3. Regulatory implications for public-sector purchasing pools: The article notes that the rehabilitator has been active with the National Association of Insurance Commissioners, suggesting the case could inform broader regulatory thinking. It specifically points to potential impacts on how regulators evaluate a range of collective benefits purchasing arrangements, including oversight and solvency expectations. The case is also framed as relevant to how stakeholders assess public employee benefits trust solvency risks. Separately, officials indicated the trust will shift to fully insured group health coverage for 2027, signaling a move toward a different risk-bearing structure.

Employers need to be prepared for accidental overdoses on jobsites

By DeAnna Thomas – Last month, the U.S. Department of Labor issued guidance to help employers better respond to opioid-related overdose emergencies in the workplace. With that in mind, it’s vital to note: The overdose epidemic is not a community problem happening outside your company’s doors. It is a workforce problem happening inside them. In 2025, over 70,000 Americans died from drug overdoses, about 194 people every day, according to data from the Centers for Disease Control and Prevention. This is the emergency most workplaces have not planned for and cannot ignore. Read Full Article...

HVBA Article Summary

1. Overdose preparedness is framed as a core safety responsibility: The piece argues that employers should treat overdose response similarly to other emergency planning, rather than viewing substance use as solely a private matter. It links preparedness to workplace realities, including the likelihood that employees may experience or witness an overdose at work. The author emphasizes that readiness depends on both equipment and an environment where workers feel safe seeking help.

2. Workplace policies and culture can affect whether employees ask for support: The author describes a “perception gap” in which some employers avoid action due to stigma or assumptions about who is at risk. They contend that fear of job consequences can discourage employees from disclosing substance-related struggles, which may increase safety risks. The article positions leadership behavior and organizational norms as central to changing that dynamic.

3. Practical measures highlighted include naloxone access, crisis resources, and structured programs: The article outlines steps such as keeping naloxone with emergency supplies, sharing 988 crisis information year-round, and reviewing HR policies and benefits for barriers to treatment. It also points to Recovery Friendly Workplace certification as a way to formalize training, policies, and accountability. The overall message is that organizations can implement these actions proactively without waiting for regulation.

Why the breakthrough pancreatic cancer drug stops working: 5 notes

By Elizabeth Gregerson – Most patients with advanced pancreatic cancer treated with daraxonrasib will see the drug lose its effect, and researchers are starting to identify why, according to a Sept. 30 report in The New York Times. The FDA approved Revolution Medicines’ daraxonrasib Aug. 26 after trial data showed pancreatic cancer patients who received the drug lived almost twice as long as those on chemotherapy. It is the first targeted drug approved for pancreatic cancer that acts on multiple forms of RAS, a protein that drives tumor growth in most pancreatic adenocarcinoma cases. Read Full Article...

HVBA Article Summary

1. Resistance appears common and can limit durability of benefit: The article reports that the drug’s effectiveness often fades after roughly seven months, even among people who initially respond. A Dana-Farber specialist quoted in the piece says resistance develops in nearly every patient treated with the therapy. This frames daraxonrasib as an important advance that still leaves a major unmet need around long-term disease control. It also suggests clinicians and drug developers should anticipate and plan for next-step options after progression.

2. Circulating tumor DNA analysis links progression to specific genetic changes in many patients: A Nature Medicine study cited in the article examined pre-treatment and post-progression blood samples from 44 patients in the phase 1/2 trial. It found resistance-associated genetic alterations in 59% of patients, most commonly amplification of mutant KRAS (36%). The report also notes an association where tumors with pre-existing TP53 mutations were more likely to develop extra KRAS copies. Together, these findings point to measurable, biology-driven pathways that may be targetable or monitorable over time.

3. Not all resistance is explained by mutations, and multiple research efforts are underway to map tumor evolution: Roughly 40% of patients in the blood-based study had no identified genetic driver of resistance, implying other mechanisms may be involved. The article highlights the possibility of non-mutation changes within the tumor or its microenvironment contributing to treatment failure. It also describes a separate biopsy-based study enrolling 66 patients with sampling before treatment, about two weeks after starting therapy, and at progression to track cellular shifts. In parallel, some centers are already planning trials for patients whose cancers stop responding, indicating a move toward sequencing strategies and combination approaches.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

Health cybersecurity standards bill passes Senate

By Allison Bell – Members of the Senate agreed unanimously Wednesday to pass the Health Care Cybersecurity and Resiliency Act. The bill would direct the secretary of the U.S. Department of Health and Human Services to set "minimum risk-based cybersecurity practices" for any organizations covered directly by federal health data security requirements. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Proposed Cybersecurity Standards: The bill would direct HHS to establish stronger cybersecurity requirements for covered healthcare organizations and extend those requirements to their business associates. The proposed standards would include data encryption, multifactor user authentication or successor technologies, and ongoing system security monitoring to help protect sensitive health information. By applying the rules across organizations and outside partners that handle healthcare data, the legislation would create a broader federal framework for managing cybersecurity risks throughout the healthcare system.

2. Bipartisan Proposal Amid Rising Cyber Threats: Sen. Bill Cassidy, R-La., chairman of the Senate HELP Committee, introduced the legislation with four cosponsors representing both sides of the political aisle. The proposal comes as the Health Information Sharing and Analysis Center reported a 55% increase in known U.S. healthcare security incidents, reaching 5,744 in 2025. Recent incidents demonstrate that cybersecurity concerns remain significant, including a TriZetto medical billing system breach affecting 3.4 million people and unauthorized access involving archived patient records at Amazon One Medical Seniors.

3. Potential Impact Across the Healthcare Sector: If enacted, the legislation could establish new cybersecurity obligations for health insurers, employer-sponsored health plans, third-party administrators, hospitals, physician practices, and the business associates that support these organizations. Affected entities could be required to assess and potentially strengthen their existing technology, security controls, monitoring practices, and procedures for protecting healthcare information. The proposal could therefore have implications not only for healthcare providers and insurers, but also for employers and vendors responsible for administering or supporting health benefit programs.

Healthcare's high-stakes courtroom battles

By Anastassia Gliadkovskaya, Cailey Gleeson, Dave Muoio, Heather Landi, and Paige Minemyer – Healthcare is facing a wave of high-stakes litigation that could redefine drug pricing, insurance oversight, health technology competition, AI deployment, labor policy and public health regulation. The cases span nearly every corner of the industry, with courts increasingly serving as the venue where major policy disputes are decided. Together, these legal fights will influence how healthcare is paid for, regulated and delivered in the years ahead. Read Full Article...

HVBA Article Summary

1. Courts are increasingly setting healthcare policy and business rules: The report describes litigation touching drug pricing, insurance oversight, health tech competition, AI use, workforce policy and public health regulation. Rather than being confined to narrow disputes, the cases are framed as shaping how care is paid for, regulated and delivered. The breadth suggests that legal outcomes may drive operational changes across multiple segments of the healthcare industry.

2. Multiple flashpoints are converging around payment and coverage administration: The article highlights disputes involving Medicare Advantage star ratings, Affordable Care Act exchange rules and the No Surprises Act’s arbitration framework. It also points to the 340B drug discount program as another focal point where stakeholders are litigating over program scope and oversight. Across these areas, the common theme is that methodology and administrative decisions can translate into significant financial and coverage consequences.

3. AI, privacy and competition disputes are expanding beyond traditional healthcare litigation: The report notes an upswing in lawsuits over algorithmic claim determinations, ambient AI tools used in clinical settings and AI developers’ potential liability. It also outlines legal battles over patient data access, interoperability and alleged anticompetitive conduct involving major health IT platforms. Separately, tracking-pixel and privacy enforcement actions show how digital marketing and analytics practices can trigger regulatory and class-action exposure.

HRSA names 10 drugmakers for revised 340B rebate pilot ahead of 2027 launch

By Dave Muoio – The Health Resources and Services Administration (HRSA) has identified 10 drug manufacturers and 21 drugs that will participate in its revised 340B Rebate Model Pilot Program, which launches Jan. 1. The administration published its list online Thursday, ahead of the pilot’s start in just three months. It includes major names like Pfizer, AbbVie, Merck and AstraZeneca, and is a more expansive list of participants and products than HRSA was planning during the effort’s first go-around. Read Full Article...

HVBA Article Summary

1. Participant list and timing are now set: HRSA posted an online list of drug manufacturers and drugs selected for the revised 340B Rebate Model Pilot Program. The agency did so about three months before the pilot’s stated Jan. 1 start date. The list includes large manufacturers such as Pfizer, AbbVie, Merck and AstraZeneca, and HRSA characterized it as broader than what was contemplated during the earlier iteration.

2. The pilot changes how discounts are delivered and what data must be submitted: The revised model would replace statutory upfront 340B discounts with rebates coordinated by participating manufacturers. Covered entities would generally have up to 45 days after drug dispensation to submit claim-level data through an IT system maintained by the manufacturers in order to receive the discount. The design introduces new operational steps for hospitals and other safety-net providers compared with the traditional upfront discount approach.

3. Provider opposition continues as related federal reporting ramps up: Provider groups have criticized the rebate approach, citing concerns about administrative burden, cash-flow strain and the risk that manufacturers could delay or deny payments; HRSA’s guidance says manufacturers must provide rationale and documentation when claims are denied. The earlier attempt to start the pilot in 2026 was blocked in court, after which HRSA restarted the process and finalized the revised version in July despite ongoing pushback. Separately, CMS has launched a Medicare Part D 340B claims data repository that is voluntary initially, but CMS has proposed making submissions mandatory at the start of 2027 to support Inflation Reduction Act-related Part D inflation rebate calculations that must exclude 340B drugs.

Rethink Cybersecurity Awareness Month: 4 different approaches

By Damon Garn – Cybersecurity Awareness Month shouldn't be measured by how much training employees complete. For executives, its value is greatest when October becomes a catalyst for specific actions that reduce risk, simplify security operations and assign accountability. The familiar Cybersecurity Awareness Month playbook includes mandatory training, phishing simulations, newsletters, policy reminders and other communications. Reframe awareness as an organizational action for greater impact. Read Full Article...

HVBA Article Summary

1. Shift awareness from completion metrics to measurable risk reduction: The article argues that Cybersecurity Awareness Month is more effective when it produces tangible improvements in security and risk posture, rather than focusing on training completion. It suggests leaders should judge success by what is safer on November 1 than it was on October 1. This reframing is aimed at turning October into an operational catalyst, not a communications campaign. The emphasis is on executive accountability for outcomes rather than participation.

2. Use a structured, executive-led set of weekly security actions: The piece proposes four weekly leadership exercises: identifying the most valuable digital asset, removing an unnecessary privilege, testing a critical recovery process, and reviewing a decision-relevant cyber-risk metric. The intent is to create executive engagement without requiring leaders to become technical security practitioners. Each action is scoped to be achievable in about a week and designed to improve prioritization, access control, recoverability, and governance. The article stresses that documented procedures and activity dashboards are not sufficient without proof and decision utility.

3. Reduce complexity by subtracting and deleting, then assign one role-based improvement per person: The author recommends stopping at least one low-value security activity to return time to the security team for higher-impact work such as automation, remediation, recovery testing, and threat detection. It also introduces an annual “delete day” to remove unused accounts, applications, credentials, and other digital assets, with guardrails like ownership and rollback planning. Finally, it outlines a “one person, one action” approach that assigns a specific, role-appropriate security improvement to different parts of the organization. Across these ideas, the common goal is reducing attack surface and operational burden while producing evidence of real change.

The challenge of measuring clinical value in mental health

By Ben Conner – For many large employers, annual pharmacy costs can run into the hundreds of thousands — if not millions — of dollars. The natural reaction is to fix this by implementing cost-cutting measures such as rebates or moving a drug to a different tier. But these actions don’t address what is driving the costs: the conditions themselves. According to the American Diabetes Association, an individual with diabetes faces healthcare costs 2.6 times higher than an employee without the condition. When the disease itself is the primary cost driver, adjusting a formulary tier is like repacking your suitcase for vacation — the clothes might fit better, but the bag still weighs the same. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Prevention and Disease Management Can Improve Outcomes and Control Costs: Employer-sponsored diabetes prevention and management programs can address gaps such as inconsistent medication use, limited lifestyle support and fragmented care. Strategies including dedicated clinics, home medication delivery and health coaching incentives have been associated with stable per-patient costs and reductions in ER visits and hospital admissions. Research also indicates that lifestyle-change programs can reduce the risk of developing type 2 diabetes by more than 50% among high-risk individuals.

2. Mental Health Medications Present a Growing Cost and Measurement Challenge: Some newer and specialty mental health medications can cost $15,000 to $20,000 or more per member annually, while utilization has also increased as more employees seek behavioral health treatment. Unlike diabetes, where A1C provides a measurable indicator of treatment effectiveness, psychiatric medications generally lack routine laboratory benchmarks and are evaluated through patient-reported symptoms and clinical judgment. This makes it more difficult for employers and benefit advisors to assess whether higher pharmacy spending is translating into measurable long-term health outcomes.

3. Employers May Need to Balance Access, Clinical Outcomes and Affordability: The goal is not to restrict necessary mental health treatment, but to ensure high-cost medications are paired with appropriate clinical support and evaluated for their effectiveness. As additional mental health therapies enter the market, employers may need to examine both the clinical value and total cost of treatment rather than relying primarily on prescription utilization as a measure of success. A more outcomes-focused pharmacy benefits strategy could help organizations balance access to treatment with accountability and long-term affordability.

Cutting vendors won't fix your 9.9% trend

By Dana Y. Lujan – Segal put next year's median medical trend at 9.9%. Highest in fifteen years. This publication ran the number on July 28. Now watch what happens in every 2027 planning meeting between now and October. Someone will pull up the vendor list. Fourteen point solutions. Three navigation platforms nobody uses. A musculoskeletal app with 11% engagement. And the committee will decide that the way out of a 9.9% trend is to have fewer vendors. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Trend drivers extend beyond employer vendor stacks: The piece argues that rising costs are being pushed by factors such as inflation, provider pricing power, and how disputes and reimbursement dynamics play out in the market. In that framing, trimming point solutions may reduce administrative fees but does little to change the underlying unit prices or utilization that drive claims. The author emphasizes that some cost accelerators sit on the provider side—outside an employer’s direct ability to “cancel” a vendor. The core claim is that focusing on vendor count can distract from addressing the actual sources of medical trend.

2. “Explainable” cuts can win over higher-impact but complex strategies: The article describes why vendor consolidation often becomes the go-to move in planning discussions: it is easy to communicate and quickly translates into a slide showing fee savings. In contrast, approaches like building tighter referral steering, curating networks, and establishing data/audit rights can be harder to explain and take longer to show results. This dynamic can bias decision-making toward actions that are legible to finance leadership rather than actions with the biggest impact on total spend. The author’s point is that narrative simplicity can substitute for financial effectiveness.

3. Referral control and price variation are presented as central levers: The author highlights wide price variation for the same procedures within networks and argues that where patients are referred can materially affect employer plan costs. Examples in the piece focus on colonoscopies and broader findings from transparency analyses to illustrate how facility fees can vary substantially without corresponding quality differences. The proposed path forward centers on employers increasing ownership of referral pathways, strengthening contractual data and audit rights, and using direct contracting or centers-of-excellence models where appropriate. The article frames these steps as infrastructure and contracting decisions rather than vendor-shopping exercises.

Labcorp settles $2.3B data breach lawsuit brought by 44 states

By Chad Van Alstin – The fallout from a 2019 hack that exposed 27.5 million patient records is finally wrapping up, as 44 state attorneys general have come to a settlement agreement with diagnostics company Labcorp, one of the largest sources of data stemming from the breach on a medical debt collections company. That company, American Medical Collection Agency (AMCA), is a subsidiary of an even larger debt collector called Retrieval-Masters Creditors Bureau. When its network was breached in March 2019, records from Labcorp accounted for 10.5 million of those exposed to cybercriminals. Read Full Article...

HVBA Article Summary

1. Settlement resolves states’ case without an admission of fault: The agreement ends the multi-state lawsuit that sought to hold Labcorp partly responsible for sharing data with AMCA, the debt-collection vendor that was breached. The article states Labcorp is not required to admit wrongdoing and has not been found liable for AMCA’s security failures. Even so, the settlement closes the attorneys general action and establishes requirements Labcorp must follow going forward.

2. Vendor access and oversight requirements are a central part of the deal: Labcorp agreed to implement an incident response plan focused on cybersecurity events affecting its vendors, including steps to secure data quickly. The company also agreed to limit data sharing to what third parties need for their work and to perform regular vendor compliance checks to assess exposure risk. Additional vendor cybersecurity requirements and the hiring of a third-party cybersecurity firm to build ongoing privacy protocols are also included.

3. Breach context highlights the scale and sensitivity of exposed data: The article describes the AMCA intrusion as the largest healthcare-related breach reported to the federal government in 2019, with the attacker present in the network for nearly eight months (Aug. 1, 2018, to March 30, 2019). It says the potentially exfiltrated information extended beyond billing basics, including Social Security numbers, financial records, medical testing details, and diagnostic billing codes that could reveal test results. The incident also led to multiple class action lawsuits against AMCA, with Labcorp named in some of those cases.

Data privacy concerns could hold patients back from using AI

By Anuja Vaidya – AI has quickly become integrated into Americans’ lives, with 40% of survey respondents saying they use AI at least once daily in their personal lives, according to the survey, which was conducted by market research firm Ipsos on Wolters Kluwer’s behalf. The survey polled 254 U.S. patients in March. Read Full Article...

HVBA Article Summary

1. Reluctance rises when AI needs sensitive health data: The survey indicates patients are less willing to use AI for healthcare when it would require access to personal data or protected health information. This suggests adoption may depend not just on usefulness, but on how much data patients believe the tool must collect to work. The findings point to privacy as a central barrier for consumer-facing healthcare AI. It also implies that AI vendors and providers may need clearer consent and data-handling practices to increase comfort.

2. Trust concerns span privacy, accuracy, and known AI limitations: Respondents’ worries extend beyond data privacy to the reliability of AI-generated information. Concerns cited in the article include bias and “hallucinations,” indicating patients are thinking about both safety and fairness. The survey also reflects expectations that AI outputs should not be used without human review. Together, these views suggest patients are differentiating between AI as a convenience tool and AI as a source of clinical guidance.

3. Governance and accountability may influence patient acceptance: The article notes that patients want human experts to validate AI-generated health responses and expect clinical AI tools to be approved by their health system. It also highlights patient unease about unclear responsibility if AI recommendations are wrong or harmful. Nearly half of respondents said AI tools used for health advice should undergo federal testing and approval akin to new medications. These preferences imply that transparency about governance, approval, and liability could play a meaningful role in building trust.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

Senate confirms Keith Sonderling as DOL secretary

By Allison Bell – Members of the U.S. Senate voted 47-41 Wednesday to confirm Keith Sonderling as the secretary of the U.S. Department of Labor. All Republicans who participated voted for confirmation, and all Democrats and independents who participated voted against confirmation. The former Florida labor lawyer has been working as the department's acting secretary since the previous secretary, Lori Chavez-DeRemer, resigned after some questioned her travel arrangements and management style. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Confirmation finalizes leadership at the Labor Department: The Senate confirmed Keith Sonderling as Labor secretary after he had been serving in an acting capacity since April. The vote followed a resignation by the prior secretary, Lori Chavez-DeRemer, amid questions about travel and management. Sonderling publicly credited President Donald Trump for support and described goals of accountability, effectiveness, and responsiveness at the department.

2. Confirmed status may affect how DOL rules fare in court: The article notes that while acting secretaries can handle most day-to-day responsibilities, there can be legal differences in how regulations are treated. It cites the Center for Presidential Transition for the idea that rules approved by Senate-confirmed officials may better withstand court challenges. This dynamic could influence the department’s willingness to issue final rules and stronger guidance.

3. Health-benefits regulation work is highlighted as near-term focus: The piece points to the Office of Information and Regulatory Affairs tracking two major health benefits rulemakings. One involves implementing new employer plan pharmacy benefit manager reporting requirements adopted in February, which Sonderling described as a top priority during his confirmation process. The other involves efforts to update association health plan regulations, shown as being at the proposed-rule stage with meetings scheduled with outside stakeholders.

When Insurance Says No, Some Patients Are Going Straight to the Top

By Wendell Potter – Last month, Elizabeth Nicholas wrote in Vanity Fair about being diagnosed with breast cancer at 36 and then watching her insurer refuse to pay for a recommended course of chemotherapy. Her oncologist delivered the news. Nicholas’s response was to email the company’s CEO directly, laying out her case in plain, human terms rather than routing it through the black box of the standard appeals process. Read Full Article...

HVBA Article Summary

1. A detailed appeal escalated to leadership changed the outcome: Donald Grant Jr. sent a formal appeal to UnitedHealth Group CEO Stephen Hemsley and copied a wide set of stakeholders, including insurer executives, public officials, and reporters. The appeal argued for a “network exception” so an out-of-network surgeon could be paid at in-network rates because the requested operation was time-sensitive and the insurer lacked a comparably qualified in-network option. According to the post, UnitedHealthcare ultimately approved both the surgeon and the procedure at the in-network rate. The article presents this as an example of patients bypassing standard channels when they believe delay could cause harm.

2. AI-assisted tools and legal framing are becoming part of patient advocacy: The post says Grant received help from Claimable, an AI-assisted appeal service, and that his letter emphasized specific federal claims-processing rules and documentation requests. It also describes the appeal as demanding safeguards around who reviews the case, including specialization and independence from the original denial. A notable component was Grant’s request that no algorithm or automated tool be used in deciding the appeal, alongside references to public reporting and litigation about algorithmic denials. The article frames this as patients learning to speak in the compliance-focused language that insurers and plan administrators respond to.

3. The story highlights a gap between formal rights and practical access: The author argues that mounting an effective challenge can require expertise, time, and persistence that many patients may not have. The piece contrasts Grant’s extensive legal-medical submission and broad escalation strategy with how most people experience opaque and slow appeals processes. Even though the author notes the insurer was responsive once the appeal was underway, the post suggests the burden placed on patients to secure what they are entitled to can be unusually high. It raises the question of how many patients would know how to replicate this approach without professional help or media/public pressure.

Value-based care could cut healthcare costs. Employers aren’t buying it.

By Ginger Christ – While value-based care has long been heralded as a way to reduce healthcare costs, 40% of employers said they haven’t linked any of their spending to such a model, according to results of a survey by professional services organization EY. Among those that have tried value-based frameworks, adoption is not widespread, EY found. Of the about 100 U.S. HR and benefits leaders surveyed in April, just shy of half said their company’s use is limited rather than widely scaled. EY’s findings come as employers face continually skyrocketing healthcare costs and grapple with which benefits to provide — and at what price. Read Full Article...

HVBA Article Summary

1. How value-based care differs from fee-for-service: The article describes value-based care as tying payment to medical outcomes rather than to the volume of services delivered. It notes that the health system’s shift toward these models has been underway since the Affordable Care Act took effect in 2010. The framing suggests the approach is often promoted as a cost-management strategy, even if employer uptake varies. This context helps explain why the model is frequently part of broader discussions about healthcare affordability.

2. Employer plans for change appear limited in the near term: EY’s survey results cited in the article indicate that 45% of companies do not expect to change their value-based arrangements over the next three years. The same survey data suggests deeper investment is uncommon, with only 3% of companies routing more than 31% of medical spending through value-based payment models. Together, these points imply that many employers are not quickly expanding these arrangements. The article presents this as a contrast with the idea that such models could help reduce costs.

3. Cost pressure and benefit priorities shape decision-making: The piece links the survey findings to the broader backdrop of rising healthcare expenses for employers. It reports that employers ranked controlling company medical and pharmacy costs as their top health and wellness benefits priority, followed by employee engagement/utilization and controlling employees’ share of costs. The article also references a view that broader adoption should be considered, quoting the president and CEO of Codametrix. It additionally points to research suggesting coding automation and insurer claims processing dynamics can contribute to increasing costs.

Employers increasingly tie digital health payments to outcomes, PHTI survey finds

By Cailey Gleeson – Performance-based contracting is becoming the norm for digital health solutions, with the majority of employers and health plans tying vendor payments to clinical and financial outcomes, according to a new survey from the Peterson Health Technology Institute (PHTI). Specifically, 68% of employers and 55% of health plans are using such contracts. Eighty-five percent of contracts tie at least a quarter of fees to performance, while 31% tie more than half, PHTI analysts wrote in the report (PDF). Read Full Article...

HVBA Article Summary

1. Policy alignment is reinforcing outcome-based payment models: The article connects the move toward performance-based contracting with the U.S. Centers for Medicare and Medicaid Services’ (CMS) new ACCESS model. It describes the model as establishing outcome-aligned payments for digital health solutions and chronic care management. This linkage suggests purchasers may be responding not only to internal ROI goals but also to external payment-model signals that favor measurable results.

2. Data and verification challenges are a key friction point in performance contracts: The article reports that organizations using performance-based arrangements often rely on vendor-reported clinical and financial data. It highlights integration difficulties with internal claims or utilization data, as well as problems independently verifying outcomes. These issues can make contract negotiation and adjudication harder, even when buyers and sellers agree on tying payment to outcomes.

3. Spending appears steady, with fewer buyers increasing budgets than in 2024: The report cited in the article indicates a smaller share of purchasers are increasing digital health spend compared to two years earlier, while a notable portion say they are maintaining spending levels. It also lists the leading reasons organizations cite when they do increase investment, including engagement, access, cost savings and health outcomes. The article further notes that most respondents expect spending to hold flat over the next 12 months, with a smaller group planning increases.

Leading causes of death by age group: CDC

By Mariah Taylor – Heart disease, cancer and unintentional injuries ranked among the 10 leading causes of death for every age group in 2024, and unintentional injuries were the top cause of death for people ages 1 to 44, according to a CDC report. Read Full Article...

HVBA Article Summary

1. Overall 2024 leading-cause profile and concentration: The CDC’s National Vital Statistics Report lists the 10 leading causes of death in 2024 as heart disease, cancer, unintentional injuries, stroke, chronic lower respiratory diseases, Alzheimer’s disease, diabetes, kidney disease, liver disease and suicide. The article reports these 10 causes accounted for 70.9% of all deaths in the U.S. The ordering highlights that chronic diseases remained prominent while external causes and mental health-related mortality also appeared among the top causes.

2. Ranking changes and COVID-19’s impact on shifts: The article notes that suicide rose to the 10th leading cause of death in 2024, up from 11th in 2023. It also reports that COVID-19 deaths declined, including a 37% drop among older adults from 2023 to 2024, and that these declines contributed to changes in rankings across age groups. This indicates that year-to-year movement in the top 10 can reflect both changes in specific causes and indirect effects when one major cause falls substantially.

3. Age-group patterns show differing risks across the life course: For ages 1–44, unintentional injuries are shown as the top cause of death, with especially high shares in ages 10–24 (37.5%) and ages 25–44 (33.6%). In middle and older ages, the leading causes shift toward cancer and heart disease, with cancer leading ages 45–64 (25.4%) and heart disease leading ages 65+ (24%) and 85+ (27.3%). The article’s age breakdown also shows suicide and homicide ranking high in younger groups, while Alzheimer’s disease appears prominently in the oldest cohorts.

PBM satisfaction hits wall amid transparency concerns

By Alan Goforth – Pharmacy benefit managers have been under a microscope in recent years as regulators, plan sponsors and consumers seek solutions to rising health care costs. "The PBM marketplace is more competitive and diverse than ever, and pharmacy benefit management is entering a new era," according to the 2026 Pharmacy Benefit Manager Customer Satisfaction Report from Pharmaceutical Strategies Group. "Customer satisfaction with PBMs fluctuates over time and is not uniform across metrics." Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Satisfaction levels are steady year-over-year but lower versus earlier highs: The report pegs overall PBM satisfaction at 7.2 out of 10 in 2026, described as nearly unchanged from 2025. Even with that stability, the article notes satisfaction is down meaningfully from a prior peak earlier in the decade. The piece also describes differences by PBM grouping, with satisfaction falling among non-Big Three customers while still generally exceeding satisfaction among Big Three customers.

2. Operational experience rates better than clinical and financial functions: Survey respondents rated items tied to operational performance, accountability, partnership, and account support more favorably than measures related to clinical and financial management, flexibility, and innovation. The article adds that employers tended to report higher satisfaction with PBMs than health plans across many of these dimensions. At the same time, specialty drug management is characterized as a persistent challenge across groups.

3. Transparency and perceived conflicts remain central concerns despite perceived value: The article highlights transparency—particularly around PBM revenue sources—as an ongoing pain point, including a subset of respondents saying their PBM is not at all transparent on this topic. In parallel, it reports that many respondents still view their PBM as a proactive partner in managing drug spend, suggesting mixed views that combine utility with skepticism. It also says benefits leaders want change but are uncertain whether current or promised reforms will materially improve transparency or satisfaction, and they rate the expected impact of ongoing developments as only minor to moderate.

Let’s build behavioral health on usage, not headcount

By Trevor Colhoun – For employees seeking behavioral health services, coverage is just the beginning. The benefit only works if that person reaches an appropriate provider and successfully enters care without getting lost in a maze of disconnected directories and referrals. The role and position brokers and advisers play affect that employee experience. They are responsible for creating RFPs, evaluating networks, negotiating pricing and reviewing vendor performance. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Shift the Focus from Network Size to Successful Care Access: Behavioral health benefits are often evaluated based on provider network size and PEPM fees, but those measures do not show whether employees actually receive appropriate care. Brokers can instead define success as completing care with a properly credentialed provider who fits the employee’s clinical needs, insurance coverage, location, and preferences. A structured care pathway with qualified navigation, provider verification, scheduling support, and follow-through can help measure whether referrals ultimately convert into treatment.

2. Use Active Provider Capacity and Clearly Defined Utilization: Provider directories may include clinicians who are no longer available, accepting new patients, or participating in a member’s insurance plan, creating potential “ghost network” issues. Vendors can be evaluated using active network information such as credential status, insurance participation, current availability, specialty, location, language, and care modality. For pricing, contracts can clearly define what constitutes utilization and establish billable services, unit prices, volume thresholds, and annual spending caps rather than relying solely on PEPM charges for all eligible employees.

3. Measure the Full Path from Request to Treatment: Quarterly reporting can track requests, assessments, matches offered and accepted, appointments scheduled, first visits completed, and the time between each step to identify where employees encounter delays or drop off. Metrics should include clear denominators, reporting periods, exclusions, and data sources, while network performance can also be evaluated through measures such as out-of-network use, new-patient acceptance, appointment availability, and provider claims activity. At renewal, these measures can give employers a clearer picture of how benefits were used, whether employees successfully accessed care, and where improvements may be needed.

Can Patients on GLP-1s Stop Taking Insulin?

By Sara Novak – A quarter of patients diagnosed with diabetes take a GLP-1 medication. In recent years, this number has been increasing as patients see the effectiveness of the drugs for both weight loss and controlling their diabetes symptoms. At the same time, many of these patients are also taking insulin, an essential hormone for regulating blood sugar when damaged beta cells in the pancreas can no longer produce enough. However, insulin can also cause a host of negative side effects including weight gain and hypoglycemia. For these reasons, many patients with diabetes hope that taking GLP-1 medications will help them to reduce or discontinue their need for insulin. Read Full Article...

HVBA Article Summary

1. Evidence from a VA EHR study suggests limited basal insulin discontinuation across drug classes:Researchers analyzed electronic health record data from nearly 9000 US Department of Veterans Affairs patients taking a GLP-1 receptor agonist, an SGLT2 inhibitor, or a DPP-4 inhibitor. In this cohort, about 17% of patients discontinued insulin, and discontinuation rates did not differ meaningfully between GLP-1s and the comparator medication classes. The article emphasizes that these results may not settle the question, because real-world discontinuation depends on patient selection and how clinicians taper insulin.

2. Patient and care-setting factors may have constrained the ability to stop insulin safely: The piece notes the study population included VA patients older than 65 years with uncontrolled diabetes (A1c > 9%), a context in which beta-cell dysfunction may be advanced and insulin withdrawal can be harder. It also reports that most care occurred in primary care settings, with only about 10% of patients managed by endocrinologists, which may influence how aggressively or safely insulin is reduced. Experts quoted argue that clinicians currently have limited guidance on when and how to withdraw basal insulin, so starting a GLP-1 does not automatically translate into stopping insulin.

3. Medication choice and lifestyle support could change outcomes, but key questions remain: The study followed semaglutide and did not evaluate tirzepatide, which the article describes as more powerful and associated (in a head-to-head study cited) with greater average weight loss than semaglutide. Clinicians quoted add that, in practice, combining GLP-1 therapy with diet and exercise support may be more likely to enable insulin reduction than prescribing a GLP-1 alone. Another expert suggests a larger sample might reveal differences between drug classes, and underscores that GLP-1s have broader benefits beyond insulin discontinuation, including effects on weight and metabolic risk.

Insurers say AI could add billions in health costs. Billing companies disagree.

By Jacqueline LaPointe – The healthcare industry is looking down the barrel of what the insurers say is a billion-dollar question: Are artificial intelligence-backed billing tools driving up healthcare costs? Autonomous medical coding, AI-assisted documentation and ambient listening tools for notetaking all promise to reduce administrative burden in healthcare. But that has come at a price for Blue Cross Blue Shield Association of about $942 million over two years, according to research the insurer released last week. Read Full Article...

HVBA Article Summary

1. Insurers’ concern centers on higher billing intensity without more care: Blue Cross Blue Shield Association argues that AI-enabled coding and documentation tools may be contributing to higher spending by increasing the number and complexity of diagnosis codes submitted. It points to patterns where diagnoses rise but related treatments do not, which it interprets as inconsistent with patients simply being sicker. The insurer frames this as a systemwide cost issue that could ultimately raise premiums and affect employers and patients.

2. Billing-technology vendors dispute the framing and emphasize existing payment incentives: Executives from Solventum and CodaMetrix say the tools are primarily helping providers capture legitimate reimbursement under current rules, rather than enabling improper “upcoding.” They argue that in a fee-for-service model, more complete coding of clinical encounters can increase payments even when clinical practice does not change. They also say their products include compliance guardrails and that outright fraud, waste, or abuse should be rare rather than typical.

3. The article ties the debate to fee-for-service vs. value-based payment and operational fallout: Sources suggest that the long-running shift toward value-based care could reduce sensitivity to coding volume because payment would be more tied to outcomes than to each submitted code. The piece also notes that increased payer scrutiny can translate into more audits, denials, and appeals, adding administrative burden across the system. Even amid disagreement over causes and accuracy, the article portrays revenue-cycle AI as becoming entrenched in clinical documentation and coding workflows.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

The Infusion Spend Problem Self-Funded Health Plans Can No Longer Ignore

By Jake Velie – Some of the biggest drug costs in a self-funded health plan never show up in the PBM report. They sit inside the medical claim, in infused and provider-administered therapies, where the same drug can cost dramatically different amounts depending on how it is sourced, where it is administered and how the contract is structured. Drawing on a recent industry fireside chat, Velie points to a case in which a plan cut roughly $80,000 per administration of Ultomiris by changing the procurement path and contracting structure, while keeping treatment in the same physician-office setting. “It was the same medicine, in the same chair, in the same building, just a different contract,” writes Velie. “The right question is not only whether the treatment should happen. The right question is whether it is being delivered through the lowest reasonable net-cost path.” Read Full Article...

HVBA Article Summary

1. Infusion spend hides in the medical benefit: Velie argues that a meaningful share of high-cost drug exposure is billed on the medical claim, not the pharmacy claim, where many employers still rely on passive default pathways. The economics are shaped by four factors: the therapy selected, the place of service, the reimbursement structure and the discipline of the people managing the claim. When those go unmanaged, high-cost cases tend to flow to the most expensive channel. That is why two plans can cover the same therapy for the same condition and end up with very different financial outcomes.

2. Pre-cert and prior auth are where leverage begins: The article calls the authorization process the linchpin, since it is where high-cost therapies can be reviewed before they become paid claims. At that point, a plan can weigh a clinically appropriate lower-cost option, a biosimilar or a move out of the hospital outpatient department. Velie notes that self-funded plans with full-detail claims data, including diagnosis codes, CPT detail, drug identifiers and place of service, can ask far sharper questions than groups working from summary reports. “Without that level of visibility, employers are not managing trend. They are absorbing it,” he writes.

3. Contracts and member experience determine the result: Velie cautions that fixing infusion spend is not as simple as shopping PBM to PBM, because restrictive plan documents and vendor contracts can block an employer from using a better option. He also stresses that redirected care must feel coordinated and supportive to the member, not like something is being taken away. Managed correctly, the savings stack, affecting the immediate paid amount, the next renewal and the stop-loss conversation that follows. The article closes with direct questions for brokers, plan sponsors, TPAs, stop-loss carriers and PBMs to bring into their next renewal.

New Senate bill targets specialty drug costs

By Allison Bell – A new, bipartisan Senate bill could help employers and their benefits advisors push down the cost of covering specialty drugs and mail-order drugs. Sen. Bill Cassidy, R-La., and Sen. Mark Warner, D-Va., have joined to introduce the Ensuring Accurate Payments to Specialty Pharmacies Act bill. The bill would require the team that manages the federal government's National Average Drug Acquisition Cost survey to include specialty pharmacies and mail-order pharmacies in their survey sample. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Specialty Drug Costs Highlight Need for More Accurate Pricing Data: Specialty pharmacies dispense complex, high-cost medications for serious conditions, including biologics and cell and gene therapies that may require specialized handling. Some treatments carry exceptionally high prices, with the hemophilia B gene therapy Hemgenix costing as much as $3.5 million per patient. These costs increase the importance of reliable acquisition-cost information when determining pharmacy reimbursement and managing prescription drug spending.

2. Bipartisan Bill Would Expand NADAC Reporting: Sens. Bill Cassidy and Mark Warner reintroduced the Ensuring Accurate Payments to Specialty Pharmacies Act, which would require specialty and mail-order pharmacies to participate in federal drug acquisition-cost surveys used to calculate the National Average Drug Acquisition Cost (NADAC). Currently, these surveys primarily cover retail community pharmacies, while the proposal would provide HHS with broader information about what pharmacies actually pay for prescription drugs. The expanded data could also give employer plan sponsors another pricing benchmark to consider alongside commercial sources such as average wholesale price data.

3. Proposal Focuses on Pharmacy Reimbursement and PBM Transparency: Medicaid programs and their PBMs use NADAC data to help establish pharmacy reimbursement rates, making the completeness of the underlying acquisition-cost information important to payment calculations. The legislation is intended to produce more representative specialty-drug cost data and help ensure PBM reimbursement rates reflect pharmacies’ acquisition costs. Supporters, including Cassidy and Warner, say the changes could improve reimbursement accuracy and help protect patient access and out-of-pocket affordability, although those are stated goals of the legislation rather than established outcomes.

Why open enrollment should be more than a once-a-year campaign

By Jimmy Nesbitt – Benefits communication too often focuses on what employers need to explain rather than what employees actually need to decide. “People are busy, and benefits can feel overwhelming enough without adding more jargon or information,” said Cass Pratt, chief human resources officer at Progyny, a fertility and family-building benefits provider. “The goal isn’t to tell employees everything, it’s to help them quickly understand what’s relevant to their lives so they can make confident decisions for themselves and their families,” she said. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Open Enrollment as a Year-Round Process: Employers can approach open enrollment as more than a once-a-year administrative campaign, with benefits education continuing before, during, and after the enrollment period. Ongoing communication can give employees more opportunities to understand their options, ask questions, and revisit available resources as their circumstances change. Success can therefore be measured not only by enrollment completion, but also by whether employees understand and can effectively use their benefits.

2. Relevant and Personalized Benefits Communication: Benefits communications may be more meaningful when they connect available programs to real-life situations such as starting a family, caring for aging parents, managing chronic conditions, addressing mental health, or making financial decisions. Employers can tailor messaging for different employee populations while avoiding assumptions about individual needs or circumstances. Using multiple communication channels and resources such as employee resource groups can also help reach employees with different preferences and experiences.

3. Measuring Understanding and Benefits Utilization: Enrollment figures and email open rates provide limited insight into whether benefits communications are helping employees make informed decisions. Employers can also evaluate employee confidence, access to care and support, utilization of available benefits, engagement across different employee populations, and direct employee feedback. These measures can help identify areas of confusion and determine whether communications are translating into employees taking action and using their benefits when needed.

Half of Denials Get Reversed. So Why Deny Them in the First Place?

By Wendell Potter – Bloomberg’s John Tozzi, Tanaz Meghjani, and Ike Swetlitz analyzed 2025 prior-authorization data that insurers have been required to disclose under new federal rules. The analysis found that five major publicly traded insurers (Aetna, Centene, Elevance, Humana, and UnitedHealth) denied more than 10% of standard prior authorization requests in most of their Medicare, Medicaid, and ACA plans in 2025. When patients appealed, they won roughly half the time. In some plans, the reversal rate hit nine out of ten. Read Full Article...

HVBA Article Summary

1. Appeals Frequently Reverse Prior Authorization Denials: Data cited in the article indicates that patients who appeal denied healthcare claims or prior authorization decisions succeed in at least half of cases, although many patients may not know they have the right to appeal. The article highlights a Kentucky cancer patient whose liver transplant was initially denied but later approved after an appeal. These reversals raise questions about whether some initial denials reflect medical-necessity determinations or administrative and documentation issues.

2. Administrative Issues Contribute to Denials and Provider Burden: Duly Health and Care reported that about 60% of the appealed cases it successfully overturned involved issues such as missing records or documentation confusion rather than disagreements over medical necessity. Healthcare providers may therefore devote significant staff resources to resolving authorization requirements, with the Iowa Clinic reporting that approximately 30 employees continue to work on prior authorizations. Insurers maintain that prior authorization helps prevent unnecessary care and control healthcare spending, while critics point to variation in denial and reversal rates as evidence of potential inefficiencies.

3. Insurers Are Reducing and Streamlining Prior Authorization Requirements: UnitedHealthcare says it is reducing prior authorization volume by 30%, CVS Health's Aetna reports standardizing 88% of its prior authorizations, and Humana says it has eliminated requirements for roughly one-third of its outpatient codes. Industry-wide efforts cited by AHIP have eliminated prior authorization requirements for 11% of services, representing approximately 6.5 million requests, while participating insurers have also agreed to honor existing authorizations for three months when patients change plans. The potential impact of these changes will depend partly on how frequently the eliminated requirements were previously used and whether the reforms meaningfully reduce delays and administrative work for patients and providers.

Lilly's amylin-Zepbound combo posts best-ever weight loss in patients with obesity and diabetes

By Elizabeth Cairns – Forget Wegovy and Zepbound. Never mind CagriSema, and even retatrutide. The latest big name in obesity is eloraTZP. Data revealed Wednesday show that Lilly’s amylin-incretin combination delivered weight loss of up to 23.3% at about 11 months in patients with both obesity and type 2 diabetes. This is the best-ever data seen in this population, beating the previous record-holder, Lilly’s own retatrutide. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. EloraTZP Produces Significant Weight Loss in Phase 2 Trial: Lilly’s eloraTZP combination produced an average 23.3% weight reduction at the highest dose among patients with obesity and diabetes, compared with 3% for placebo. Lower doses resulted in weight loss ranging from approximately 13% to 20%, while 25% of patients receiving the highest dose lost at least 30% of their body weight. The combination also reduced glycated hemoglobin by an average of 2.9% at the highest dose, compared with 0.3% for placebo.

2. Results Compared With Other Obesity Drug Candidates: EloraTZP combines Lilly’s investigational amylin eloralintide with tirzepatide, the active ingredient in Zepbound, and is being developed as a potential competitor to Novo Nordisk’s CagriSema. CagriSema produced 15.7% weight loss in a Phase 3 obesity-diabetes trial conducted over a longer treatment period, while Lilly’s retatrutide achieved up to 20.8% in a comparable population. Differences in trial design, treatment duration, and development stage limit direct comparisons among the therapies.

3. Safety and Tolerability Remain a Focus Ahead of Phase 3: Discontinuation due to side effects ranged from 10.8% to 27.0% among patients receiving eloraTZP, with gastrointestinal effects occurring primarily during dose escalation. Lilly plans to use the Phase 2 findings to adjust dosing and titration schedules, similar to changes previously made during Zepbound’s development. Phase 3 trials are planned in patients with obesity with and without diabetes, with eloraTZP expected to be reformulated as a single injection and potential data anticipated in 2028 or 2029.

4 largest PBMs control 75% of U.S. market, AMA finds

By Cailey Gleeson – The four largest pharmacy benefit managers in the U.S. controlled 75% of the national market in 2024, up from 70% in 2022, a new report from the American Medical Association (AMA) found. Moreover, the concentration of PBM markets increased from 82% in 2022 to 94% in 2024—which the report notes is due to thresholds set by federal antitrust guidelines. Analysts used 2024 data from the Decision Resources Group (DRG) on PBMs and prescription drug plans (PDPs). Read Full Article...

HVBA Article Summary

1. PBM Market Concentration Continues: The AMA analysis found that the four largest PBMs controlled 75% of the national market in 2024, led by OptumRx and Express Scripts at 23% each, followed by CVS Caremark at 18% and Prime Therapeutics at 11%. Express Scripts increased its share from 17% in 2022 to 23% in 2024, while CVS Caremark declined from 21% to 18%. The AMA said continued concentration and limited competition in many local markets warrant greater scrutiny, transparency, and accountability.

2. Vertical Integration Is Widespread: Insurers vertically integrated with PBMs covered 69% of people enrolled across commercial health plans and Medicare Part D in 2024. The share was higher in Medicare Part D at 73%, compared with 67% in the commercial market. UnitedHealth Group was the largest payer offering prescription drug benefits in both the commercial market, with a 14% share, and the Medicare Advantage prescription drug market, with a 30% share.

3. Concentration Presents Potential Benefits and Risks: The report noted that larger PBMs could potentially use their purchasing scale to negotiate greater drug rebates, which could benefit consumers if those savings are passed through through lower premiums or out-of-pocket costs. However, high concentration could also contribute to higher PBM service costs, higher insurance premiums, incomplete rebate pass-through, and lower pharmacy reimbursement. The authors said additional empirical evidence is needed to determine the overall impact of PBM concentration and vertical integration on consumers.

After GLP-1s, biosimilars are the new frontier in direct-to-employer plans

By Lydia Ramsey Pflanzer and Shelby Livingston – Fresenius Kabi will sell biosimilars directly to employers. To accomplish that, the drugmaker is working with Eversana-owned Waltz Health, which runs a marketplace that helps employers shop for better deals on prescription drugs. Waltz began striking up these types of arrangements in 2025, when Eli Lilly and Novo started selling GLP-1 weight loss drugs directly to employers at a fixed price, similar to the direct-to-consumer cash pricing that has risen in popularity. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Direct-to-Employer Biosimilar Pricing: Waltz Health has reached an agreement covering Fresenius Kabi biosimilars to Humira, Stelara, and Actemra, with the first clients expected to implement the pricing in early 2027. The model provides drug pricing directly to employers rather than relying solely on traditional PBM rebate arrangements. Waltz estimates that an employer covering about 1 million people could save approximately $11 million to $12 million annually through the direct approach.

2. Potential to Increase Biosimilar Adoption: Biosimilars have faced challenges gaining market share despite offering competition to higher-cost branded biologic medications, although PBMs have increasingly prioritized biosimilars and introduced private-label alternatives. Waltz believes direct employer contracting could make biosimilars more competitive by providing employers with upfront pricing while maintaining insurance coverage for employees. Drug manufacturers are also showing interest in employer-based arrangements as an alternative to direct-to-consumer channels, where adoption has reportedly been more limited.

3. Model Could Expand to Other High-Cost Drugs: Waltz works with employers, health plans, and PBMs to apply negotiated direct pricing after a medication is prescribed and coordinate delivery to the patient or provider. The company expects direct-to-employer agreements to contribute to greater biosimilar utilization as more employers consider alternative drug purchasing models. Waltz is also pursuing similar arrangements in oncology and migraine treatments, focusing on therapeutic areas with high prices and significant utilization.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

No, the UnitedHealth AI-Denial Lawsuit Isn’t New. Here’s Where It Actually Stands.

By Wendell Potter – If your feed served you a “BREAKING” post last weekend about UnitedHealth using an AI with a 90% error rate to deny care, you should know that the story is real, but it’s not new. I flagged the underlying reporting back in November 2023, when STAT first exposed the algorithm. What I never did was come back and walk you through the actual lawsuit, or tell you where it’s gone since, even as the case has quietly become one of the most important health insurance fights in the country. Read Full Article...

HVBA Article Summary

1. The lawsuit’s timeline and current procedural posture: The post explains that the legal fight over UnitedHealth’s use of the nH Predict tool is not a new development, despite recent social media framing. It describes how the case has progressed through court, including surviving an important early challenge. The article emphasizes that recent public posts implied major new revelations, but much of the latest docket activity has been routine scheduling and filings.

2. How nH Predict is alleged to influence coverage decisions: According to the article, the nH Predict model uses a large patient database to estimate how many days of post-acute care a patient “should” need, and the complaint argues this estimate drove coverage cutoffs. The post also describes internal performance pressure tied to keeping rehab stays close to the model’s predicted length, even when treating physicians disagreed. The piece frames these allegations as raising the question of whether the tool’s outcomes reflect technical flaws or a system optimized to reduce utilization.

3. Broader industry implications beyond one insurer: The article argues this is not only a UnitedHealth issue because similar algorithm-related denial allegations are playing out across other major insurers. It notes that related litigation and reporting involve additional companies and tools used to scale or accelerate claim and coverage determinations. The post suggests that if plaintiffs succeed—especially if class certification is granted—the case could become a template for other contract-based challenges to algorithmic denial practices.

Why workforce sentiment is a critical fiduciary data point

By Donovan Pyle – In our previous installment, we examined how a comprehensive forensic audit quantifies program performance across seven core operational pillars to solve the health and welfare value equation. We demonstrated that true value balances human experience and program quality against overall spend. Yet in executive boardrooms across the country, a fundamental strategic mistake occurs every year during renewal season. At its core, the foundational business purpose of any health and welfare program is clear: to attract, serve and retain top talent. Outside of direct compensation, the benefits portfolio is an employer’s most powerful tool for competing in the labor market. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Employee Feedback as Benefits Market Research: The article argues that employers should approach benefits decisions with the same market research discipline used for major consumer investments. Structured employee feedback can help identify which benefits contribute to retention, where employees experience friction, and which offerings receive little meaningful use. Measuring satisfaction, utilization, and vendor-level issues can provide leadership with data to guide benefits spending.

2. Evaluating Point Solutions and Reallocating Spending: Employers may accumulate digital health tools, wellness programs, and other point solutions without sufficient evidence that employees value or use them. One example cited a company spending nearly $180,000 annually on four solutions, three of which had adoption rates below 4%, leading the employer to eliminate those programs and redirect roughly $135,000 toward lowering the medical plan deductible. Regular evaluation can help organizations determine whether resources should remain with supplemental programs or be redirected toward core benefits and employee out-of-pocket costs.

3. Balancing Financial Performance With Employee Experience: The article recommends evaluating benefits programs using both financial measures and workforce sentiment, including satisfaction scores, utilization data, and administrative friction such as claims or network issues. It also connects this approach to employers’ fiduciary responsibilities under ERISA, while emphasizing that employers retain authority over benefits strategy, budgets, and talent objectives. Incorporating employee experience into ongoing benefits reviews can give leadership additional information when making decisions about coverage, vendors, costs, and future plan changes.

New pharma tariffs begin today: 4 things to know

By Ella Jeffries – Section 232 tariffs on patented pharmaceutical products and associated pharmaceutical ingredients took effect Sept. 29 for companies not covered by the earlier July 31 implementation date. The tariffs follow a Commerce Department investigation that found U.S. dependence on imported pharmaceuticals and pharmaceutical ingredients threatened to impair national security. Read Full Article...

HVBA Article Summary

1. Two-phase rollout and who is affected: The tariff framework began with a subset of manufacturers listed in Annex III, which were brought under the policy earlier than the rest of the market. Companies not included in that initial group became subject to the tariffs on Sept. 29. This creates a staggered compliance and cost timeline, depending on whether a firm was named in the proclamation’s annex. The structure also implies that the operational and pricing impact may differ across manufacturers based on their category and start date.

2. Exemptions tied to pricing and onshoring commitments: The policy includes a zero-tariff pathway for companies that meet certain most-favored-nation pricing and onshoring agreement requirements. Those qualifying arrangements extend the zero rate through Jan. 20, 2029, effectively delaying tariff costs for participating firms. The article notes that, as of an Aug. 31 White House announcement, all 17 Annex III companies had signed these MFN deals. As a result, none of those named companies were paying the tariff at the time described.

3. Rates, future increases, and downstream uncertainty for providers: The baseline tariff rate for covered patented products and related ingredients is set at 100%, with a lower 20% rate available for companies with approved U.S. onshoring plans. That 20% rate is scheduled to rise to 100% on April 2, 2030, and the article also notes that different rates may apply for certain trading partners. The article specifies that generic drugs and biosimilars are not currently subject to these Section 232 pharmaceutical tariffs. Health system pharmacy leaders are monitoring the timeline as part of broader efforts to diversify sourcing, while price forecasts remain uncertain because the tariff effects were not included.

When Bill Gates talks world-changing technology, people listen. Have you heard what he’s saying about AI in healthcare?

By Dave Pearson – “Bill Gates warns ‘there is no plan’ for the ‘upheaval’ AI will cause.” … “Bill Gates says AI will either be ‘greatest equalizer’ or ‘worst source of injustice’” … “Bill Gates is deeply worried about AI—and he’s no longer staying quiet” … These are just three of countless headlines that popped in the 24 hours after the business magnate, Microsoft co-founder and longtime (albeit former) face of the brand blogged on the current state and future outlook of artificial intelligence. More specifically, Gates did a deep dive into his personal hopes and fears around the technology. Perhaps unsurprisingly, it’s the fears that have found the most traction with the press. Read Full Article...

HVBA Article Summary

1. Gates frames healthcare AI as both promising and socially sensitive: The article highlights Gates’s view that some tasks—especially those involving difficult, emotional conversations—should remain human-led even if automation is technically possible. He suggests a gradual approach to adopting AI in areas like education and mental healthcare, with humans staying in charge. This underscores a broader theme that capability alone shouldn’t determine where AI is deployed in care settings.

2. Public-sector input and cross-domain governance are presented as essential: Gates argues that AI solutions should be shaped through a public democratic process involving policymakers and frontline professionals, including health workers. He also emphasizes that AI’s effects span many interconnected sectors, creating challenges for government institutions that are organized in separate bureaucratic “silos.” The article conveys that managing healthcare AI responsibly may require coordination that goes beyond traditional health regulation.

3. Examples focus on access, administration and resource constraints in care delivery: Gates describes potential uses for AI to reduce friction in navigating bureaucratic systems such as applying for health insurance and other assistance programs. He also points to clinical support scenarios, such as helping smaller hospitals without on-site specialists detect emergencies in time, and assisting primary-care teams with diagnosis and patient follow-up. Separately, the article notes his expectation that AI will support the Gates Foundation’s work, including speeding discovery of vaccines and medicines and helping people use those tools.

Health care costs force 42% of women to delay care

By Joel Kranc – Health care affects different people in different ways. And a new report from KFF Women's Health Survey breaks out how women deal with issues differently, particularly with problems of lower incomes, fewer financial resources, and in many cases using the health care system more than men. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Care delays persist even with insurance coverage: The survey reports that 42% of women ages 18–64 said they delayed or postponed needed care in the past 12 months due to cost, compared with 35% of men in the same age range. It also indicates that the issue extends beyond the uninsured, with women in multiple coverage types reporting delayed care. The figures vary by coverage, including higher reported delays among uninsured women and notable shares among those with individually purchased plans, Medicaid, and employer-sponsored coverage.

2. Prescription drug costs are linked to changes in medication use: The report finds that 27% of women ages 18–64 said they did not fill a prescription in the last year because of cost, and 17% said they cut pills in half or skipped doses due to cost. It further notes higher rates of these behaviors among women reporting fair or poor health, compared with the overall group. These findings suggest that affordability can affect both access to medications and adherence to prescribed regimens.

3. Health expenses can crowd out other basic needs, with some groups more affected: According to the survey, 25% of women ages 18–64 said they spent less on basic needs like food, clothes, and electricity so they could afford health care, and this share rises to 42% among uninsured women. It also notes that roughly three in 10 women on Medicaid or with individually purchased insurance who were Black or Hispanic, low-income, or in fair or poor health reported making similar trade-offs. The article ties these pressures to broader economic differences, citing women’s lower wages, fewer financial assets, and higher poverty rates, alongside a finding that 31% of women skipped recommended tests or treatments due to cost.

Four pharmacies, one pain cream playbook, $1.49M in alleged no-fault fraud

By Tez Romero – One of the pharmacies, according to the complaint, was created for the purpose of running the alleged scheme. It is one of four that Allstate is now suing. The insurer and its affiliates filed four federal lawsuits on the same day - September 28, 2026 - in the US District Court for the Eastern District of New York. Each complaint tells the same story: a pharmacy exploited New York's no-fault auto insurance system to bill for expensive, medically unnecessary topical pain creams while cheaper alternatives went unprescribed. Every filing includes a claim under the federal Racketeer Influenced and Corrupt Organizations Act - a law originally designed to combat organized crime that, when invoked successfully, can triple the payout. That detail alone signals how seriously Allstate is treating the alleged conduct. Read Full Article...

HVBA Article Summary

1. Multiple lawsuits allege a shared no-fault billing approach: Allstate and its affiliates filed four separate federal complaints targeting different pharmacies, but the filings describe a similar alleged approach to billing topical pain creams through New York’s no-fault auto insurance system. The allegations center on prescriptions for topical products that Allstate says were not medically necessary, even when lower-cost alternatives were available. The cases were filed in the Eastern District of New York, and the article notes there were no responses on record at the time of publication. The piece also emphasizes that the claims remain unproven and have not been ruled on by a court.

2. RICO claims raise the legal and financial stakes: Each complaint includes a claim under the federal Racketeer Influenced and Corrupt Organizations Act (RICO), which the article notes can allow for treble (triple) damages if successfully invoked. The inclusion of RICO suggests the insurer is framing the alleged conduct as coordinated and systematic rather than isolated billing disputes. The suits also seek recovery of money already paid and relief from paying additional bills that Allstate says are not owed. This approach reflects how insurers may use civil racketeering statutes as a tool in contested fraud matters tied to billing and documentation practices.

3. Allegations focus on documentation, pricing, and relationships with clinics: The complaints describe alleged financial arrangements between the pharmacies and no-fault clinics, with clinics prescribing particular topical creams to accident patients. The article reports that the filings claim documentation was sometimes boilerplate and designed to justify continued prescribing, rather than reflecting individualized medical need. The suits also allege exploitation of New York’s no-fault fee schedule by selecting products with high reference prices, allowing billing at amounts described as inflated relative to acquisition costs. Additionally, the complaints cite prior federal reports (from 2015 and 2018) that flagged topical pain cream billing as a significant fraud risk.

Broker consolidation tests agility, part 3

By Bruce Shutan – As the nation’s largest benefits brokerages become even bigger, some industry insiders are concerned that their massive growth may exacerbate the potential for conflicts of interest on the health and welfare side of the industry. This worry comes amid allegations over breaches of fiduciary duty under ERISA tied to overpaying on medical claims, prescription drugs and voluntary benefits. With soaring healthcare costs now serving as the biggest P&L expense other than payroll for so many employers, there’s growing scrutiny about the vertical integration of large health insurers that own a pharmacy benefit manager (PBM), third-party administrator (TPA) for administrative-services-only (ASO) contacts, and stop-loss carrier to lock up business for both fully insured and self-funded group health plans. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Brokerage Consolidation Raises Questions About Conflicts of Interest: Industry experts cited in the article argue that vertical integration among brokerages, carriers, PBMs, TPAs, and stop-loss providers can create structural conflicts when multiple services are owned by or financially aligned with the same organization. They contend that these arrangements may make it more difficult for employers to determine whether recommendations are fully independent or influenced by existing financial relationships. Independent firms may offer an alternative by operating outside these ownership structures, although the article acknowledges that independence alone does not guarantee better outcomes.

2. Independent Oversight May Become More Important as Integration Expands: Experts highlighted concerns that consolidation can reduce the separation between organizations administering health plans and those responsible for auditing costs, rebates, claims, or contract terms. Independent payment integrity reviews and broker oversight were presented as potential ways for plan sponsors to identify issues such as overpayments, rebate leakage, or unfavorable stop-loss provisions. The article also connects these concerns to employers’ ERISA fiduciary responsibilities and growing scrutiny of whether financial relationships and potential conflicts are adequately disclosed.

3. Employers Are Seeking Greater Transparency Around Adviser Relationships: The article suggests that employers increasingly want clarity about how brokers and consultants are compensated, who owns or controls recommended vendors, and whether financial incentives could affect plan recommendations. At the same time, representatives of larger brokerages maintain that advisers can use their scale, data, and resources while still evaluating fully insured, ASO, pharmacy, stop-loss, and point-solution options objectively. As brokerage consolidation continues, transparency, measurable data, and clear alignment with employer goals around cost, access, outcomes, and employee experience are likely to remain important considerations for plan sponsors.

Navigating GLP-1 Switches: A Guide for Primary Care

By Erica Lamberg – As GLP-1 receptor agonists and dual incretin agents become more common in treating obesity and type 2 diabetes, primary care providers are handling more medication switches. The reason may be insurance coverage, ongoing gastrointestinal side effects, inadequate response, or the need for better blood sugar control or weight support. Whatever the driver, switching is not simply trading one prescription for another. It requires planning around half-lives, dose history, side effects, and the risk for blood sugar swings. Recent guidance from the American Diabetes Association’s Standards of Care in Overweight and Obesity also stresses a person-centered approach, including access, tolerability, side effects, and patient preferences. Read Full Article...

HVBA Article Summary

1. Switching is a clinical transition, not a simple substitution: The article emphasizes that changing GLP-1 receptor agonists or dual incretin therapies requires deliberate planning rather than direct “like-for-like” replacement. Clinicians are advised to account for pharmacokinetics (including half-life), the patient’s prior dose exposure, and prior tolerability before choosing a starting dose on the new agent. The piece also frames the decision as person-centered, incorporating access and patient preferences alongside clinical considerations. Overall, it positions switching as an opportunity to reassess goals and reduce avoidable risks during the transition.

2. Timing and titration strategies should be individualized to reduce intolerance: The guidance described suggests that a medication-free “washout” period is generally unnecessary; instead, the new drug can typically begin when the next dose of the previous drug would have been due. The article warns against assuming dose equivalence across agents, noting that mismatched dosing can worsen gastrointestinal side effects. It also highlights that prior titration experience matters—patients who tolerated earlier escalation may be able to move faster, while others may need slower re-escalation. If therapy has been interrupted for more than about 2-3 weeks, experts quoted recommend restarting at a lower dose and titrating again to limit GI intolerance.

3. Glycemic safety requires proactive monitoring and adjustment of other diabetes drugs: For patients with type 2 diabetes, the article underscores that glucose levels can change quickly after a switch, particularly when insulin or sulfonylureas are part of the regimen. It recommends more frequent glucose checks for at least the first four weeks after switching and after each dose increase, so clinicians can detect trends early. The piece also advises having a plan to reduce or temporarily hold insulin or sulfonylurea doses to help prevent hypoglycemia as the new incretin therapy takes effect. Continuous glucose monitoring is presented as especially useful because it can reveal daily patterns and overnight lows that A1c alone may miss.

3 ways to connect employees with help for anxiety

By Deb Smolensky – By nature, humans are time travelers. We replay the past when something goes wrong, and we fast-forward into the future imagining what might go wrong next. That mental loop of "what if?" scenarios can become anxiety: worry or uneasiness about an uncertain outcome, especially when the brain stays on alert for a threat that hasn't happened. At work, anxiety rarely lives in one lane. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Use benefits communication to build understanding and confidence: The article argues that anxiety is often fueled by uncertainty, and that clear benefit information can reduce that uncertainty. It emphasizes that understanding should start during annual enrollment but continue throughout the year. It also suggests tailoring messaging to real-life situations (for example, caregiving, pediatric mental health needs, or managing debt) to make options feel relevant and actionable.

2. Make it easy to navigate from a question to the next step: The piece notes that knowing a benefit exists is different from knowing how to use it, especially when someone is already anxious. It recommends creating a simple, visible “front door” to support—such as a navigation partner, EAP, mental health solution, benefits platform, or a single phone number. The stated aim is not adding more programs, but reducing the effort employees spend searching and comparing so the system feels guided rather than confusing.

3. Increase actual utilization by normalizing care and broadening support: The article highlights that the most effective benefit is the one employees actually use, and connects that idea to anxiety support specifically. It calls for normalizing mental health care, encouraging earlier access, and equipping managers to recognize when support may be needed without turning them into clinicians. It also frames anxiety reduction as connected to other resources—like financial coaching, caregiving help, health advocacy, condition management, and parenting support—because these can reduce practical “what if” stressors.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

State AGs call for federal AI regs without further ado; Big Tech insider suspects cynical motives behind AI doomsday warnings

By Dave Pearson – Some 26 attorneys general have signed onto an initiative urging Congress to federally regulate the AI industry “immediately.” As healthcare is one of the fastest-growing adopters of AI—a distinction that carries ramifications for Americans at the population level—it goes without saying that the sector is top of mind for the signatories. The coalition of 26, led by New York AG Letitia James, sent a letter Sept. 23 to leaders of both chambers (House Speaker Mike Johnson, House Minority Leader Hakeem Jeffries, Senate Majority Leader John Thune and Senate Minority Leader Charles Schumer). “The stakes have never been higher to ensure that AI agents cannot enact grave harms,” James and co-signers assert in the letter. “If AI labs cannot prevent their models from conducting harmful and illegal activity, allowing them to release their models into the hands of bad actors only guarantees catastrophe.” Read Full Article...

HVBA Article Summary

1. Attorneys general urge rapid federal AI regulation: A coalition of state and territorial attorneys general is pressing Congress to move quickly on a federal framework for AI oversight. Their argument emphasizes the potential for serious harm if AI systems are deployed without adequate safeguards and accountability. They also frame the issue as requiring national and international coordination beyond what states can achieve alone.

2. Letter outlines six priority areas for oversight and enforcement: The attorneys general list specific elements they want included, such as federally directed safety testing standards and a government-led incident response process with access to company records and public findings. They also call for requirements around internal safety infrastructure and leadership that is not driven solely by profit considerations. Additional priorities include international coordination, protections for competition and antitrust enforcement, and maintaining state authority rather than preempting state laws.

3. Competing narratives from within the tech industry: The article contrasts the attorneys general’s warnings with comments from Palantir co-founder Joe Lonsdale, who criticizes what he characterizes as “doomer narratives.” He argues that exaggerated fears can be used to pursue power or money and compares current rhetoric to past public risk debates. The piece also notes Lonsdale’s view that some calls for regulation may serve strategic interests, such as shifting liability from companies to government or consolidating control of AI development.

The Biggest Health Care Companies in America Don't Treat Anyone

By Wendell Potter – If you rank the ten largest health care companies in America by revenue, you will not find a single hospital system or drugmaker. Not Pfizer, not Eli Lilly, not the Mayo Clinic or HCA. Every company in the top ten is a middleman, and together they take in about $2.6 trillion a year. Read Full Article...

HVBA Article Summary

1. Who dominates the biggest-by-revenue list: The piece argues that the largest U.S. health-care businesses by revenue are primarily intermediaries rather than organizations that directly provide care or manufacture drugs. It describes several common business types among the top companies, including insurers that own pharmacy benefit managers, major drug distributors, and firms focused on Medicare and Medicaid managed care. The author’s framing emphasizes that these entities operate between patients/providers and the flow of payments. The overall point is that the system’s biggest corporate players are largely “middlemen” in the financing and distribution chain.

2. International comparison and system structure: The article contrasts the U.S. model with other wealthy countries, saying they did not build a similarly large, for-profit intermediary layer in health care. It uses Germany as an example, noting that nonprofit “sickness funds” cover most people and are restricted from operating for profit, while countries like the U.K., Canada, and Japan are described as relying on different public or nonprofit financing approaches. The author also calls out pharmacy benefit managers as a uniquely American category, presented as part of why comparable giants are not seen elsewhere. The takeaway is that structural choices about financing and administration differ sharply across countries and shape the corporate landscape.

3. Administrative overhead and political influence: The piece links the presence of many intermediaries to higher administrative costs, citing per-person and share-of-spending comparisons between the U.S. and peer countries and providing estimated ranges for total administrative spending when broader billing-related costs are included. It also describes extensive industry political activity, including lobbying and election-cycle spending, and suggests this activity supports policies that preserve current payment arrangements and limit reforms. The author frames “choice” as a central argument used to defend the existing system, while contending that consumers’ choices can be constrained by tools like narrow networks and prior authorization. Overall, it presents administrative complexity and political spending as reinforcing factors that help maintain the status quo.

How AI is already changing health plan administration

By Dan Thompson – For decades, open enrollment has followed the same script: a flood of PDFs, a confusing comparison chart, either in a printed guidebook (that had multiple versions) or on a digital handbook that is emailed out to employees. This is coupled with a benefits team inbox buried in questions, and employees clicking through choices they only half understand — maybe. This script has to be rewritten. Artificial intelligence is moving into benefits administration at scale, and it's changing not just how enrollment gets managed, but how employees experience one of the most consequential — and most avoided — decisions of their work year. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. AI is being applied to reduce enrollment friction and repetitive work: The article argues that open enrollment has long been dominated by heavy documentation and employee confusion, creating a predictable surge in basic questions. It describes AI chatbots and assistants taking on common “definition” and navigation queries that otherwise consume benefits team time. In the piece’s framing, this shifts HR/benefits staff away from answering the same questions repeatedly and toward higher-level support. The result is positioned as a different employee experience during an often-avoided annual decision cycle.

2. Personalization and decision support are expanding beyond Q&A: Beyond answering questions, the article describes AI tools analyzing employee preferences and other available data (such as demographics and past selections) to guide plan choices. It presents this as a way to steer members toward elections that can improve outcomes, rather than leaving them to make rushed decisions. The piece emphasizes that these recommendations can help employees make more informed comparisons across plan options. This approach is portrayed as a practical response to increasing benefits complexity and ongoing regulatory change.

3. Claims monitoring, self-funding support, and trust are central considerations: The article says AI can help employees get more value from supplemental/worksite policies by identifying when claims may be triggered, citing categories like accident, critical illness, hospital supplement, and cancer plans. It also connects AI to administrative challenges in self-funded plans and references a Milliman study projecting 12 million Americans shifting from fully insured to self-funded plans by 2030. At the same time, it notes that trust and privacy concerns may slow adoption even if employers are eager to deploy these tools. The piece concludes that strong communication, visible privacy protections, and access to a human are key to successful use.

Rising healthcare costs may force small businesses to cut coverage

By Paola Peralta – With the rise of healthcare costs hitting a critical point, small businesses are reconsidering their ability to provide employees with that coverage. According to a new survey of more than 500 owners and managers of small to midsized businesses from digital health insurance marketplace eHealth, 54% of small and midsized businesses offering group coverage are facing double-digit premium hikes for 2027. As a result, 73% of those small businesses are actively weighing whether to drop the benefit altogether. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Rising Healthcare Costs Are Creating Budget Uncertainty: Employers are facing unpredictable healthcare expenses while also managing higher wages and other operating costs. Reducing or eliminating health benefits may generate immediate savings, but employers could need to offset those changes through higher compensation. Scaling back coverage may also affect recruitment and retention, particularly in competitive labor markets where health benefits remain an important part of total compensation.

2. Employers Have Multiple Options to Manage Costs: Employers can reassess their broker relationships and existing plan designs to identify potential savings, including higher deductibles or less comprehensive coverage in exchange for lower premiums. Alternative approaches such as ICHRAs, reference-based pricing, and direct primary care may also provide options depending on an employer’s location, workforce, and needs. Some of these strategies can be combined with existing group health plans rather than requiring employers to replace their current coverage entirely.

3. Long-Term Planning Can Help Employers Balance Cost and Coverage: Employers may benefit from evaluating healthcare strategies over a three- to five-year period instead of focusing only on annual cost increases. For example, an employer could use an ICHRA for employees in markets where individual coverage is favorable while maintaining group coverage for other portions of its workforce. Because costs and market conditions can change from year to year, the article emphasizes evaluating different approaches as part of a broader, longer-term benefits strategy.

Report: 21 states have obesity rates at or above 35%

By Andrew (Drew) Rhoades – Twenty-one states had adult obesity rates at or above 35% in 2025, according to a new report from Trust for America’s Health, or TFAH. The new estimate represents an increase from 19 states in 2024 and no states in 2012, but a decrease from 23 states in 2023, TFAH said. Read Full Article...

HVBA Article Summary

1. Adult and youth obesity trends moved in different directions in the latest national estimates: The report summarizes national data indicating adult obesity declined compared with prior survey years, while obesity among children and adolescents increased over the same general period. It frames the adult change as encouraging but not sufficient to indicate the overall crisis is resolved. It also notes that youth trends raise concerns even as adult rates show signs of stabilization.

2. State-by-state obesity rates varied widely and included notable year-over-year changes in a few places: The assessment describes substantial geographic variation across states, with some states much lower and others close to 40% adult obesity prevalence. It reports that, from 2024 to 2025, no states had statistically significant increases, while Louisiana and West Virginia posted statistically significant decreases. The article also highlights that the count of states at or above 35% rose compared with 2024, even though it was lower than in 2023.

3. Policy recommendations emphasized prevention infrastructure and food-access measures alongside treatment: TFAH’s recommendations included maintaining staffing and resources for federal agencies, investing in prevention initiatives, and expanding access to healthy meals in schools. The article also points to calls for changes affecting nutrition security, including reversing reductions in SNAP access linked to the “One Big Beautiful Bill Act”. Experts quoted argued that medications can be important but should be paired with prevention and public health investments, and that coverage and affordability remain uneven.

When star employees are squeezed from both sides

By Chuck Greenblott – Let me tell you about the most dangerous person in your client’s workforce. She’s 47 years old. A senior manager. Been with the company for 12 years. She knows where the bodies are buried and she’s the one who fixes things when they go wrong. She’s exactly the kind of employee your client cannot afford to lose. She’s also up at 2 a.m. because her teenager didn’t come home. Up at 4 a.m. because her mother with dementia got confused and fell trying to get to the bathroom. She’s been running on coffee and adrenaline for three years and doesn’t remember what a full night of sleep feels like. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Sandwich-Generation Caregiving Is Affecting the Mid-Career Workforce: Nearly half of Americans in their 40s and 50s are simultaneously caring for an aging parent and a child under 18 or a young adult still living at home. These employees may be balancing full-time work with medical appointments, childcare, eldercare, care coordination, and other family responsibilities. The article suggests that many existing benefits programs were not designed to address overlapping caregiving demands across multiple generations.

2. Flexibility and Benefits Can Address Multiple Sources of Caregiving Pressure: The article identifies flexible scheduling, manager discretion, and benefits that support both children and older adults as potential ways employers can respond to sandwich-generation needs. Care navigation, mental health resources, and leave policies may be more useful when they account for responsibilities involving multiple family members rather than a single caregiving situation. Manager training and workplace practices that allow employees to discuss caregiving challenges are also presented as important components of support.

3. Caregiving May Have Implications for Retention and Workforce Planning: The article argues that caregiving pressures can contribute to burnout and may be an overlooked factor when mid-career employees leave organizations for “personal reasons.” Employers and advisers may benefit from examining whether caregiving responsibilities are contributing to turnover and whether current benefits adequately address those pressures. As parents live longer and younger adults remain dependent for longer periods, sandwich-generation caregiving could become an increasingly important consideration in benefits and workforce strategies.

Insurance Formularies Holding Up Lower-Emission Asthma, COPD Inhalers

By Crystal Phend – Commercial insurance formularies have posed a barrier to cutting greenhouse gas emissions from metered-dose inhalers used to treat asthma and chronic obstructive pulmonary disease (COPD), a study showed. Lower-emission versions -- dry powder inhalers and soft mist inhalers -- had less coverage and less often were covered on tier 1 or 2 without prior authorization or step therapy as compared with more polluting metered-dose inhalers, Soko Setoguchi, MD, DrPH, of the Rutgers RWJBarnabas Center for Climate, Health, and Healthcare in New Brunswick, New Jersey, and colleagues reported in JAMA Network Open. Read Full Article...

HVBA Article Summary

1. Coverage and access rules differ by inhaler type: The analysis compared commercial-formulary coverage of metered-dose inhalers with lower-emission alternatives like dry powder and soft mist devices across multiple medication classes. It found that lower-emission options were not only covered less often, but also less frequently placed on preferred tiers without added requirements. The article frames these design choices as a practical barrier for patients and clinicians who want to reduce inhaler-related emissions.

2. Preferred-tier placement strongly favored metered-dose inhalers: Across the three medication categories assessed, metered-dose inhalers were much more likely to be available on tier 1 or 2 without prior authorization or step therapy. The reported preferred-tier/no-utilization-management rates were 99.2% for SABAs, 93.8% for ICS, and 88.7% for ICS-LABA combinations. For propellant-free versions, the comparable rates were far lower: 7.8% (SABAs), 61.8% (ICS), and 52.2% (ICS-LABA).

3. Study scope, limitations, and proposed payer actions: Researchers used the MMIT Coverage Search to examine formularies from all 50 states plus Washington, D.C., as of May 2026, focusing on plan-level rules rather than individual enrollment or patient out-of-pocket costs. The article notes the study did not evaluate real-world prescribing, dispensing, clinical appropriateness of switching devices for particular patients, or the impact of coverage exceptions, and it also cited difficulty distinguishing some generics in the dataset. The authors argue that payers could improve access and sustainability by ensuring at least one propellant-free option per class sits on preferred tiers, reducing utilization management for those options, and improving transparency for employers and purchasers.

UnitedHealthcare, Cigna, Centene join new provider verification platform

By Allison Bell – A health care data firm is starting a National Shared Credentialing Program. The new program will help plans team up to verify whether physicians really have the credentials they say they have. CertifyOS, the company organizing the new program, says the program will create a centralized credentialing site with standardized credentialing events and verification. The list of carriers that have agreed to use the program includes UnitedHealthcare, Cigna and Centene. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. New shared credentialing initiative and participants: CertifyOS says it is starting a National Shared Credentialing Program to centralize and standardize credentialing events and verification. The article identifies UnitedHealthcare, Cigna, and Centene as carriers that have agreed to use the program. A UnitedHealthcare provider data operations executive, Mike Kane, is quoted saying streamlining verification could give providers more time to focus on patient care. The piece frames the effort as a way for plans to collaborate rather than run separate processes.

2. How credentialing currently works and why it matters: The article describes credentialing as an elaborate set of checks governed by government program rules and private quality organization rules. It outlines that plans and network administrators verify physicians’ education, work history, licensure status, and other background factors, including whether they have faced large numbers of malpractice suits. The stated goal is to reduce the risk of contracting with physicians who have fake medical degrees or concerning disciplinary histories. This context explains why verification can be time-consuming and resource-intensive for both providers and plans.

3. Existing CAQH data collection vs. duplicate verification costs: The story notes that “DataSpring, powered by CAQH,” has collected provider credentialing information via the Universal Provider Datasource since 2002, reducing manual re-entry. Even with that data collection, the article says insurers have continued to verify physicians’ credentials separately. CertifyOS estimates that unifying verification could save about $2 billion per year and reports that the average physician submits 17 credentialing or recredentialing applications annually at about $700 per application. For plans and networks, the article puts the cost at about $200 to $500 per provider per credentialing cycle.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

New employer, clinician alliance to advocate for direct contracting

By Paige Minemyer – A new coalition is bringing together employers, clinicians and other stakeholders to push for the expansion of direct contracting. The Association for Direct Care will advocate for policies that ease barriers to direct contracting arrangements between employers and providers, boost transparency and support new payment models. A key goal, according to the announcement, is to support lower costs and better quality as well as the relationship between providers and their patients. The organization will focus on the expansion of direct employer contracting in the commercial space as well as in federal health programs. Read Full Article...

HVBA Article Summary

1. A new advocacy group is targeting direct contracting growth: The Association for Direct Care is forming a coalition of employers, clinicians and other stakeholders to promote broader use of direct contracting between employers and providers. Its policy agenda includes reducing barriers to these arrangements, increasing transparency, and encouraging alternative payment models. The group frames direct contracting as a mechanism to improve both affordability and care quality while strengthening provider-patient relationships.

2. The effort spans commercial employers and government programs: The organization says it plans to focus on expanding direct employer contracting in the commercial market as well as within federal health programs. This indicates the coalition is not limiting its approach to private-sector employer plans and is also aiming to influence public-sector purchasing and contracting structures. The stated scope suggests a strategy oriented toward policy change and adoption across multiple payer environments.

3. Named participants reflect a cross-section of stakeholders: The announcement lists participating organizations including Nomi Health, the American Academy of Family Physicians, the National Alliance of Healthcare Purchaser Coalitions, the ERISA Industry Committee, the Employer's Forum of Indiana and Grounded Health. The presence of both clinician and employer-purchaser groups signals an attempt to align provider and buyer interests around contracting approaches. The article also notes employer interest in cost-management solutions as broader healthcare expenses rise.

Private employer health benefits costs surge 7.4%

By Allison Bell – Private-sector employers in the United States are facing much higher health insurance costs but struggling to hold their benefits packages together. The Bureau of Labor Statistics painted that picture today in a new batch of National Compensation Survey employee benefits data. The average cost of health benefits for a single employee at a private-sector employer rose 7.4% between 2025 and 2026, to $633.77, according to the survey report. But those private-sector employers continued to offer health benefits to 72% of employees, with the offer rate falling only slightly, from 73%, the year before. Employers continued to cover 80% of the cost of the health benefits for a single employee, just as they did in 2024 and 2025. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Public vs. private employer benefit patterns: The BLS data shows state and local government employers continued to offer health benefits to 89% of employees while private-sector employers offered them to 72%. Average single-employee health benefit costs at state and local government employers rose 7.1% to $652.56. The piece frames these results as consistent with what large insurance brokers and insurers have been telling investors about employers trying to keep benefit offerings roughly unchanged despite rising costs.

2. Coverage access varies sharply by work status: The detailed tables cited in the article indicate employers provide access to health benefits for 87% of full-time civilian workers but only 24% of part-time workers. It also notes access fell year over year for both groups, with full-time offers dropping from 89% in 2025 and part-time offers dropping from 25%. This highlights that benefit availability is far more common among full-time roles and that recent declines are small but measurable.

3. Retirement and paid leave access edged or held steady: The article contrasts findings that only 49% of small and medium-sized U.S. businesses offer retirement plans with BLS figures showing 70% of private-sector workers had access to defined contribution retirement plans. It also reports the share of workers with access to paid sick leave increased to 81% from 80%. The piece suggests differences between employer counts and worker counts can reflect that larger employers are more likely to maintain benefits than smaller firms.

Leveraging ICHRAs for Healthcare Cost Predictability

By Emily Boyle – As employers continue to determine how best to address rising healthcare costs, increasing the use of individual coverage health reimbursement accounts may offer some predictability for company budgets. Launched in 2020, an ICHRA is an employer-funded benefit that reimburses an employee for the cost of purchasing individual health insurance, rather than the employer providing a group health plan. With an ICHRA, employers contribute a fixed dollar amount that employees then use to buy their own individual health coverage. Read Full Article...

HVBA Article Summary

1. ICHRA Can Provide More Predictable Employer Costs: Individual Coverage Health Reimbursement Arrangements (ICHRAs) can reduce employers’ exposure to claims volatility because employers provide a defined contribution rather than directly absorbing employee healthcare claims. The approach may also provide an alternative to group plans facing significant premium increases while allowing employees to select coverage from the individual market. Employers are encouraged to review utilization and available plan designs annually to determine whether an ICHRA or other strategy aligns with workforce needs and cost objectives.

2. Individual Coverage Expands Employee Plan Choices: ICHRAs allow employees to choose among individual-market options, including bronze, silver and gold plans, based on their preferred balance of premiums and out-of-pocket costs. Lower-premium options may leave some employees with additional funds that can potentially be directed toward eligible HSA contributions or other healthcare expenses. ICHRAs may be particularly relevant for smaller employers, organizations struggling with group-plan participation requirements, and workforces with higher turnover.

3. Education and Affordability Concerns Remain Adoption Barriers: Employers continue to cite concerns about individual-market premiums, out-of-pocket costs, employee preferences for group coverage, and the complexity of helping workers select their own plans. Broker familiarity is increasing, with 95% reportedly aware of ICHRAs, 56% recommending or implementing them, and 37% having moved at least one client to an ICHRA, up from 15% in 2024. With roughly 1 million people now enrolled in ICHRAs, continued education for brokers, employers and employees is viewed as an important factor in determining future adoption.

ACA cuts push more workers to employer health plans

By Mav Rodriguez – A federal crackdown on Affordable Care Act (ACA) enrollments is landing just as a more expensive individual insurance market pushes more Americans toward coverage through work. The Centers for Medicare & Medicaid Services canceled about 315,000 Marketplace enrollments covering more than 760,000 people on August 31 after determining they were unauthorized. Its latest anti-fraud measures also freeze new agents and brokers from entering the federally facilitated Marketplace until February 1, 2027. The enforcement action is separate from the affordability squeeze already reshaping the ACA market, but the effects are converging. Marketplace enrollment fell 13% from its 2025 peak to 19.2 million people by February after enhanced premium tax credits expired. Read Full Article...

HVBA Article Summary

1. More people are expected to seek coverage through employers as Marketplace affordability shifts: The article describes how the expiration of enhanced premium tax credits is changing the ACA Marketplace, with modeling suggesting a larger movement into employer-sponsored insurance in 2026. This dynamic is presented as separate from, but occurring alongside, CMS’s enrollment integrity actions. Together, these forces could increase attention on workplace coverage as an alternative for people who previously relied on Marketplace plans. The net effect is that employers may see greater demand for eligibility and plan access from their workforces.

2. Eligibility gaps within employer plans could become a more prominent pressure point: The piece highlights that, even among employers that offer health benefits, eligibility varies widely by wage levels, industry, and employment status. It notes that eligibility is lower at firms with many lower-wage workers and in retail, and that coverage availability for part-time employees is limited at large firms. Because the ACA’s employer responsibility rules focus on employees averaging at least 30 hours per week, expanding eligibility may be driven more by employer strategy than new federal mandates. The article suggests employers may revisit who can join plans, how much employees contribute, and whether plan designs fit current workforce needs.

3. Marketplace distribution changes and plan cost-sharing trends may influence benefit design discussions:CMS’s agent-and-broker moratorium is described as potentially affecting who can help consumers enroll and when, with industry voices warning about impacts on enrollment and risk pools while others argue for more targeted enforcement. Separately, the article points to a shift toward bronze plans and rising deductibles in the Marketplace, implying more out-of-pocket exposure for those who remain insured. In response, the article frames supplemental products (such as accident, critical illness, and hospital indemnity coverage) as potentially more relevant in workplace offerings. This connects Marketplace cost-sharing trends to employer conversations about complementary benefits alongside high-deductible coverage.

Breast cancer and Black women: Investigating the disparities

By Anastassia Gliadkovskaya – Racial disparities in breast cancer have persisted for years. Though Black women have a slightly lower incidence of breast cancer, they face a mortality rate that is 38% higher than that of white women. One researcher in Georgia is focused on addressing those inequities in her community. Lauren McCullough, Ph.D., an epidemiology researcher, is running several studies investigating disparities across breast and gynecologic cancers. Read Full Article...

HVBA Article Summary

1. Mortality gap persists despite incidence differences: The article describes an ongoing disparity where Black women experience a higher breast-cancer death rate even though the disease is reported as slightly less common in this group than in white women. It frames the disparity as longstanding rather than a recent development. The piece positions this gap as a central problem motivating research and community-focused interventions.

2. Research focus on disparities across multiple cancers: Epidemiology researcher Lauren McCullough is conducting several studies aimed at understanding inequities not only in breast cancer but also in gynecologic cancers. The article presents her work as an effort to investigate what drives unequal outcomes across patient populations. It also suggests that insights from these studies could have broader applicability beyond a single community if expanded.

3. Peer support as a complementary approach to clinical research: In addition to running studies, McCullough founded a peer support community intended to elevate the perspectives of marginalized patients undergoing cancer treatment. The article highlights this as part of a broader strategy that includes both research and patient-centered support. It implies that combining evidence generation with platforms for patient voice may help inform solutions and improve experiences during treatment.

Employers need to rethink access to mental health and recovery care

By Jimmy Nesbitt – Most employers have seen a rise in the use of mental health and substance use disorder services, but timely access to care remains a critical issue. Seventy-three percent of companies reported an increase in those services in 2025 compared with the previous year, according to a Business Group on Health survey. That’s one reason Connections Health Solutions is building crisis receiving centers designed to serve as “the equivalent of an emergency room for behavioral health,” said Colin LeClair, CEO of the mental health crisis care provider. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Crisis Care Models Aim to Reduce Inpatient Stays: Behavioral health crisis centers are providing walk-in mental health care, stabilization services, and connections to longer-term community resources for patients regardless of insurance status. The organization highlighted operates nine clinics nationwide plus a mobile unit in Montana, with some locations also serving pediatric patients. It reports that about 65% of patients who meet inpatient criteria can instead be stabilized and discharged with a coordinated plan within 24 hours, with patients typically seeing a clinician in less than 30 minutes.

2. Employers Focus on Trust and Earlier Access to Mental Health Support: Workplace stigma remains a barrier, with a 2026 NAMI-Ipsos poll finding that 41% of employees uncomfortable discussing mental health cited stigma or judgment, 23% feared lost opportunities or retaliation, and 48% worried about judgment from colleagues. Employers are being encouraged to emphasize confidentiality, clearly communicate available resources, and equip managers to connect employees with appropriate support. Benefits strategies are also increasingly focused on earlier access to counseling, everyday mental health tools, and communication outside annual open enrollment to improve awareness and utilization.

3. Digital Recovery Tools Expand Into Employee Benefits: Apps supporting recovery from vaping, alcohol, nicotine pouches, and other substance-use challenges are increasingly being incorporated into workplace wellness and benefits programs. These platforms can offer structured recovery plans, habit tracking, coaching, and peer communities as lower-barrier options for employees who may not initially seek traditional treatment. A 2024 Pelago study found that about 60 million U.S. workers report personal or family substance-use problems, while 54% say they are uncomfortable asking for help, highlighting the potential role of more private and accessible support options.

Eli Lilly, Novo Nordisk, Sanofi sued over insulin prices

By Alan Goforth – Florida has become the latest state to sue leading pharmaceutical manufacturers and pharmacy benefit managers over the high cost of insulin. State Attorney General James Uthmeier announced the lawsuits against Eli Lilly, Novo Nordisk and Sanofi, which he said supply more than 90% of the world's insulin. The state also is suing the PBMs, CVS Caremark, Express Scripts and OptumRx, which process about 8 in 10 U.S. prescriptions, as well as rebate aggregators Zinc, Ascent and Emisar. "These companies told Florida families they were working to make insulin affordable," Uthmeier said in a news release. "Instead, they inflated the sticker price of a medicine people cannot live without and left Florida patients to pay it. My office is holding them accountable." Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Scope of Florida’s allegations and defendants: Florida’s attorney general says the state is suing major insulin manufacturers as well as pharmacy benefit managers and rebate aggregators tied to insulin pricing and formulary placement. The complaint centers on claims that list prices were pushed higher while intermediaries collected rebates and fees tied to preferred coverage decisions. The state frames these practices as harmful to patients who end up paying based on published list prices rather than post-rebate net costs.

2. Products and pricing mechanics highlighted in the case: The state’s claims address insulin and related diabetes therapies, including GLP-1 and combination products that it says are part of the alleged pricing and rebate structure. The article explains that patients without insurance, those facing deductibles, or those with percentage-based coinsurance can be charged the published list price. Florida argues that this structure can leave certain patients paying more even when rebates reduce what manufacturers ultimately retain.

3. Legal basis and remedies sought: The defendants face two counts under the Florida Deceptive and Unfair Trade Practices Act and one count under the Florida Antitrust Act, according to the article. Florida is seeking a permanent injunction and multiple forms of monetary and equitable relief, including restitution, disgorgement, damages, and civil penalties. The article also places Florida’s action in the context of other states bringing insulin-pricing lawsuits this year, including Delaware, Indiana, and Missouri.

GLP-1s and Mental Health: What's Safe to Say to Patients?

By Debbie Koenig – "Could this help my depression? Could it make it worse?" If you prescribe GLP-1 medications, expect to hear more questions like these. While early regulatory warnings linked the drugs to suicidal ideation, recent research suggests the opposite: GLP-1s may offer significant benefits for people with serious mental illnesses (SMI), including major depressive disorder, bipolar disorder, and schizophrenia. Read Full Article...

HVBA Article Summary

1. Overall psychiatric safety signal appears reassuring: The article describes evidence that GLP-1 medications have not shown a clear association with serious psychiatric adverse events or worsening depressive symptoms in larger reviews compared with placebo. It also notes that quality-of-life measures in this research were modestly improved rather than worsened. Clinicians are encouraged to communicate that, based on currently available data summarized here, there is not a strong basis to warn patients that GLP-1s generally exacerbate depression or other major psychiatric symptoms.

2. Potential mental health benefits are being studied but remain preliminary: Beyond safety, the piece summarizes newer studies suggesting GLP-1 use may be linked with favorable outcomes such as reduced risk of mental illness worsening, fewer hospitalizations for bipolar disorder, and lower risk of substance use disorder. It also highlights the possibility—still under investigation—that some effects could be mediated through GLP-1 pathways and not solely through weight loss. The practical message presented is to share cautious optimism with patients while emphasizing that research is still emerging and not definitive.

3. Clinical approach emphasizes coordination and stability in serious mental illness: The article frames GLP-1s primarily as cardiometabolic treatment, not a direct therapy for depression, bipolar disorder, or schizophrenia, while acknowledging possible “spillover” benefits. It advises screening for current psychiatric stability (eg, avoiding initiation during a recent crisis or medication changes) rather than excluding patients solely based on diagnosis history. It also recommends proactive, low-friction communication with the patient’s psychiatrist about dosing plans and what adverse effects or symptom changes to monitor during titration.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

The Biggest Health Care Companies in America Don't Treat Anyone

By Wendell Potter – If you rank the ten largest health care companies in America by revenue, you will not find a single hospital system or drugmaker. Not Pfizer, not Eli Lilly, not the Mayo Clinic or HCA. Every company in the top ten is a middleman, and together they take in about $2.6 trillion a year. Read Full Article...

HVBA Article Summary

1. Who makes up the “top ten” and what roles they play: The article says the largest U.S. health care companies by revenue are intermediaries rather than direct care providers like hospitals or drug manufacturers. It describes several categories among them, including insurers that own pharmacy benefit managers (PBMs), drug distributors, and firms built around Medicare and Medicaid managed care. The author argues these businesses sit between people who deliver care and the payments that fund it, shaping how money moves through the system.

2. How the U.S. intermediary model compares internationally: The piece argues that other wealthy countries do not have an equivalent for-profit “middleman layer” on the same scale. It contrasts the U.S. with systems such as Germany’s nonprofit sickness funds, Britain’s tax-funded NHS, Canada’s provincial single-payer approach, and Japan’s nonprofit insurance structure with standardized fees. It also frames PBMs as a uniquely American development, helping explain why similar giants do not appear elsewhere.

3. Administrative cost, lobbying, and the politics of reform: The author points to administrative spending as a major channel through which health dollars are diverted away from care, citing estimates that total administrative spending can reach 15%–25% of U.S. health spending (including provider billing-related costs). It also highlights industry political influence, noting that the health sector spent $743.9 million lobbying the federal government in 2024 and that PBM-related advocacy has expanded in recent years. The article concludes that future reform debates aimed at lowering costs and improving coverage would likely have to grapple with the size and power of the intermediary industry.

Cigna Group, OpenAI team up to support patients with complex conditions

By Paige Minemyer – Cigna is teaming up with OpenAI to build out more personalized supports for individuals with complex conditions, starting with a focus on cancer patients. The companies said in an announcement that Cigna intends to embed OpenAI's frontier reasoning models into both its clinical workflows and consumer-facing experiences across its ecosystem. This will allow its teams to better support cancer patients by identifying potential needs or concerns more quickly and enhancing care coordination, even between in-person physician visits. Read Full Article...

HVBA Article Summary

1. Embedding AI into care workflows and member experiences: Cigna says it plans to integrate OpenAI’s reasoning models into both clinical operations and consumer-facing tools across its ecosystem. The stated intent is to help care teams surface potential patient needs and concerns earlier and to improve coordination, including outside of scheduled in-person visits. The initial focus is on individuals with complex conditions, beginning with cancer care. The companies frame this as an effort to make patient support more personalized within Cigna’s existing channels and programs.

2. Early initiative targets oncology nursing and case management: One of the first programs described would provide oncology nurses and case managers at Cigna Healthcare and Accredo Specialty Pharmacy with AI-enabled tools. The goal is to bring together clinical, pharmacy, behavioral, and benefits information so staff can see a more complete picture of each patient. Cigna says this includes incorporating patient-reported inputs such as questions, side effects, and preferences. The company expects that consolidating these inputs can help teams choose supports and interventions and make the care journey feel simpler over time.

3. Partnership positioned as part of broader AI strategy and expansion: Cigna notes the OpenAI collaboration builds on other AI-related efforts already underway, including Accredo’s Pharmacy Forward program aimed at medication adherence and reducing time to treatment. The insurer also points to a recent announcement about using AI to support personalized care management programs. Executives from both organizations emphasize AI as a way to improve personalization and navigation for patients and caregivers rather than simply speeding up work. The announcement indicates the partners intend to broaden the collaboration over time to support additional health needs beyond oncology.

Stop-loss premiums to rise 14.5% in 2027: Aegis

By Allison Bell – The cost of stop-loss insurance increased a lot more than expected this year, and increases for a typical employer's health plan could easily average 14.5% in 2027. Analysts at Aegis Risk, a stop-loss consulting firm, gave that assessment in a new stop-loss market review prepared for the International Society of Certified Employee Benefit Specialists. A year ago, Aegis found that actual 2025 increases for stop-loss were 8.8% for a policy with a $100,000 individual deductible and 10.4% for a policy with a $750,000 deductible. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Premium increases are running above prior expectations: Aegis reports that stop-loss pricing rose more than it anticipated in the latest renewal cycle, pushing typical renewal levels higher than the firm had projected previously. It also indicates that some employers may still see renewal hikes that exceed 20%, suggesting variability by group and risk profile. The firm links continued pricing pressure to high-cost claims risk, including large-dollar gene therapies, cancer treatments, and unusually high inpatient billing.

2. Employer plan strategy could be affected by stop-loss costs: The article notes that rising stop-loss prices come as some employers with fully insured coverage are considering moving to self-insurance to manage benefit costs. Because stop-loss is a key financial backstop for self-insured arrangements, higher premiums could make that shift less attractive or harder to budget for. It adds that employers facing higher protection costs may be more likely to pursue alternatives such as giving employees cash to buy individual coverage or discontinuing health benefits entirely.

3. Survey findings include plan size details and more 'lasering' activity: Aegis bases its conclusions on an annual survey of plan sponsors, with this year’s responses coming from 1,378 sponsors covering 1.4 million enrollees. The participating plans ranged from 21 employees to 35,000 employees, indicating the results reflect a wide spread of employer sizes. The report also finds a higher share of sponsors experienced “lasering out” of at least one participant, rising to 19% from 16% in 2025, highlighting tighter underwriting and coverage constraints for certain high-cost individuals.

10 blind spots brokers should be watching

By Wes Steele – Brokers have more data, technology and automation than ever. But that does not necessarily make it easier to see what is really happening inside a client’s benefits program. Sometimes, a strong completion rate or high email opens can conceal deeper problems. That creates challenges, but it also can create opportunities for advisers. As more routine benefits work becomes automated, brokers can add more value by spotting problems clients may not recognize themselves. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Enrollment Completion Does Not Necessarily Mean Good Benefits Decisions: Enrollment rates alone may not reflect whether employees understand or are satisfied with their choices, with 35% reporting regret over at least one benefits decision. Employees who spent more than two hours making decisions reported a 62% regret rate, compared with 23% among those spending less than 10 minutes. Employers and brokers can supplement completion metrics with measures such as decision confidence, support-tool usage, errors, repeated questions and post-enrollment satisfaction.

2. Personalized Communication Can Address Different Employee Needs: Benefits understanding and engagement can vary by life stage, employment status and other workforce characteristics, making a single enrollment approach less effective for some populations. The survey found that 41% of employees intended to revisit a benefits message but never did, while only 20% said communications consistently reached them when they were ready to act. Part-time employees also reported a significant information gap, with just 6% feeling well-informed about ACA coverage compared with 36% of full-time employees.

3. Benefits Engagement Extends Beyond Open Enrollment: Post-enrollment education can help employees understand when coverage starts, how to access ID cards, what payroll deductions to expect and how to use their benefits. Benefits satisfaction was 62% among employees who knew what to do after enrolling, compared with 14% among those who remained confused, while 36% said uncertainty about the rules prevented them from changing their benefits. These findings suggest employers and brokers can evaluate benefits engagement throughout the year by examining utilization, employee understanding, voluntary participation and post-enrollment support.

How this AT&T benefit is helping employee navigate stage IV cancer diagnosis

By Lee Hafner – When a stage IV cancer diagnosis rocked AT&T program manager Jose Conde, he remembered a benefits email about specialty care support platform Lantern, and connected with a registered oncology nurse who his family now calls “our angel.” AT&T offers Lantern for cancer care as well as for support with a broad range of planned surgeries, providing employees with personal assistance from experts in these health areas who also connect them with top healthcare specialists while guiding them through their experience. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Personalized Cancer Navigation Supports Employees Through Complex Care: AT&T’s partnership with Lantern provides employees facing cancer with an assigned oncology nurse navigator who helps coordinate appointments, claims, benefits, medical information, and treatment planning. The navigator remains involved throughout the care journey, from diagnosis and second opinions to treatment and return-to-work planning. This approach is designed to reduce the administrative burden on patients and their families while helping them focus on treatment and recovery.

2. Access to Specialized Cancer Expertise Is a Key Part of the Strategy: AT&T identified cancer as one of its highest areas of healthcare spending and sought a solution that could combine care coordination with access to specialized providers. Through Lantern, employees can connect with cancer experts at organizations including MD Anderson, Mayo Clinic, and Johns Hopkins, depending on their individual needs. The model reflects an employer strategy focused on improving both the employee experience and access to specialized cancer care.

3. Patient Experience Illustrates the Role of High-Touch Support: One AT&T employee diagnosed with metastatic clear cell renal cell carcinoma described receiving ongoing assistance from his oncology nurse navigator while undergoing immunotherapy. He reported that his kidney tumor decreased from 15 centimeters long and 12 centimeters in diameter to 8.4 centimeters long and 5 centimeters in diameter, while smaller metastatic spots also shrank, with surgery planned as a next step. While these clinical results reflect an individual case, the employee said navigation support provided significant peace of mind and allowed him and his family to devote more attention to his treatment and recovery.

Express Scripts sued over alleged underpayments to Arkansas pharmacies

By Kristen Smithberg – Based on the individual pharmacy totals listed in the complaint, the plaintiffs identified at least 48,306 prescription claims that they say Express Scripts paid below Arkansas' statutory reimbursement floor between Aug. 5, 2025, and March 31, 2026. They allege the underpayments have continued since then. Under Arkansas law, PBMs generally may not reimburse pharmacies less than the National Average Drug Acquisition Cost, or NADAC, for a drug's ingredient cost. The Centers for Medicare & Medicaid Services calculates and updates NADAC using pharmacy acquisition-cost data. Read Full Article...

HVBA Article Summary

1. Scope of the alleged reimbursement shortfalls: The suit centers on claims from independent Arkansas pharmacies that Express Scripts reimbursed below the state’s statutory floor for ingredient costs. The pharmacies argue the issue spans a defined time window and continued beyond it, rather than being confined to a handful of isolated incidents. The case is anchored to pharmacy-by-pharmacy totals referenced in the filed complaint, which the plaintiffs say show a large number of affected prescription claims.

2. Legal mechanism and potential remedies under Arkansas Act 990: The pharmacies brought the case under Arkansas Act 990, which took effect in August 2025 and allows private actions over alleged violations of the state’s pharmacy reimbursement rules. The statute provides for recovery of attorneys’ fees and costs for a prevailing plaintiff, and it also allows for statutory damages up to a set amount per violation through one enforcement pathway. The plaintiffs’ theory is that each underpaid prescription claim constitutes a separate violation, which they say could materially increase exposure depending on how the court applies the law.

3. Arguments about cause, operational burden, and requested relief: The pharmacies allege the underpayments stemmed from Express Scripts’ centralized pricing and adjudication systems rather than one-off errors, and they contend Express Scripts had the necessary claim and CMS data to apply the reimbursement floor. They also argue that forcing pharmacies to identify and appeal underpayments individually shifts enforcement costs onto pharmacies that already paid to obtain the medications. In addition to monetary relief, the pharmacies seek injunctive remedies, including changes to how Express Scripts processes Arkansas claims and an appeal process that can accept bulk submissions with invoice-based documentation.

Vision benefits: why more usage is a cost saver

By Steve Randall – The vision benefits conversation in most broker offices begins and ends with price. That, says Dr. Don Railsback of Vision Care Direct, is precisely the problem. Railsback, an optometrist and co-founder of Vision Care Direct – a provider-owned and operated vision plan based in Wichita, Kansas – says that treating vision coverage as a commodity race to the lowest premium strips out the very feature that makes vision benefits valuable to employers: utilization. When employees avoid using a plan because they fear out-of-pocket costs at time of service, the preventative health screening that a routine eye exam delivers never happens, and the downstream costs to a group health plan can be significant. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Utilization over lowest premium pricing: The article argues that vision coverage is often evaluated mainly on price, which can discourage employees from using benefits when out-of-pocket costs at the point of service feel too high. It presents the idea that higher utilization—especially routine eye exams—can create value by supporting preventive screening rather than treating vision as a commodity. The underlying point is that plan design can influence participation, which then affects broader medical outcomes and costs. This frames vision benefits as part of a health cost management strategy, not just an ancillary add-on.

2. Plan design aimed at predictable costs and participation: Vision Care Direct is described as structuring plans around lower costs at the time of service instead of focusing on the lowest monthly premium. The company’s stated intent is to reduce “sticker shock” so employees actually use the plan, aligning utilization with the plan’s purpose. The article also contrasts this approach with models that start with low introductory rates and then face later cost increases as utilization becomes clearer. The implication is that pricing and employee behavior are linked, and stability depends on how the plan is initially built.

3. Eye exams and workplace factors extend the value proposition: The article highlights that comprehensive eye exams can reveal health issues beyond vision correction, positioning routine exams as a form of early detection with potential medical cost implications for employers. It also describes computer vision syndrome as a growing issue tied to heavy screen use, with symptoms that can affect comfort and work output. Beyond exams, it points to ergonomic assessments and computer-specific eyewear as interventions that may reduce fatigue and help address work-related strain. Brokers are presented as able to add value by bringing utilization data, educational sessions, and screening options—not just renewal pricing.

As Health Insurance Costs Soar, Healthcare Workers Also Feel the Pinch

By Hayat Norimine – Joshua and Ashley Durham run a family medicine practice, and for the first time in their lives, they have no health insurance. When the Durhams began their practice at the end of 2023 — he as a primary care physician and she as a pharmacist who handles the billing — the couple bought coverage for themselves and their two kids on the Affordable Care Act marketplace. But they said their monthly premiums for a similar health plan for this year rose several hundred dollars to nearly $1,600. They decided to pay out-of-pocket for their medical expenses instead, leaning on $50,000 they had set aside in a health savings account over several years. “It’s nerve-racking,” said Joshua Durham, 47. “It just takes, you know, one little accident, and then you got a big fat bill.” Read Full Article...

HVBA Article Summary

1. Healthcare workers are not immune to affordability pressures: Even in a sector where coverage rates are typically higher than the general population, rising premiums are pushing some clinicians and staff to reconsider whether they can stay insured. The article describes how both employer-sponsored plans and marketplace coverage can become financially out of reach for families. It also notes that premium increases can affect different roles across the healthcare workforce, from physicians to nurse practitioners. These pressures can change household budgeting decisions and, in some cases, prompt people to take on more financial risk by going without coverage.

2. Policy changes and market dynamics are contributing to higher costs and more uninsured people: The story points to the end of certain pandemic-era Affordable Care Act marketplace credits as a factor that increased what some people pay each month, particularly those in small businesses or self-employment. It also cites estimates that coverage losses could rise over time, which can reshape who remains in insurance risk pools. When healthier people opt out, insurers may face a sicker, more expensive enrollment base, which can put upward pressure on premiums. The article frames this as a feedback loop that can make insurance progressively less affordable for those who remain.

3. Rising premiums and cost-sharing can force difficult trade-offs in care and household spending: The article provides examples of people delaying or reconsidering care due to high deductibles and ongoing monthly premium obligations. Some families respond by cutting other forms of coverage (such as dental insurance) or reducing other household expenses to keep medical coverage. The piece also highlights how small practice owners may try to help patients with bills but still need sufficient revenue to operate. Overall, it depicts affordability challenges as affecting both personal health decisions and the financial realities of running or working in healthcare settings.

Anthropic, OpenEvidence partner to bring medical AI worldwide

By Nancy Lapid – Artificial intelligence startup Anthropic and medical knowledge platform OpenEvidence are collaborating to bring AI-powered clinical decision support to physicians in regions without access to the technology, the companies said on Tuesday. Read Full Article...

HVBA Article Summary

1. Partnership goal and target regions: Anthropic and OpenEvidence said they are working together to expand AI-enabled clinical decision support to places that have not had access to such tools. The effort focuses on low- and middle-income countries where gaps in medical literature access, specialist availability, and continuing medical education can affect care. The companies framed the project as improving access to medical knowledge regardless of geography.

2. How the product is positioned and delivered: OpenEvidence is described as a question-answering platform for doctors that draws from peer-reviewed research and treatment guidelines, and it is free to clinicians in the United States and Canada. Under the collaboration, Anthropic will provide back-end technology support while OpenEvidence adapts the system for different regional contexts and healthcare infrastructure. The initiative is being rolled out broadly, with OpenEvidence listing about 100 countries included.

3. Broader debate and operational details: The article notes that health systems are testing whether generative AI can help address physician and specialist shortages by making it easier to navigate large volumes of medical information. It also highlights concerns that AI trained mainly on high-income-country data may not fit local conditions in other settings. The companies did not disclose financial terms, and OpenEvidence cited high usage among U.S. clinicians as evidence of demand.

DAILY INDUSTRY REPORT | SPECIAL PODCAST ALERT

Good afternoon, DIR readers!

A new episode of Relentless Health Value dropped this week, and we're sending this special afternoon update because the topic deserves your attention.

Brokers, TPAs, benefits leaders, and self-funded employers: When a health plan overpays for infusions, the cost may not end with the claim. It can also add pressure to stop-loss renewal premiums. 📈

In Episode 530, host Stacey Richter is joined by Jake Velie, CPT, Founder, Chairman and CEO, and Keith Hartman, RPh, Chief Strategy Officer, of National Integrative Health. They explore this connection and explain why clinical oversight and appropriate sites of care belong in the conversation. Relentless Health Value

National Integrative Health is a fully integrated fiduciary pharmacy program that brings together data, clinical oversight, sourcing, site of care, actuarial, and stop-loss coordination to intervene on high-cost, specialty, and infusion medications. That hands-on experience shapes this discussion.

Three voices. One timely discussion.

Jake Velie makes the stop-loss connection clear: "It is absolutely 100% directly connected to how premiums are being set now."

Keith Hartman highlights the clinical priority: "It's very important that the site of care is appropriate for that particular therapy."

Stacey Richter connects the dots: "There is also a direct non-dotted line between runaway infusion bills, again, which tend to be quite expensive, and stop-loss renewal premiums."

What should you be asking your clients?

Use this episode to start a conversation around three questions:

• Are we overpaying for infusion treatments, and how are we evaluating those costs?

• How might our infusion claims be affecting our stop-loss renewal premiums?

•  Are members receiving infusions in clinically appropriate settings, and could a lower-cost setting meet their care needs?

These are the questions National Integrative Health helps brokers, TPAs, and employers answer every day.

At HVBA and the Daily Industry Report, we're excited to spotlight conversations that help our audience turn industry insights into practical questions for their clients. This episode brings the financial and clinical perspectives together on an issue that deserves a closer look.

LISTEN NOW: Relentless Health Value, Episode  530

See how National Integrative Health helps plans control infusion costs

Keep the conversation going! Forward this special alert to a colleague, client, or benefits leader who needs to hear it.

The Daily Industry Report Team
Health & Voluntary Benefits Association (HVBA)

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

Disclosure: Jake Velie serves as Vice Chairman and President of HVBA and Editor-in-Chief of the Daily Industry Report.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

The GLP-1 Market Has Changed, Now Plans Need a Strategy

By Jake Velie – The GLP-1 market has already changed. The real question now is not whether these therapies will keep growing. They will. The question is whether plan sponsors have a real strategy for managing them.¹ ² Too much of the conversation is still framed the wrong way. It gets reduced to a yes or no coverage debate, cover it or exclude it, as if that alone settles the issue. It does not.² ³ Coverage alone is not a strategy. Exclusion alone is not a strategy either. Read Full Article...

HVBA Article Summary

1. Strategy, not just coverage: The first mistake is treating GLP-1s like a yes-or-no benefit decision. A plan can cover them and still lose control if there are no clear rules around who qualifies, how the drug is sourced, and how long therapy is allowed to continue. A plan can also exclude them and still face pressure from members, appeals, and employers who want a better answer. Coverage posture alone is not a strategy.

2. The market is already splitting: Nearly every plan covers GLP-1s for diabetes, but coverage for obesity is far less consistent. The article notes that 40% of plans cover obesity GLP-1s, while 49% of plans that do not cover them say they would not at any price.¹ ² That tells you this is no longer a niche debate. It is now a real plan design and cost-governance issue.

3. Execution is where plans win or lose: The levers are clear, set strong clinical criteria, manage the right channel, and stay disciplined on net cost. The article points to NIH modeling using a fixed GLP-1 price of $521 per utilizing member per month, compared with $800 standard and $1,200 risk-managed estimates, with projected annual savings of $11.5 million to $25.8 million depending on take-up. It also notes that tighter guardrails did not increase unit cost in that model, while rebate-driven approaches became more expensive as eligibility tightened. That is why someone has to own the full picture.

Senators reintroduce $1.3B health care cybersecurity bill

By Kristen Smithberg – Sens. Mark Warner, D-Va., and Ron Wyden, D-Ore., have reintroduced legislation that would establish new cybersecurity requirements across the health care system and provide $1.3 billion to help hospitals improve their defenses. The senators first introduced the measure in 2024. Read Full Article...

HVBA Article Summary

1. Federal minimum cybersecurity standards for health care entities: The bill would task the Department of Health and Human Services with setting baseline security requirements for providers, health plans, clearinghouses, and their business associates. Entities whose disruption could significantly impact access to care would be subject to stricter requirements than other covered organizations. HHS would be required to revisit and update the standards on a regular cadence, at least every two years. This would move parts of health care cybersecurity from voluntary guidance toward enforceable rules.

2. Required testing, executive sign-offs, and public transparency: Covered organizations and business associates would need to perform yearly security risk analyses and develop and test plans for major technology disruptions. Senior executives—including the CEO and the chief information security officer (or equivalents)—would have to formally attest to compliance. The proposal also calls for organizations to publish information about their compliance on a public website. Together, these elements aim to increase accountability and make security posture more visible to stakeholders.

3. Audits, penalties, and Medicare-linked incentives/pressure: The legislation calls for annual independent security audits, with the possibility of waivers where the burden would outweigh the benefit, and it would raise civil penalties for security violations. It also sets expectations for HHS auditing activity, including a requirement starting four years after enactment to audit at least 20 covered organizations or business associates per year. Separately, it ties adoption of specified practices to Medicare payment consequences beginning in fiscal 2031, while allowing hardship exceptions. The bill also includes mechanisms for accelerated payments to certain providers facing major Medicare claims-processing disruptions after a cyber incident.

Howden recruits Ryan Specialty Benefits' former CEO

By Jonalyn Cueto – Howden has appointed John Zern as vice chair of health and benefits at Howden US, bringing in a 35-year industry veteran whose career has been built specifically around the lines of spend now driving the steepest employer health cost increases since 2010. Read Full Article...

HVBA Article Summary

1. Senior hire to lead US health and benefits: Howden named John Zern vice chair of health and benefits at Howden US and placed him on the firm’s senior American leadership team. The article frames the move as aligned with current pressures in employer-sponsored health plans. Zern’s background includes leadership roles at Ryan Specialty Benefits as well as earlier senior positions at Aon and Marsh. The role centers on oversight of Howden’s Health and Benefits practice.

2. Health benefit costs are projected to rise sharply in 2026: Employer health benefit cost per employee is expected to increase meaningfully in 2026, with cited surveys indicating mid-to-high single-digit to near-double-digit projections. The article notes that cost-management actions (such as plan design changes) could reduce, but not eliminate, the increase. It also points to compounded growth since 2017 as evidence the cost trend has been building for years. The broader implication presented is that employers are approaching renewals under intensified budget scrutiny.

3. Key cost drivers and implications for brokers: The piece highlights three main contributors to rising costs: GLP-1 drug utilization, higher cancer diagnosis and treatment rates, and increased mental health service use. It also includes commentary that both healthcare prices and utilization are rising at the same time, limiting traditional offset strategies. As a result, brokers are described as facing greater demand for clinical and data-oriented guidance beyond simply presenting renewal terms. Howden’s specialist-led approach is positioned as a strategy to compete for mid-market and large-employer advisory work in these areas.

FBI hacked – sensitive agent data leaked

By Matthew Sellers – The extortion group that dumped the National Association of Insurance Commissioners' data onto the dark web this summer says it has now breached the FBI. The files it has shared suggest the damage goes well beyond a defaced website. Read Full Article...

HVBA Article Summary

1. Hackers claim access to FBI applicant and agent data: ShinyHunters said it compromised the FBI’s recruitment site, FBIJobs.gov, replaced site imagery with its branding, and asserted it holds sensitive information tied to agents and applicants. A sample shared with journalists reportedly includes highly personal identifiers and contact details, including emergency contacts who may be family members. Reuters reported it verified details for more than 22 people but could not validate the entire dataset, and the hackers described the broader haul as two to three terabytes.

2. Unclear intrusion path, with third-party systems in focus: The FBI has not explained how attackers gained access and said it had not yet determined whether the incident began with a third-party provider or within FBI systems. Reporting cited by the article describes a possible initial compromise of an Oracle PeopleSoft server, followed by movement into an Amazon-hosted government cloud, though the FBI has not confirmed that account. The article connects this to earlier ShinyHunters activity affecting other organizations, underscoring how widely used HR and recruiting platforms can become high-impact entry points.

3. Insurance-market relevance centers on extortion trends and concentrated vendor risk: The article says ShinyHunters framed the motive as pressure for the FBI to withdraw a prior advisory and claimed the attack was not about money. It also notes insurers are already seeing more theft-only extortion behavior, with data-theft-only attacks rising from 49% of extortion claims in the first half of 2025 to 65% in the second half. For brokers and insureds, the FBI incident is presented as a reminder that HR and applicant systems can contain an organization’s most sensitive data and may sit on third-party infrastructure with patch timing outside client control.

Insurance Coverage Lags as Cancer Science, Treatment Move Forward

By Arthur Allen – Eighteen months after his initial diagnosis, chemotherapy hadn’t slowed 21-year-old Mason Henderson’s rare brain tumor, which had spread to his spinal fluid. So he left his home in southeastern Texas to spend three weeks in a clinical trial in New York City. But that failed, too, leaving a murky path for Henderson, whose cancer was so rare the World Health Organization had only given it a name in 2021. So early this year, Henderson’s doctors, evaluating his tumor’s deep genetic language, turned to a drug made by Merck and AstraZeneca called Lynparza. It was not the standard of care for Henderson’s condition — there wasn’t really any standard, which is not unusual for rare cancers. And Henderson’s insurance would not pay for it, despite the careful justification given by the two specialists treating him. Read Full Article...

HVBA Article Summary

1. Rare cancers can fall outside insurer rules built around labels and guidelines: The article describes how insurers commonly rely on FDA labels and expert guidelines to decide what to reimburse. For many rare tumors, targeted FDA-approved options may not exist even when molecular testing points to a plausible therapy. That can leave patients and clinicians navigating appeals and exceptions rather than straightforward coverage decisions.

2. Off-label precision-medicine decisions often rely on limited evidence by necessity: Henderson’s specialists considered Lynparza in combination with chemotherapy based on tumor biology and prior case experiences, even without large trials in that specific cancer. The article notes that for extremely rare cancers, trials involving hundreds of patients are unlikely to happen. This creates tension between evidence standards designed for common diseases and the practical realities of treating small patient populations.

3. “Tissue-agnostic” drugs and genetics-driven trials are expanding, but access remains uneven: The FDA has approved nine drugs for use based on tumor mutations regardless of where the cancer started, following 2022 guidance described in the article. Research efforts such as basket trials (including ASCO’s TAPUR study) attempt to match therapies to genetics and have influenced treatment guidelines. However, the article notes that some trials exclude primary brain tumors, and clinicians disagree about how far genetics alone can take cancer diagnosis and treatment today.

Helping employees select the right healthcare during open enrollment

By Lee Hafner – No matter what type of health insurance a company offers, employees need guidance in selecting the best plan option during open enrollment, and not just what appears cheapest. “There are very small nuances inside [a] benefits guide that could be cost prohibitive or a cost improvement for an employee,” said Brandy Thompson, founder and CEO of ICHRA administration platform Benefitbay. With the right education on all relevant factors — individual and family health needs and how other available benefits work alongside a plan, for example — employees have a better chance of signing up for what truly fits them best. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Plan Selection Should Go Beyond Payroll Deductions: Employees often focus primarily on the amount deducted from each paycheck, but that figure does not reflect the full cost or value of a health plan. Factors such as employer HSA or FSA contributions, deductibles, coinsurance, prescription drug tiers, provider networks, and specialty care copays can significantly affect overall expenses. Better education around these components can help employees compare plans based on their individual healthcare and financial needs.

2. Network and Carrier Assumptions Can Lead to Coverage Gaps: Employees may pay more for PPO coverage because of concerns about out-of-network emergencies, even though true emergencies generally have protections for out-of-network care. Others may select a familiar carrier without confirming that their physicians, prescriptions, and services are covered under the specific plan or network being offered. Reviewing provider access, prescription coverage, virtual care options, and plan-specific network details can reduce the risk of unexpected costs or disruptions in care.

3. Education and Decision Support Can Improve the Enrollment Experience: Employers can support plan selection through a combination of technology, licensed advisers, AI-assisted tools, webinars, microsites, and opportunities for employees to ask individualized questions. The article argues that investing in education is particularly important as employers offer employees more plan choices and employees take greater responsibility for selecting coverage. Reviewing employee feedback after enrollment can also help employers refine education and decision-support resources in subsequent years.

Florida AG sues PBMs, pharmas over rise in insulin prices

By Paige Minemyer – Florida Attorney General James Uthmeier is suing three drug manufacturers as well as three pharmacy benefit managers, alleging that they worked together to drive up the price of insulin and line their own pockets. In the lawsuit, filed this week in the state's 11th Judicial Circuit Court, targets Eli Lilly, Novo Nordisk and Sanofi, which Uthmeier's office said produce 90% of the world's insulin, alongside the PBM industry's "Big Three" organizations, CVS Caremark, Express Scripts and Optum Rx. It also includes the three PBMs' associated group purchasing organization—Zinc Health Services, Ascent Health Services and Emisar Pharma Services, respectively. Read Full Article...

HVBA Article Summary

1. Scope of defendants named in Florida’s case: The lawsuit names major insulin manufacturers and large pharmacy benefit managers, along with affiliated group purchasing organizations tied to those PBMs. The filing is in Florida’s 11th Judicial Circuit Court and alleges coordinated conduct across multiple parts of the drug supply chain. The case frames the alleged conduct as aimed at increasing insulin prices and generating profits for the companies involved.

2. Alleged pricing-and-rebate dynamic described by the AG: The complaint asserts manufacturers set higher list prices and then used rebates and fees to obtain favorable formulary placement through PBMs. Florida alleges this structure benefited both sides by linking access decisions to payments rather than lowering net costs for patients. The lawsuit also contends the conduct affected not just insulin but other diabetes medications, including GLP-1 drugs.

3. Connection to prior federal action and current status: Florida’s case parallels prior Federal Trade Commission action focused on PBMs and related GPOs over insulin pricing practices. The article notes that Express Scripts and CVS reached settlements with the FTC, while Optum is described as working toward its own resolution. It also highlights the FTC’s characterization of vertically integrated companies as distorting competition in the pharmaceutical supply chain.

Broker consolidation tests agility, part 2

By Bruce Shutan – Does size really matter when it comes to serving up innovative and creative thought leadership in employee benefits consulting? It depends on who you ask. “Whether you’re talking about the biggest or smallest brokers, everything is always around the team that is working with you and their abilities,” opined Lester Morales, founder and CEO of Dysrupt Healthcare who has worked on both sides of the advisory aisle. He said the “right” advisory team that doesn’t access the level of resources that their organization may or may not have risks becoming irrelevant if they do not deploy them. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Scale Can Create Both Barriers and Opportunities for Innovation: Industry leaders noted that larger benefits organizations may face greater organizational inertia, making it harder to adopt new approaches quickly, while smaller or AI-native firms can build around newer technologies and operating models. At the same time, larger firms can use their resources, data, analytics and broad talent bases to support innovation when their cultures encourage entrepreneurial thinking. The impact of scale therefore depends partly on how organizations structure decision-making and invest their resources.

2. Smaller Firms Have Helped Drive Changes Across the Brokerage Market: Several industry executives said innovations that initially gained traction among boutique firms, including level-funded and self-funded strategies, have increasingly been adopted by national brokerages. This illustrates how ideas developed by smaller organizations can eventually influence larger firms as client demand and competitive pressures evolve. New entrants from technology and retirement-plan backgrounds are also adding competition, including firms bringing AI capabilities and experience with fiduciary accountability under ERISA.

3. M&A Outcomes Depend on How Firms Integrate Ideas and Capabilities: Consolidation can limit creativity when acquired firms are required to follow centralized processes, but it can also expand access to R&D, data science, technology and other resources that smaller organizations may struggle to fund independently. Large brokerages are increasingly acquiring technology-focused and regional firms, illustrated by WTW’s announced $1 billion acquisition of Newfront as part of its efforts to expand its capabilities and reach. Industry leaders emphasized that successful integration requires balancing the benefits of scale with the ability to preserve and expand effective ideas from across the organization.

FDA adcomm votes in favor of benefit-risk of Grail’s cancer test

By Zachary Brennan – An FDA advisory committee spent most of Wednesday raising questions about the utility and effectiveness of Grail’s multi-cancer test Galleri, but ultimately a majority of the panelists voted in favor of the test. The FDA’s Molecular and Clinical Genetics Panel voted 7 to 2, with one abstention, in favor of Galleri’s benefit-risk profile. The advisory committee also voted 6 to 4 that Galleri is effective and they voted unanimously that it’s safe. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. FDA Panel Supports Grail’s Multi-Cancer Test: An FDA advisory panel voted in favor of Grail’s Galleri test, citing its potential to detect cancers that lack established screening methods. Panelists emphasized that it should be used alongside recommended cancer screenings. The test is already commercially available, and FDA approval could expand insurance and Medicare coverage.

2. Detection Limits Raise Questions: Panelists questioned how reliably Galleri detects individual cancer types because the trials included limited samples for each cancer. An FDA reviewer estimated that the test would detect about one in three cancers. The reviewer also estimated that 66% to 77% of positive results would correspond to a true cancer finding.

3. Patient Outcome Data Remains Limited: Grail has not yet provided data showing whether cancers detected by Galleri lead to improved survival. The company reported that 82% of cancers detected in its trials were treated with curative intent, which does not establish a mortality benefit. Panelists also noted that the trials’ 12-month follow-up may not capture cancers that appear later.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

Employers, benefits groups push DOL for broader ERISA e-delivery rules

By Allison Bell – Many benefits, insurance and employer groups have told the U.S. Department of Labor that they love its proposal to make electronic delivery the default delivery for communications at health plans governed by the Employee Retirement Income Security Act of 1974. The Employee Benefits Security Administration, the DOL division in charge of overseeing the employee benefits sector, should expand the scope of the proposed e-communications regulations and make e-delivery the default communications method for all employee welfare plans governed by ERISA, according to a comment letter that the organizations sent Monday. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Industry coalition urges broader scope for e-delivery: A set of benefits, insurance, and employer organizations submitted a comment letter asking the Department of Labor to apply electronic delivery rules beyond group health plans. They want the default e-delivery approach to cover all ERISA-governed welfare plans, not just health-related communications. The argument is that aligning rules across plan types would make communications more consistent for workers. The groups also say it would reduce administrative complexity for employers and plan administrators.

2. Large, diverse sign-on list signals broad stakeholder interest: The letter was led by the ERISA Industry Committee, which represents large employers. Signatories include major insurance and benefits organizations as well as companies like MetLife and Marsh. It also includes general-interest employer groups such as the Associated General Contractors of America, the National Retail Federation, and the U.S. Chamber of Commerce. The mix suggests the issue affects multiple segments of the benefits and employer ecosystem.

3. Regulatory timeline and projected savings frame the policy debate: EBSA released proposed health plan e-communications regulations in July, and the article notes that adoption could make the rule effective on New Year’s Day following final publication in the Federal Register. The coalition projects substantial long-term savings for uniform e-communications rules. Separately, federal regulatory impact analysts estimated savings on the order of hundreds of millions of dollars per year for the proposed regulation. These projections and timing details are likely to shape how stakeholders evaluate implementation and compliance planning.

CMS to cancel ACA coverage for 760K, crack down on brokers in latest anti-fraud push

By Paige Minemyer – The Trump administration plans to cancel enrollment in Affordable Care Act plans for more than 760,000 people as part of its crackdown on fraud, waste and abuse. The Centers for Medicare & Medicaid Services announced on Tuesday that it would cancel 315,000 "unauthorized enrollments" covering that population, a move the agency said will return $2.2 billion in taxpayer funds from premium subsidies. In addition, CMS said it will terminate more than 200 agents and brokers that have failed to comply with enrollment standards for the ACA's marketplaces. It submitted 569 notices of intent to terminate to brokers and agents over the summer after identifying that they submitted applications for 2026 coverage that lacked key information about the enrollee, such as Social Security numbers. Read Full Article...

HVBA Article Summary

1. Enrollment reversals and subsidy recovery are central to the action: CMS says it is canceling hundreds of thousands of marketplace enrollments that it characterizes as unauthorized, affecting more than 760,000 people. The agency also states the cancellations will result in returning $2.2 billion tied to premium subsidies. The announcement frames these steps as part of a broader effort to address fraud, waste and abuse in the federal health insurance marketplace.

2. Broker and agent oversight is being tightened through terminations and new requirements: CMS says it will terminate more than 200 agents and brokers for not complying with ACA marketplace enrollment standards. It also reports sending 569 notices of intent to terminate after finding applications for 2026 coverage missing key enrollee information, including Social Security numbers. Beyond enforcement, CMS says it will require brokers and agents to re-identify through federal channels, restrict adding them to consumer-completed applications, and require electronic consumer authorization for any agent or broker activity.

3. A temporary registration moratorium and internal coordination group are part of the strategy: CMS says it will issue an interim final rule imposing a temporary moratorium on new broker or agent registrations for the 2027 plan year for those without an active 2026 agreement. The agency also says it has formed an anti-fraud coordination group for the federal insurance exchange that brings together leaders across CMS and HHS and will meet regularly. CMS characterizes these steps as elements of a three-part approach: preventing fraudulent enrollments, eliminating improper enrollments that occur, and strengthening oversight of brokers and agents.

Broadband deserts hinder telehealth access, especially in rural areas

By Anuja Vaidya – Telehealth can significantly improve access to healthcare for those in underserved communities, but new research reveals that broadband access gaps are hindering telehealth. Published in JAMA Health Forum, the study showed that rural residents are more likely to live in broadband deserts. These areas lack adequate access to broadband internet, which constrains their access to telehealth services. Lack of broadband access has long been a significant social determinant of health that hinders digital healthcare services, like telehealth. Read Full Article...

HVBA Article Summary

1. Broadband deserts disproportionately affect rural communities: The analysis found that 11.9 million people lived in areas without broadband speeds adequate to meet the study’s definition, and most of those residents were in rural areas. This concentration suggests connectivity limitations are more likely to affect people who already face geographic barriers to in-person care. As a result, telehealth’s ability to expand access may be unevenly distributed across regions and populations.

2. Connectivity alone may not resolve care-access gaps: The study identified that only 946,278 rural residents in places lacking ambulance and healthcare access also had sufficient broadband to support telehealth. This implies many communities facing multiple access barriers cannot rely on telehealth as a practical substitute for nearby services. It also indicates that policy or program efforts focused solely on telehealth expansion may fall short without parallel improvements in underlying infrastructure and local care availability.

3. Device availability and subscriptions differ, and additional barriers influence telehealth use: While most households reported owning a computing device (96.7%), a smaller share had broadband subscriptions (91.7%), indicating a gap between hardware access and reliable connectivity. Rural households trailed urban households in both device ownership and having a device with broadband, highlighting potential disparities in readiness to use telehealth. The authors also emphasized that even with broadband and subscriptions, actual telehealth use depends on other factors, including socioeconomic constraints, clinical and health-system offerings, and behavioral considerations.

2 countries now supply 90% of new US drug ingredient filings: 5 notes

By Ella Jeffries – China and India together account for 90% of new active pharmaceutical ingredient drug master files submitted for U.S. medicines in 2025, as the U.S. share continues to shrink, according to a Sept. 11 analysis from U.S. Pharmacopeia’s Medicine Supply Map. Read Full Article...

HVBA Article Summary

1. China’s role in API filings is rising: The article reports China now holds 21% of active API drug master files tied to U.S. medicines, up from 18% in 2024 and 13% in 2021. It characterizes this as the country’s largest single-year gain recorded. The data points to an increasing concentration of U.S.-linked API documentation associated with China over the past several years.

2. India remains the largest holder, but new filings are less dominant than before: India is described as the largest single holder of active API drug master files at 49%. However, the article notes India’s share of new filings has declined substantially from a 2021 peak of 62%. This suggests India’s overall footprint remains large even as the pace of incremental additions has moderated.

3. U.S. share is declining amid policy efforts to encourage domestic production: The article says the U.S. share of active API drug master files fell to 6% in 2025 (down from 10% in 2021) and that the U.S. accounted for 3% of new filings. It ties the findings to federal actions intended to reduce reliance on overseas API sources, including tariffs and onshoring-related agreements with manufacturers. The piece also cites announced commitments and government investments aimed at expanding domestic manufacturing and reducing supply-chain vulnerability.

Eliquis patent expiry may cut employers' blood thinner spending

By Allison Bell – Bristol Myers Squibb's monopoly on U.S. sales of apixaban, the active ingredient in Eliquis — a new-generation blood thinner — is about to end, and new battles over efforts to create real competition in the market for the new-generation blood thinners are about to begin. Warfarin, a generic blood thinner, can help patients who have a history of blood clots be protected from new blood clots for just $300 per year. But patients who take the drug need to change their diet, get frequent blood tests, and face frightening consequences such as ugly bruises and bleeding gums. Eliquis can protect patients against blood clots without forcing the patients to change their diet or suffer from other side effects at a full cash price of about $6,000 per year. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Patent expiration creates a complex path to competition: The article says Bristol Myers Squibb’s patent on apixaban ends in November, but it also notes that court settlements and other barriers could delay generic entry until April 2028. That gap suggests employers may not see immediate price relief even after the nominal patent expiry. It also signals that legal and regulatory developments will heavily influence when and how savings materialize for plan sponsors.

2. Savings may be delayed by market dynamics and exclusivity periods: The piece highlights that the first generic entrant often receives a 180-day exclusivity period, which can limit early competition and slow price declines. It also points out that brand manufacturers may respond to patent expirations by steering demand to newer patented products, shifting costs rather than reducing them. As a result, employers and pharmacy benefit managers may need active formulary and procurement strategies to ensure potential savings aren’t offset by substitution to other branded drugs.

3. Prior experience with Xarelto shows how pricing can evolve after loss of exclusivity: The article uses rivaroxaban (Xarelto) as a recent example, noting its patent ended in February 2025 and that while the brand still sells for about $600 per month, coupon-discounted generics are available for about $30 per month to cash-pay patients. This comparison suggests that substantial price drops can occur, but may depend on multiple generic entries and the channels through which patients access the drug. The article also argues that lower out-of-pocket costs could improve adherence for long-term blood thinner therapy, potentially affecting overall employer health spending and premiums.

U.S. Cancer Mortality Declined 35% Since 1991, AACR Report Shows

By Mike Bassett – The overall cancer mortality rate in the U.S. declined by 35% between 1991 and 2024, resulting in almost 5 million cancer deaths averted, according to the 2026 American Association for Cancer Research (AACR) Cancer Progress Report. Read Full Article...

HVBA Article Summary

1. Smoking declines are central to the long-term mortality improvement: The report attributes much of the overall reduction in cancer deaths to lower smoking rates and the resulting drop in lung-cancer mortality. It also indicates that progress accelerated as early detection and treatments improved over time. The framing highlights prevention as a major driver of population-level gains alongside clinical advances.

2. Survival gains are uneven across cancers and stage at diagnosis: The article notes a milestone overall 5-year cancer-related survival rate of 71% across all cancers combined, while also emphasizing stark differences by cancer type. It contrasts very low survival for cancers like pancreatic cancer and glioblastoma with much higher survival for breast and prostate cancer. It also points out that even for higher-survival cancers, outcomes vary sharply between localized and metastatic disease.

3. Research momentum depends on policy and funding stability: AACR leaders warned that proposed changes to federal grant rules could add political considerations and enable termination of grants for reasons unrelated to scientific merit or performance. They argued that uncertainty and turmoil at NIH and other federal health agencies could slow progress for patients. The group urged Congress to maintain bipartisan support for sustained federal investment to keep cancer research and clinical advances moving forward.

UnitedHealth Wants to Shine “Sunlight” on Providers. It Should Try Some on Itself.

By Wendell Potter – Wayne DeVeydt, UnitedHealth Group’s chief financial officer, stood in front of a room of investors in Boston a few days ago and reached for a phrase that should never come out of that company’s mouth with a straight face. “We’re putting a lot of sunlight on the IDR process,” he told the crowd at a Wells Fargo health care investor conference, referring to the No Surprises Act’s independent dispute resolution system. “The greatest disinfectant is sunlight.” Read Full Article...

HVBA Article Summary

1. UnitedHealth’s messaging targets the IDR system and provider behavior: The article argues that UnitedHealth is framing the No Surprises Act’s independent dispute resolution (IDR) process as a key driver of cost pressure, with providers cast as the main problem. It notes that the CFO’s comments were made in an investor-focused setting, suggesting the intent was to explain financial pressures rather than inform patients or the broader public. The author characterizes this as part of a broader communications strategy meant to steer attention toward “greedy” providers and away from insurer practices.

2. Courts and external analyses raise questions about how the benchmark (QPA) is calculated: The piece points to the Fifth Circuit’s ruling in Texas Medical Association v. HHS (TMA III), which it says found regulators unlawfully allowed insurers to depress the qualifying payment amount (QPA) using “ghost rates” and by excluding certain payments. It also cites a commissioned NDP Analytics study reporting that median in-network rates in insurers’ Transparency in Coverage files were higher than the QPA 60.6% of the time, with an average difference of 290.5%. The author uses these references to argue that IDR volumes may be linked to how benchmark rates are set, not just to provider tactics.

3. The author calls for transparency focused on insurer operations, not only on providers: The article contends that if “sunlight” is the goal, scrutiny should also apply to UnitedHealth’s internal methods and revenue streams. Specific areas the author says should be disclosed include how UnitedHealth’s QPA compares to contracted rates, fees in administrative-services contracts for self-insured employers, and how Optum Rx rebate and spread-pricing revenue is distributed. It also calls for disclosure of denial and prior authorization data that the author says UnitedHealthcare has kept proprietary.

Broker consolidation tests agility, part 1

By Bruce Shutan – Bigger isn’t always better in employee benefits consulting, based on interviews with a dozen high-profile thought leaders from across the industry who offered a nuanced perspective. “Scale used to be the moat. It isn’t anymore and that’s the real story here,” said Dave Chase, co-founder and CEO of healthcare company Health Rosetta. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Technology Is Narrowing the Gap Between Large and Independent Brokerages: Technology that once gave large national brokerages a significant advantage is increasingly available to smaller independent firms through third-party platforms and tools. Boutique firms can now access advanced plan analytics, PBM transparency solutions and payment integrity capabilities without building large proprietary technology infrastructures. This shift may allow smaller firms to compete more effectively while large brokerages continue to offer advantages through broader expertise, carrier relationships and organizational resources.

2. Brokerage Consolidation Remains Historically High: Employee benefits brokerage consolidation reached record levels in 2021 and 2022 with 213 transactions, and activity from 2020 through 2024 was nearly double the number recorded from 2015 through 2019. Benefits firms remain attractive acquisition targets because of recurring revenue, high client retention and opportunities to cross-sell services such as HR, retirement, payroll and compliance. Private equity-backed buyers have become a major driver of activity, accounting for approximately 73% of all insurance brokerage acquisitions last year, including many employee benefits firms.

3. Consolidation Creates Trade-Offs Between Scale and Independence: Larger organizations can provide employers with expanded technology, specialized expertise, analytics and carrier relationships, while successful consolidation may also depend on maintaining local knowledge and personalized advisory service. Independent brokers may offer greater autonomy, flexibility and closer alignment with individual client needs, particularly as technology reduces some traditional scale disadvantages. Industry perspectives differ on the optimal model, suggesting that the value of consolidation can vary based on an employer’s size, complexity, service expectations and need for specialized resources.

Lilly captures 70% of new Medicare GLP-1 patients, CEO says

By Ella Jeffries – About 700,000 new Medicare beneficiaries have started GLP-1 treatment since the Medicare GLP-1 Bridge launched in July, and 70% of those patients are taking Eli Lilly medicines, Lilly CEO Dave Ricks told CNBC in a Sept. 21 interview. Read Full Article...

HVBA Article Summary

1. Early uptake in a new Medicare access pathway: The article describes a large number of Medicare beneficiaries initiating GLP-1 therapy since the Medicare GLP-1 Bridge launched in July. It also reports that Eli Lilly’s products represent a substantial portion of that new use, based on comments from CEO Dave Ricks. The update frames the Bridge as a significant near-term channel for expanding beneficiary access to specific GLP-1 treatments.

2. Program structure and pricing terms for beneficiaries and manufacturers: The Medicare GLP-1 Bridge is presented as offering eligible Medicare Part D beneficiaries access to several GLP-1 options for a $50 monthly copay. Manufacturers are described as supplying the drugs at a net price of $245 per monthly supply. The article notes the demonstration is scheduled to run through December 2027, setting a defined window for these terms.

3. Prescribing patterns, rollout experience, and what happens after the demo: According to Ricks’ comments, physicians are using Zepbound heavily, particularly for patients with higher body weights and complications, while Foundayo is positioned for patients seeking less weight loss. He also says he has not heard of major logistical problems and credits CMS with handling the launch well. Separately, the article points to concerns raised in prior reporting about what coverage will look like for beneficiaries once the demonstration ends.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

Medical debt impacts 1 in 3 insured adults

By Sara Heath – A third of adults with private insurance are managing medical debt, with a new survey from the Commonwealth Fund underscoring the impact rising healthcare costs are having on patients. The survey of 6,535 privately insured adults under age 65 showed that having health insurance coverage isn't enough to insulate people from high healthcare costs anymore. "Medical debt is often viewed as a problem limited to people who are uninsured or who face a major medical emergency," Sara R. Collins, a study coauthor and Commonwealth Fund senior scholar for Expanding Coverage and Access and Tracking Health System Performance, said in a press release. "But this survey shows that it is also widespread among Americans with private insurance." Read Full Article...

HVBA Article Summary

1. Medical debt is common even among the privately insured: The survey reports that 32% of privately insured adults under 65 carry some medical debt. The burden is not evenly distributed, with higher rates among lower- and moderate-income respondents, Black and Hispanic respondents, and people living in the South. The results suggest that having private coverage does not necessarily prevent exposure to out-of-pocket costs that can translate into debt.

2. Debt amounts and bill-payment capacity show a mismatch: Among those with medical debt, 46% reported owing $2,000 or more, while others reported smaller balances (less than $500 or between $500 and $1,999). Separately, the survey indicates many people are not positioned to handle an unexpected $1,000 medical bill, with reported difficulty more common in several demographic groups (including low-income respondents and some racial/ethnic groups). Taken together, the findings point to affordability pressures that can arise even outside of extremely large or rare medical events.

3. Sources of debt and preferred remedies highlight multiple intervention points: Respondents reported that a large share of medical debt is tied to hospital services, but sizable portions also stem from doctors’ visits, lab work/diagnostic tests, and care related to ongoing chronic conditions. The report also describes stress and behavioral impacts, including worry/anxiety and actions like delaying care or cutting back on necessities. When asked about potential fixes, respondents rated options such as interest-free payment plans, hospital financial assistance, and removing medical debt from credit reports as helpful.

Trump administration takes on mental health parity

By Adriel Bettelheim – The Trump administration is wading into the difficult issue of mental health parity, laying out requirements aimed at making health plans cover behavioral health at the same level as physical health. Why it matters: It's a sign that the administration could steer in a different direction from the Biden administration, which put a focus on compliance reporting that the Trump team is rejecting. Read Full Article...

HVBA Article Summary

1. New enforcement approach from the Labor Department: The Department of Labor issued guidance this month describing how it plans to enforce mental health parity requirements, with a proposed regulation expected by the end of the year. The guidance emphasizes a goal of “fair and even-handed” enforcement, according to an Assistant Secretary directive dated Sept. 8. It highlights scrutiny of care-management tools such as pretreatment claims reviews and also examines whether insurer networks are adequate. This signals an attempt to clarify what enforcement will prioritize in practice.

2. Policy shift from the prior administration’s rulemaking: The administration’s move follows its refusal to enforce a Biden-era parity rule that would have required plans to routinely evaluate networks, payment rates, and other factors. That earlier rule was challenged in court by an employer group that argued the rule exceeded statutory authority. The current guidance suggests the government may rely less on ongoing compliance reporting and more on targeted enforcement priorities. The result could be a different compliance roadmap for insurers and employers compared with the previous approach.

3. Ongoing access and payment gaps remain central to the parity debate: Advocacy groups and experts cited in the article describe persistent disparities in access to behavioral health services relative to medical and surgical care, including longer waits and greater out-of-network use that can increase patient costs. In an analysis referenced from the Kennedy Forum, mental health and substance use treatment was paid 16% to 59% less than physical health in four major insurance networks. The article also notes concerns that some organizations may use internal guidelines to limit coverage in ways that conflict with professional standards, as discussed in a 2023 Health Affairs analysis. Employers, while generally supportive of parity, argue compliance standards can be subjective and investigations lengthy, complicating efforts to demonstrate adherence.

Telehealth Companies Keep Exposing Customers' Medical Data. What Should They Do?

By Associated Press – The appeal of telehealth is easy to explain: Instead of calling a doctor, booking an appointment, and hoping to eventually get a prescription, you can log onto an app or website and get approved for a new medication within minutes. Since the COVID-19 pandemic, scores of online health services have launched with the promise of quick, convenient access to drugs for attention deficit-hyperactivity disorder, sexual dysfunction, anxiety, weight loss, and more. Increasingly, though, government regulators are accusing these companies of deceptive, unethical business practices, including disclosing their customers' health data, signing them up for hard-to-cancel subscriptions, and bypassing real-time consultations with doctors. The Federal Trade Commission (FTC)'s latest lawsuit alleges that telehealth pioneer Hims & Hers engaged in all of those tactics, running afoul of U.S. consumer protection laws. Read Full Article...

HVBA Article Summary

1. Regulators are increasingly targeting telehealth business practices: The article describes government scrutiny of telehealth firms for practices that allegedly include sharing sensitive health data, pushing customers into difficult-to-cancel subscriptions, and minimizing live clinical interaction. The FTC lawsuit involving Hims & Hers is presented as the most recent example in a growing set of enforcement actions. The company disputes the allegations, underscoring that these cases can be contested and complex. The broader message is that convenience-driven care models are colliding with consumer-protection and privacy expectations.

2. Care delivery can be questionnaire-driven with limited real-time clinician contact: The piece says many telehealth encounters start with intake questionnaires rather than live conversations with a physician. It cites research on online GLP-1 sellers indicating that less than a third required real-time video or audio consultation, and that approvals could occur within minutes. The article notes that this can fall short of medical-society recommendations for initiating GLP-1 therapy, such as setting goals and reviewing relevant history. It also highlights that some intake workflows may not consistently screen for issues like eating disorders that can be relevant to GLP-1 treatment.

3. Privacy protections are uneven, so consumers are advised to take defensive steps: The article argues that many consumers assume HIPAA protects any health information they share online, but says those protections often do not apply to direct-to-consumer telehealth and similar platforms. As a result, regulators frequently rely on the FTC’s broader authority focused on deceptive or unethical practices, and remedies may be limited to agreements to stop certain behaviors. Some states have enacted privacy laws with health-data protections, but the article says enforcement has been limited. In the meantime, experts quoted recommend practical measures like ad blockers, private browsing modes, and closely reading user agreements—while warning that opting out of terms of service may be the only certain way to avoid data use.

Aetna expands bundled prior auths for cancer care

By Paige Minemyer – Aetna is expanding bundled prior authorizations across all types of cancer for enrollees in its Medicaid plans across eight states. The latest expansion took effect on Sept. 1, the company said in an announcement, and the insurer expects to roll the program out to all of its lines of business next year. Eligibility is expected to extend to Medicare and commercial plans in the first half of 2027. Aetna said that it recognized providers were submitting multiple prior authorizations for patients in need of cancer treatment. Read Full Article...

HVBA Article Summary

1. Program scope and timeline expansion: The insurer is extending its bundled oncology prior authorization approach to cover all cancer types for Medicaid members in eight states. The change took effect Sept. 1, and Aetna says it plans to broaden the program to all of its business lines next year. It also projects that Medicare and commercial eligibility would begin in the first half of 2027.

2. What “bundling” changes in the authorization process: Aetna’s model aims to reduce the need for multiple separate prior authorization submissions tied to a single patient’s cancer care. The bundle combines medical oncology treatments (including chemotherapy and immunotherapy) with radiation oncology-related services, such as imaging, under one request. The stated goal is to reduce delays and make it easier for patients and care teams to move through treatment steps.

3. Provider burden as a stated driver: The company frames the initiative partly as a response to administrative workload on clinical staff. In a July survey cited by Aetna, 74% of providers identified administrative burden as the top challenge facing clinical staff, and 31% pointed to prior authorization as the single biggest contributor. Aetna argues that reducing the volume of submissions can ease paperwork demands while allowing clinicians more flexibility as treatment plans change.

New House bill could add opioid coverage rules for employers

By Allison Bell – A new House bill could require employer-sponsored health plans to cover treatment and support services for people facing opioid addiction without imposing cost-sharing requirements on the patients. If the Maximizing Opioid Recovery Emergency Savings Act bill were enacted and implemented as written, an employer plan would have to eliminate deductibles, copayments and coinsurance bills for the medications used to treat opioid use disorders. Employer plans would also have to eliminate out-of-pocket costs for access to Narcan and other overdose-reversal medications; treatment in outpatient settings; and recovery support services. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Scope of the proposed mandate for employer plans: The bill would require employer-sponsored health plans to provide certain opioid use disorder treatments and support services without patient cost sharing. The article describes removing out-of-pocket costs not only for medications but also for overdose-reversal drugs (such as Narcan), outpatient treatment, and recovery support services. If enacted as written, the change would affect how plan designs structure deductibles, copays, and coinsurance for these services. The proposal is framed as a coverage requirement rather than a voluntary benefit expansion.

2. Legal and market reach beyond employer coverage: The article says the mandate would be made federal law through changes to the Public Health Service Act, ERISA, and the Internal Revenue Code. It also notes the requirement would extend to individual health insurance, not just employer-sponsored plans. For Medicare, the piece indicates cost-sharing could continue in many states, while a five-year pilot would remove out-of-pocket costs for opioid use disorder treatment in 15 states. This suggests the legislation would create different rules across coverage types if implemented as described.

3. Legislative status and policy context: The bill is sponsored by Rep. Madeleine Dean, and the article places it under multiple House committees’ jurisdiction (Energy & Commerce, Ways & Means, and Education & Workforce). Dean ties the proposal to estimates that 20 million Americans are struggling with opioid use disorder and argues that a coverage mandate could help families affected by addiction. The piece also frames the proposal within continued federal attention to mental health and substance use disorder coverage. As an example of that broader focus, it mentions recent federal funding for the Substance Abuse and Mental Health Services Administration.

The business case for effective multilingual education

By Melissa Burkhart – While debate and controversy on many topics in the realm of employee benefits are rampant, there is one thing we can all agree on: costs are astronomical and growing, and employers and employees are struggling. The industry is bombarded with point solutions, competing carriers and alternatives to traditional approaches from ICHRAs and direct primary care to health shares. All have their pros and cons; none is a silver bullet. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Multilingual Education Can Improve Benefits Engagement: The article identifies effective multilingual benefits education as a strategy for increasing employee participation and improving understanding of available coverage. The author argues that clearer communication can contribute to higher enrollment, increased revenue for benefits providers, and fewer unnecessary claims. However, inconsistent communication practices across the benefits industry may limit these potential outcomes.

2. Automated Translation Creates Communication and Compliance Risks: Reliance on automated translation without professional review can produce inaccurate or confusing benefits information, potentially discouraging enrollment and creating compliance exposure. Examples include translating instructions for funding a flexible spending account (FSA) in ways that could incorrectly suggest employees must take out a loan. The article emphasizes that bilingual employees are not necessarily qualified professional editors and that AI-generated translations require appropriate oversight to ensure accuracy and clarity.

3. Professional Translation and Accessible Communication Support Employee Understanding: The article recommends professionally translated materials, multimedia education, and technology solutions tailored to employees’ language preferences and digital capabilities. It also highlights the Spanish Language Benefits Education Certification, a four-hour webinar offering two continuing-education credits for brokers or two SHRM renewal credits. Brokers and HR teams are encouraged to evaluate vendors’ multilingual capabilities and incorporate accessible benefits education into their employee engagement and communication strategies.

Novo talks up drug launches in effort to win back investors

By Jonathan Gardner – Novo ushered in a new era for obesity care when its daily GLP-1 shot for diabetes, liraglutide, was cleared for weight loss as Saxenda 12 years ago. Much has changed since, as weekly injections have soared in popularity and Lilly has overtaken Novo with a dual-acting medication it markets as Zepbound for obesity and Mounjaro for diabetes. Lilly’s ascent has been fueled in part by trial data showing Zepbound spurs more weight loss than Novo’s Wegovy — a claim Novo has contested. Read Full Article...

HVBA Article Summary

1. CagriSema Faces Mixed Clinical Results and Competitive Pressure: Novo Nordisk has reported mixed results for its experimental obesity drug CagriSema, which was outperformed by Eli Lilly’s Zepbound in one clinical trial. A subsequent trial showed CagriSema outperforming Zepbound, although the comparison used the second-lowest dose of Lilly’s medication. These findings highlight the importance of trial design and dosing when evaluating the competitive potential of emerging obesity treatments.

2. Oral GLP-1 Competition and Organizational Changes: Novo Nordisk launched the first GLP-1 pill for weight loss, but sales of its oral Wegovy formulation fell short of Wall Street expectations between April and June 2026. Eli Lilly subsequently received approval for its competing oral obesity medication, Foundayo, increasing competition in the market. Amid declining share prices, Novo appointed Mike Doustdar as CEO, restructured its board, eliminated 9,000 jobs, and announced partnerships with Anthropic and Orbis Medicines to support drug development.

3. Pipeline Development and Long-Term Growth Challenges: Novo Nordisk projects that its sales growth will be in line with industry peers from 2026 through 2030, while U.S. patent protection for semaglutide, the active ingredient in Wegovy, is expected to expire in 2032. Beyond CagriSema, the company has only one other drug under FDA review, a prospective hemophilia treatment, while most of its obesity pipeline remains in Phase 2 development or earlier. Novo has also experienced a clinical setback with its cardiovascular drug candidate ziltivekimab, adding uncertainty to its longer-term development plans.

When determining GLP-1 coverage, keep these considerations in mind

By Lee Hafner – When putting together a modern health benefits plan, the question of GLP-1 coverage can’t be ignored — and certain considerations can help leaders decide if they’re worth the investment. After PBM rebates and plan negotiation, employer costs for weight-reduction approved GLP-1s now commonly fall between $600 to $900 per member per month, according to digital weight loss clinic Embla Health. As an impact example, the platform explains that for a self-funded employer with 1,000 workers and a 5% obesity-eligible utilization rate (50 employees on GLP-1s), annual cost for medication alone would range between $360,000 to $540,000 a year. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. GLP-1 Coverage and Long-Term Healthcare Costs: Although GLP-1 medications present significant upfront costs for employers, their potential benefits for weight management and cardiovascular health may influence long-term healthcare spending. Amanda Turcotte of Amalgamated Life Insurance Company suggests that employers evaluate these potential outcomes when considering coverage, particularly for workforces with longer employee tenure. Increased competition and the availability of lower-cost oral medications could also make GLP-1 coverage more financially accessible over time.

2. Coverage as an Employee Attraction and Retention Strategy: Employers with longer-tenured employees may view GLP-1 coverage as an investment in workforce health, with potential benefits emerging over several years. For employers with higher turnover, access to these medications could become a consideration in employee recruitment and retention as treatment options expand. Turcotte notes that employers can also provide support through clinical coaching, adherence programs, and information about lower-cost treatments without covering the full cost of medications.

3. Consistent Coverage and Sustainable Benefit Design: Employers considering GLP-1 benefits can explore different levels of financial support rather than adopting an all-or-nothing coverage approach. Turcotte emphasizes that coordinated clinical care and medication adherence support are important components of treatment and can complement employer-sponsored benefits. She also cautions that repeatedly introducing and removing coverage may create uncertainty for employees and potentially disrupt treatment continuity and health outcomes.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

FDA says initial rejections of new drugs have declined

By Zachary Brennan – The FDA is looking to dispel what it says are inaccurate claims that it’s increasingly rejecting new drugs after an initial review. The claims stem from a 2027 budget-related report from the House Appropriations Committee that pointed to a rising number of rejections, or complete response letters (CRLs), “across all human drug review programs, including novel drug approvals.” The committee also directed the agency to provide a report analyzing how issues that led to CRLs for medicines over the past five years could have been resolved within the first review cycle. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. FDA Drug Rejection Rates Have Generally Declined: An FDA report found that initial rejection rates for original new drug and biologic applications decreased from 47% in 2008 to approximately 27% in 2024. The agency acknowledged a temporary increase in rejections between 2018 and 2020, potentially influenced by the COVID-19 pandemic. The findings come amid congressional scrutiny and criticism of the FDA’s handling of rare disease drug applications.

2. Biologics Applications Show a Different Trend: While overall rejection rates have declined, biologics applications reviewed by the FDA’s Center for Drug Evaluation and Research (CDER) have experienced the sharpest increase in rejection rates in recent years. CDER reviews certain monoclonal antibodies, therapeutic proteins, and biosimilars, with average biologics filings increasing from 9 during 2008–2012 to 22 during 2018–2022. This trend represents an exception to the broader decline in initial drug application rejections.

3. Initial Rejections Do Not Necessarily Prevent Drug Approval: The FDA reported that approximately 77% of original new drug and biologic applications submitted between fiscal years 2008 and 2024 are currently approved and available to patients. This indicates that an initial rejection does not necessarily prevent a drug from eventually receiving approval. Additionally, first-cycle rejection rates for efficacy supplements, which often involve expanded indications or labeling changes, have consistently declined since 2008 despite submission volumes nearly doubling.

Business Group on Health taps BioRadar to boost workforce readiness for emerging threats

By Heather Landi – Biological threat intelligence is increasingly becoming a workforce and business issue, not just a public health concern. Emerging threats—infectious disease outbreaks, pandemics and potential bioterrorism events—can cause significant workforce and operational disruptions. Read Full Article...

HVBA Article Summary

1. Workforce preparedness framed as a business continuity need: The article argues that biological threats are increasingly relevant to employers because outbreaks and other events can disrupt operations and staffing, not only public health. It positions threat monitoring as part of organizational readiness and workforce planning. This framing reflects a shift toward treating biological risk as an enterprise issue that can affect productivity and safety.

2. Partnership provides employers access to an AI-enabled intelligence platform: Business Group on Health is partnering with BioRadar to give employers access to an AI-powered platform intended to identify and assess biological threats in real time. The stated goal is earlier visibility into emerging issues so organizations can make decisions before disruptions escalate. The collaboration also emphasizes translating biological intelligence into practical actions for employers, including benefits and preparedness planning.

3. Employers will help shape tools based on COVID-era lessons and broader threat types: The organizations cite COVID-19 as a catalyst for more proactive monitoring rather than relying on alerts after threats spread. The partnership is described as involving employers directly in developing the next generation of tools so workforce needs and business considerations are incorporated early. BioRadar’s founders and leadership highlight coverage of known, novel and potentially engineered pathogens, using multiple data streams to detect unusual activity.

Employers stand firm on health coverage, but is a cliff approaching?

By Allison Bell – U.S. employers managed to hold overall health coverage levels steady in 2025, and even increase the number of people covered, as the number of Americans with some other types of coverage shrank. The number of people with employer-based health coverage increased 0.1% between 2024 and 2025, to 180.7 million, according to new data from the U.S. Census Bureau's Current Population Survey program. Here's what happened to some other key indicators over that same period: Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Employer coverage stability amid shifts elsewhere: The Census Bureau figures show employer-sponsored coverage was essentially flat year over year, even as other forms of coverage moved in different directions. The article highlights declines in Medicaid and direct-purchase enrollment while Medicare enrollment rose. The overall picture suggests employers continued to anchor coverage levels during a period when public-program rules and individual-market participation were changing.

2. Policy changes are a key driver of recent coverage movement: The article links the latest coverage totals to federal decisions to return Medicaid access rules to their pre-pandemic baseline. It also notes the data do not yet incorporate the effects of allowing enhanced ACA premium subsidies to fall back to pre-pandemic levels. That timing gap means the reported coverage mix may change further as those subsidy-related effects show up in future data.

3. Potential downstream effects for employer plan costs remain uncertain: The piece reports that economists had projected expiring pandemic-era supports could affect employer plans by shifting sicker individuals into employer coverage and increasing cost pressures. It also describes a concern that providers may attempt to offset uncompensated care by passing costs on to employer plan sponsors and participants. The article frames the size and timing of this “coverage access cliff” impact as an open question for current and projected employer health-care cost increases.

Employers May Be Asking the Wrong Questions About Their Health Plans, New Survey Finds

By Jeff Williams – Employers are entering the next health plan renewal cycle focused on familiar concerns: rising costs, pharmacy spending and plan design. But a new survey of 124 health benefits brokers and advisors suggests some of the most important questions may not be getting asked. Read Full Article...

HVBA Article Summary

1. Renewal discussions may be missing governance and oversight topics: The press release says the survey results point to a mismatch between what employers raise during renewal conversations and what brokers view as key risks. Brokers highlighted concerns tied to fiduciary preparedness, vendor oversight, and whether plan decisions can be supported with appropriate documentation. The central claim is not that employers are necessarily doing anything wrong, but that the questions being prioritized may not align with where brokers see exposure.

2. Large visibility gaps are reported for NSA/IDR and recovery-related performance: Brokers reported limited ability to see or evaluate performance in areas including the No Surprises Act and Independent Dispute Resolution, as well as subrogation and recovery. The article frames these as blind spots that can affect how well a plan is performing and whether problems can be detected early. It also emphasizes that visibility and measurable results from vendors are important for employers to assess whether services are working as intended.

3. Plan management complexity is rising, increasing demand for practical broker tools: The article describes employers facing more complex choices around self-funded plan structures, pharmacy-related issues, claims, and vendor management. It also notes that brokers want more tools—such as checklists, reporting, benchmark data, and education materials—to support more sophisticated client conversations. Separately, it reports that AI use is already present in broker workflows, suggesting operational practices are evolving alongside benefit-plan complexity.

Job Lock Is Real. The ACA Doesn’t Fix It.

By Wendell Potter – Nearly 40% of Americans say they’ve stayed in a job longer than they wanted to because they or a family member needed the health coverage that came with it. That’s the headline finding of a new survey from ValuePenguin, and it’s more common among Gen Z and millennial workers, and more common among parents with young children (53%) than nonparents (32%). Most striking: 51% of people who get insurance through their employer say they’d be very or somewhat likely to leave their current job within a year if a comparable plan were available outside of work at a similar price. Read Full Article...

HVBA Article Summary

1. Employer coverage can constrain job and business decisions: The article argues that tying health insurance to employment creates “job lock,” making workers less willing to switch jobs or start businesses for fear of losing coverage. It cites research linking higher ACA marketplace premiums to lower rates of self-employment and suggesting that premium reductions could increase new business formation. It also references reporting that job lock is more pronounced among people with chronic conditions and among women, including those who may anticipate pregnancy-related care. Together, these points frame job lock as an economic and personal risk-management response to coverage uncertainty.

2. Job lock and lack of coverage vary by income and employer size: The piece highlights that employer-sponsored insurance is far more common among higher-income people than lower-income people, which affects who experiences “job lock” versus who is simply uninsured or lacks an offer of coverage. It describes how large employers’ greater use of self-funded plans can confer cost and benefit advantages compared with small employers, influencing labor-market competition. The author also notes survey findings showing small firms’ rates of offering coverage have fallen while large employers’ offer rates remain high. The result, as presented, is a two-track system in which better-off workers may feel stuck in jobs to keep good coverage, while lower-wage workers are more often shut out of job-based coverage entirely.

3. The ACA marketplace helps, but doesn’t replicate employer-plan economics: The article says ACA marketplace coverage can be a meaningful option, but often isn’t “comparable” to employer insurance because employer plans typically include substantial employer premium contributions and tax advantages. It argues that leaving a job can mean losing both the employer-paid share of premiums and the tax exclusion for employer-sponsored coverage. The author contends that subsidies can offset some costs but phase out as income rises, which matters because the article associates job lock with higher earners who may not qualify for much assistance. On that basis, the piece suggests that marketplace availability alone does not fully remove the structural incentives that keep many people tied to employer coverage.

High prescription costs force patients to quit treatment

By Alan Goforth – Not even the most effective medication will achieve the desired results if its high cost prevents patients from taking it. Nearly all physicians (96%) report that patients stopped taking a medication because of cost without telling them, the 2026 Physician Drug Cost survey from RazorMetrics found. Almost the same percentage said they would be comfortable substituting a clinically appropriate, lower-cost alternative. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Prescription Affordability Impacts Patient Care: A survey by RazorMetrics found that medication costs frequently affect treatment plans, creating challenges for patients and healthcare providers. Physicians expressed a willingness to switch patients to lower-cost medications when appropriate alternatives are available. The findings highlight the importance of providing patient-specific cost information during the prescribing process to support medication adherence and treatment decisions.

2. Administrative Burdens Increase for Healthcare Providers: More than 8 in 10 medical practices receive at least five patient calls each week concerning expensive prescriptions. Two-thirds of practices report spending at least five hours weekly resolving medication affordability issues after prescriptions are written, while 20% spend up to 20 hours. These administrative demands require physicians and staff to address medication costs alongside their existing patient care responsibilities.

3. Integrated Technology Could Improve Prescription Affordability: Nearly half of prescribers indicated that fewer workflow interruptions would make payer and pharmacy benefit manager (PBM) outreach more useful. However, nearly two-thirds have either never encountered real-time benefit tools or have had negative experiences with them. The survey identifies opportunities for health plans, employers, and PBMs to provide timely, patient-specific information about lower-cost medications within existing clinical workflows.

Low layoffs keep pressure on workers’ comp and benefits costs

By Mav Rodriguez – US layoffs remained low in the latest week, keeping the employment base relatively firm at a time when workers’ compensation pricing continues to soften and employers are bracing for another sharp increase in health benefit costs. Initial claims for unemployment benefits fell by 10,000 to 196,000 in the week ended September 12, the lowest level since mid-July. Labor Department figures also put the four-week moving average at 203,250, down 2,750 from the previous week. Continuing claims fell by 39,000 to 1.73 million in the week ended September 5. Read Full Article...

HVBA Article Summary

1. Workers’ comp pricing keeps easing despite rising claim costs: Industry survey results cited in the article show workers’ compensation premiums declined on average in Q2 2026, extending a multi-year run of price decreases. At the same time, claim severity trends are moving upward, with medical and indemnity costs rising even as claim frequency falls. The piece frames this as a negotiation environment where competitive carrier pricing coexists with worsening cost drivers that can pressure future results.

2. Carrier performance remains strong, but signals are mixed: The article notes that workers’ compensation underwriting has produced a long stretch of calendar-year gains, indicating profitability at the aggregate level. However, it also points to a weaker accident-year measure, suggesting current-year loss experience is less favorable than what calendar-year numbers alone imply. This contrast matters for brokers and employers because it can influence how long the soft pricing environment persists.

3. Health benefit renewals face higher medical inflation with stable headcount: With layoffs low, employers are not seeing meaningful reductions in benefits-eligible populations heading into 2027 renewals. The article cites survey findings that per-employee health benefit costs are expected to increase sharply in 2027 even after planned employer changes, with an even higher estimate absent those changes. It adds that many employers are considering plan design and contribution adjustments, but retention pressures may limit how aggressively costs can be shifted to employees.

Arkansas pharmacies sue Express Scripts over alleged underpayments

By Heather Landi – Twelve independent pharmacies in Arkansas are suing Express Scripts alleging the pharmacy benefit manager repeatedly underpaid them on tends of thousands of drug prescriptions, in violation of state law. In a lawsuit (PDF), filed in the Circuit Court of St. Louis County, Missouri., the pharmacies seek compensatory and statutory damages, along with court orders aimed at future compliance, reprocessing affected claims, and creating a workable appeals process. The complaint seeks hundreds of millions of dollars in statutory damages, according to attorneys representing the pharmacies. Read Full Article...

HVBA Article Summary

1. Allegations focus on reimbursement below a legal benchmark: The pharmacies argue that Arkansas law sets NADAC as a minimum ingredient-cost reimbursement level, and that paying below it violates state requirements. They claim Express Scripts had the necessary claim information and access to CMS-published NADAC data to comply at the time claims were priced. The lawsuit frames the issue as avoidable and driven by business choices rather than technical limitations.

2. The complaint describes repeated underpayments and operational strain: According to the filing, the alleged below-floor payments occurred repeatedly over a defined period across many drugs and claims. The pharmacies say the resulting shortfalls can affect working capital needed to buy ongoing inventory before reimbursements arrive. They contend that persistent underpayment can force cutbacks in staffing, hours, delivery, inventory, or overall patient capacity, potentially impacting access over time.

3. Regulatory actions and new legal pathways set the backdrop: The article notes that Arkansas regulators previously issued bulletins instructing PBMs to implement NADAC-minimum practices and support invoice-based or bulk appeals. It also cites state enforcement actions announced in 2024 that included nearly $1.5 million in penalties against multiple PBMs for below-cost reimbursement. A 2025 state law is described as giving pharmacies the right to sue for certain reimbursement violations, which the plaintiffs are now using to seek damages and court-ordered compliance steps.

Prudential eyes dental and vision acquisitions to expand group benefits

By Allison Bell – Prudential Financial probably has enough group life and group disability operations that focus on large employers. But the Newark, New Jersey-based financial services giant is interested in dental and vision deals. Prudential might also consider group life or group dental businesses that serve employers with fewer than 1,000 employees. Andrew Sullivan, Prudential's chief executive officer, gave that description of the company's corporate deal shopping list Wednesday, during a "fireside chat" session in New York at the KBW Insurance Conference. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Acquisition focus is shifting toward dental and vision: Prudential CEO Andrew Sullivan said the company is interested in potential deals in dental and vision benefits. He also indicated Prudential could look at group life or group dental businesses aimed at employers with fewer than 1,000 employees, suggesting interest beyond only large-employer segments. The comments position M&A as a tool to broaden the company’s product mix while building on existing workplace benefits capabilities.

2. Management is emphasizing product diversification and potential synergies: Sullivan framed the strategy as a way to “continue” diversifying Prudential’s products using capabilities the company already has. He argued that, with a complementary platform, there could be meaningful revenue and expense synergies to share with a counterparty. He also acknowledged the benefits-deal market is competitive, while asserting Prudential brings value beyond simply offering the highest price.

3. Investor conference setting highlights active dealmaking environment and historical context: The remarks came during a KBW Insurance Conference fireside chat that Prudential streamed and later made available online as a recording. The article situates the comments within a broader wave of investor-conference “fireside chats” where executives discuss strategy and where potential sellers may be present. It also notes Prudential previously sold its group health business (including dental and vision) to Aetna in 1999 and later attempted a small and midsize employer dental push that it ended in 2012.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

Employer plans block cancer pill access, House Republican says

By Allison Bell – Employers, health insurers and pharmacy benefit managers now face a new fight in Congress: a battle over the rules for how and where patients with cancer get chemotherapy drugs. The U.S. House Oversight Committee's Health Care and Financial Services Subcommittee held a hearing in Washington earlier this week on employer plan coverage rules that affect patients' access to chemotherapy drugs. The subcommittee chairman, Rep. Glenn Grothman, R-Wis., blasted employer plan coverage rules that often eliminate out-of-pocket costs for chemotherapy drugs delivered through an IV drip in a health care facility but set the out-of-pocket cost for filling an oral version of the same drug at $1,000 or more. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Hearing spotlights cost-sharing differences between IV and oral chemotherapy: The House Oversight subcommittee examined how employer plan benefit design can make oral chemotherapy significantly more expensive for patients than IV-administered versions. Rep. Glenn Grothman argued that plan and pharmacy benefit structures can lead to situations where patients leave without needed medications after learning their out-of-pocket costs at the pharmacy. He framed the issue as one of incentives created by intermediaries in the prescription-drug system, including pharmacy benefit managers (PBMs). The discussion positions employers, insurers, and PBMs as central stakeholders in how cancer-drug access is determined.

2. PBM incentives and plan design are a central target of criticism: Grothman said PBMs can set patient cost-sharing for pharmacy-dispensed drugs and may influence which drugs are covered and how patients are steered among options. He connected these incentives to PBM relationships with large insurers and to the complexity of PBM contracts and compensation arrangements. The article also notes that employer prescription plans may lack an out-of-pocket spending limit, which can increase financial exposure for some patients. The hearing record was made publicly available via a posted online recording.

3. A federal ‘parity’ proposal aims to extend protections to ERISA-governed plans: Grothman promoted the Cancer Drug Parity Act of 2025, which would require self-insured employer plans under ERISA to make access terms for oral chemotherapy at least as favorable as IV alternatives. He argued federal action is needed because states cannot regulate cost-sharing provisions for ERISA plans, even though many states have adopted similar rules for state-regulated insurers. Witnesses expressed support for the general approach while also pointing to additional barriers, such as step-therapy requirements that can delay access to appropriate treatments. The testimony included differing emphasis on where responsibility lies for high cancer-drug costs, with some witnesses placing more blame on insurers and PBMs than on manufacturers.

1 big thing: Calls for surprise billing fix intensify

By Caitlin Owens – The explosive growth in payment disputes between insurers and providers that go to arbitration — and the associated costs — are prompting a chorus of calls to overhaul the No Surprises Act. Why it matters: Though there's mounting evidence the process for resolving contested claims is driving up health care costs, it's hard to see a resolution anytime soon. Driving the news: The surprise billing law's dysfunction is affecting more than just providers and payers. Read Full Article...

HVBA Article Summary

1. No Surprises Act Arbitration Raises Concerns About Premiums and Provider Networks: A recent National Bureau of Economic Research (NBER) working paper found that the No Surprises Act may discourage providers in certain specialties and states from participating in insurer networks. The research also identified suggestive evidence that insurers facing greater arbitration exposure experienced larger premium increases. Insurers and benefit consultants warn that rising arbitration volumes and provider payment awards could contribute to higher healthcare premiums in 2027.

2. Insurers and Providers Disagree Over Arbitration Practices: Providers reportedly win approximately 85% of arbitration disputes, often receiving payments several times higher than typical in-network reimbursement rates. Insurers argue that high payment awards and potentially ineligible claims increase costs, while providers maintain that insurers frequently submit insufficient payment offers and delay required payments. Elevance Health reported that 69% of claims submitted for arbitration in its analysis were ineligible or improperly submitted, while CMS data cited by provider representatives showed that approximately 17% of disputes closed in 2025 were found ineligible.

3. Stakeholders Call for Reforms as Arbitration Disputes Continue to Grow: A coalition of 67 patient advocacy groups, employer organizations, and unions has urged Congress to address concerns about arbitration practices and their potential effects on insurance premiums. Proposed reforms include changing how dispute eligibility is determined, adjusting arbitrator compensation, and increasing penalties for insurers that fail to comply with payment requirements. With millions of disputes already entering arbitration and representing only a small fraction of potentially eligible cases, stakeholders anticipate continued growth in filings unless changes are implemented.

9 GLP-1 updates to know

By Ella Jeffries – New clinical findings, legal settlements and expanding use cases are shaping the GLP-1 landscape across oncology, pediatrics and addiction care. Here are nine GLP-1 updates to know. Read Full Article...

HVBA Article Summary

1. GLP-1s are being explored beyond weight loss and diabetes care: The article highlights off-label and emerging use cases, including a new telehealth addiction-care platform built around GLP-1 receptor agonists. It also points to oncology-related research presentations suggesting potential associations between GLP-1 use and breast cancer risk and outcomes. Together, these updates illustrate that clinical interest is expanding into new specialty areas, even as evidence quality varies by use case.

2. Regulatory and legal pressure is intensifying around compounded GLP-1 products and marketing claims:The FDA is monitoring a large volume of adverse event reports tied to compounded semaglutide and tirzepatide and continues to warn about misleading marketing and quality issues. In parallel, Novo Nordisk obtained a permanent injunction limiting certain marketing claims made by LifeRxMD about branded GLP-1 drugs in the context of compounded products, including required disclosures that the compounded versions are not FDA-approved for 12 months. Eli Lilly also escalated enforcement efforts by filing multiple lawsuits and making referrals to federal authorities regarding alleged sales of its investigational obesity drug retatrutide.

3. Pediatric access and prescribing trends are changing, with notable clinical and equity considerations: The piece describes a clinical trial in children under 12 that reported weight-loss outcomes without new safety concerns after 68 weeks, indicating active development and evaluation in younger populations. It also reports that GLP-1 prescribing among children ages 8 to 11 has increased sharply over time, while remaining uneven across communities by income. Separately, prescribing growth among adults with serious mental illness outpaced those without between 2018 and 2024, suggesting broader clinician adoption with some cautions noted for specific diagnoses.

PR STUNT: UnitedHealth’s Big Prior Authorization Cut

By Wendell Potter – UnitedHealthcare, the subsidiary of the massive parent company UnitedHealth Group, announced that it will eliminate prior authorization requirements for roughly 1,700 medical procedure codes beginning next month, a move the nation’s largest health insurer says will cut its prior authorization requirements by 30%. The changes reportedly will apply across its commercial, Medicare Advantage, Medicaid, individual exchange and Oxford plans. UnitedHealthcare says the move will reduce administrative work for doctors and remove barriers that can delay care for patients. Read Full Article...

HVBA Article Summary

1. Headline reduction vs. scope of impact: The piece argues the company’s “30%” figure can be misleading because it refers to a subset of services that were subject to prior authorization in the first place. It highlights UnitedHealthcare’s own framing that prior authorization applies to a small share of the medical services it covers, which makes the practical effect smaller than the headline suggests. The author’s broader point is that percentages can sound dramatic without clarifying the denominator. The article urges readers to look for clearer disclosures about how many services and members are actually affected.

2. Possible duplication inflating the “1,700 codes” claim: After reviewing UnitedHealthcare’s published code lists across multiple lines of business and state Medicaid lists, the author says there appears to be overlap and repetition. The article contends that identical codes may be listed multiple times across different plan categories and states, potentially inflating the total count when presented as “1,700.” It suggests the number of unique CPT/HCPCS codes impacted could be lower than the headline figure and calls for a deduplicated list to confirm. The takeaway is that transparency about the underlying list matters for evaluating the magnitude of the change.

3. Cuts may exclude the most contested prior-auth areas and coincide with new requirements: The author notes that while some listed removals could be meaningful, many included items are described as minor, rarely used, or broad “unlisted procedure” codes. The piece also points out that several high-profile areas in prior-authorization disputes—such as certain specialty drugs and device categories—are described as largely absent from the reduction lists. In addition, it highlights that UnitedHealthcare is simultaneously introducing new prior authorization requirements for some genetic/molecular testing codes and an oncology code on the same effective date. The overall message is that the change is not purely a one-way reduction in administrative hurdles.

When an acute behavioral health crisis hits, employees need better options

By Lee Hafner – Behavioral health issues such as depression and anxiety remain prevalent among Americans, but many lack access to intensive, timely care when their condition leads to a crisis. A 2025 study by Mental Health America revealed that 23.4% of adults — more than 60 million — had suffered from a mental illness within the previous 12 months. Another 48.4 million aged 12 and older met the criteria for a substance use disorder, as reported by the federal Substance Abuse and Mental Health Services Administration. More than 14 million reported having serious thoughts of suicide. Of every 100,000 ER visits in July this year, 5,347 were related to mental health, according to the Centers for Disease Control and Prevention.  Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Behavioral Health Crisis Centers Offer an Alternative to Emergency Rooms: Patients seeking psychiatric care in traditional emergency departments may face hours-long waits for assessment and one to three days of boarding before accessing inpatient treatment. Connections Health Solutions operates nine behavioral health crisis receiving centers nationwide and a mobile unit in Montana, providing walk-in care, crisis stabilization, and connections to longer-term recovery services. According to CEO Colin LeClair, approximately 65% of patients who meet inpatient admission criteria can be stabilized and discharged with a coordinated care plan within 24 hours, with initial access to a physician taking less than 30 minutes.

2. Specialized Crisis Care May Reduce Costs and Readmissions: LeClair estimates that a psychiatric crisis involving emergency department care, boarding, and inpatient treatment costs approximately $15,000 nationally, compared with roughly $4,000 for treatment at Connections. He also reports that the organization’s readmission rates are 30% to 40% better than those associated with traditional inpatient psychiatric care, although these figures reflect the organization’s reported experience. Connections accepts insured and uninsured patients experiencing mental health conditions, substance use disorders, or both, providing access to multidisciplinary psychiatric teams and coordinated follow-up services.

3. Employers Face Growing Demand for Acute Behavioral Healthcare: According to a 2026 Business Group on Health report, 73% of employers reported increased utilization of mental health and substance use services. While preventive care, outpatient treatment, and ongoing behavioral health support remain important components of employee benefits, LeClair emphasizes the need for employers to identify accessible treatment options for acute psychiatric crises. Incorporating specialized crisis care into benefit offerings could provide employees with an alternative to emergency departments while potentially reducing healthcare expenditures and improving continuity of care.

Blue Shield of California to expand Virtual Blue program in 2027

By Cailey Gleeson – Blue Shield of California announced Thursday that it plans to expand its Virtual Blue program, doubling program enrollment for members. Beginning in January 2027, the benefit will be included in fully insured preferred provider organization (PPO) plans for employers with 101 to 3,000 employees, as well as for certain individual and family plans, the insurer said. The expansion will allow an additional 200,000 mid-size employer PPO members and 60,000 individual and family plan members to utilize the program, increasing its total enrollment to more than 410,000 participants, executives say. The virtual-first program, first launched in 2023 in collaboration with Accolade and TeleMed2U, has more than 150,000 members as of April. Read Full Article...

HVBA Article Summary

1. Eligibility expands across more plan types: Starting in January 2027, Blue Shield of California plans to include Virtual Blue in fully insured PPO plans for employers with 101 to 3,000 employees and in certain individual and family plans. This broadens access beyond the program’s current footprint and targets mid-size employers in particular. The move suggests the insurer views virtual-first care as a scalable benefit option for multiple market segments. It also indicates the program is being positioned as a standard plan feature rather than a niche add-on.

2. Reported cost and utilization impacts are a central rationale: Blue Shield says the program’s utilization has been associated with a 7% to 10% lower overall cost of care and average employer savings of $468 per member annually. The insurer also reports emergency room visits dropped by more than 10% among Virtual Blue members. In addition, it says 60% of members reported they would have sought costlier care, such as the ER, without the plan. These figures are presented as evidence that virtual-first access can shift where and how members seek care.

3. Member experience and care coordination are emphasized: Chief Marketing and Strategy Officer Jigar Shah said the expansion was driven by member feedback and internal data. He framed the program’s goal as making care more convenient while creating a more connected, coordinated experience when members need labs, specialists or in-person visits. Shah also reported “really high satisfaction rates” of around 90% for Virtual Blue visits. The comments reflect an effort to address fragmented care navigation as part of the value proposition.

More than half of young workers want to switch jobs soon for better pay, benefits

By Ginger Christ – Generation Z is on the job hunt. In fact, 55% of the more than 440 Gen Z workers surveyed said they intended to look for a new role before the end of the year, compared to less than a third who said the same a year ago, according to a report released Wednesday by consulting firm Robert Half. Among those, 56% said they are in search of better perks and benefits, and half said their career advancement is currently limited. And 53% said they think landing a job with a new employer could increase their earnings. Compensation and financial benefits remain top of mind across generations as workers juggle inflation and higher healthcare costs. Read Full Article...

HVBA Article Summary

1. Gen Z job-search intent is rising sharply: The report indicates that a majority of surveyed Gen Z workers plan to search for a new role before the end of the year. It also notes this is a marked increase compared with the share who said the same a year earlier. The piece frames this as a sign that job hopping is becoming more common among younger workers. Robert Half positions pay and benefits as central drivers behind the interest in changing jobs.

2. Benefits and growth opportunities factor into decisions: The article says Gen Z evaluates a wide range of offerings when considering whether to accept a job. Those include insurance coverage, commuter benefits, meals, scheduling flexibility, learning opportunities and retirement savings options. It also reports that many young workers feel their career advancement is limited in their current roles. The combined emphasis suggests employers may need to address both total rewards and visible career paths to improve retention.

3. Employer compensation planning faces competing pressures: The story cites compensation planning survey results pointing to projected base and total salary increases in 2027. It also notes that many organizations use promotions and off-cycle adjustments as tools for development, competitiveness and hiring. Separately, it reports that rising healthcare costs can force employers to make tradeoffs with wage and salary increases. Taken together, the article highlights how benefit-cost inflation may constrain pay strategies even as workers prioritize compensation.

High Semaglutide Dropout Rates Signal Adherence Challenge

By Kelley Butler – Nearly half of adults who began taking semaglutide for obesity stopped treatment within a year, a large Danish study found. Higher rates of discontinuation were observed among adults younger than 30 years, men, and those with histories of using gastrointestinal or psychiatric medication. The findings, published online on August 28 in JAMA Network Open, add to growing evidence that adherence to GLP-1 medications is a major challenge in the treatment of obesity. Because maintaining weight loss with drugs such as semaglutide may require long-term therapy, understanding which patients are more likely to pause or discontinue could help clinicians provide better counsel and support before and after prescribing. Read Full Article...

HVBA Article Summary

1. Large real-world Danish cohort shows substantial discontinuation: The study used Danish registry data to follow 157,822 adults who started semaglutide for obesity between 2022 and 2024 and did not have diabetes. Using a definition of discontinuation as the end of a prescription followed by at least a 60-day gap, nearly half discontinued within 1 year. When the gap threshold was shortened to 30 days, discontinuation increased to 58%. The authors note the analysis accounted for lower dosing and suboptimal adherence, aiming to reflect real-world use.

2. Discontinuation patterns vary by demographics and prior medication history: The 12-month discontinuation risk was at least 41% across all subgroups examined, indicating no clearly “low-risk” group for stopping therapy. Relative risk of discontinuation was higher among adults younger than 30 years compared with those aged 45-59 years, and higher among men compared with women. Prior use of psychiatric medications and gastrointestinal medications was also associated with increased discontinuation risk. In contrast, prior bariatric surgery was linked to a lower risk of discontinuation (risk ratio 0.89, 95% CI 0.86-0.93).

3. Stopping was often not permanent, and clinicians emphasize support strategies: Among those who discontinued semaglutide, nearly one in four restarted within 3 months, suggesting interruptions may be common. Only small percentages switched to other obesity medications, including liraglutide (1.4%) and tirzepatide (0.7%). The article highlights clinician strategies intended to improve persistence, such as setting expectations for long-term therapy, individualized plans for activity and nutrition, and close follow-up around titration, tolerability, mood, sleep, and cost. Managing gastrointestinal side effects through counseling on meal size, timing, and food choices is presented as one practical approach to supporting continued use.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

The Era of Passive Health Plan Oversight Is Ending

By Jake Velie – Employers are getting squeezed from every direction on healthcare costs. That part is not new. What is changing is how they are starting to respond.¹ ² For years, many plan sponsors treated high-cost healthcare as something to review after the fact. They got the renewal. They looked at the trend. They asked a few questions. Then they assumed the vendor stack had it covered. That approach is breaking down. Read Full Article...

HVBA Article Summary

1. Employers are shifting from reactive renewals to active oversight: The piece argues that many plan sponsors historically reviewed costs only after renewals, asked limited questions, and relied on vendors to manage complexity. It says that model is now “breaking down,” prompting employers to scrutinize decisions earlier and more directly. The author frames this as a change in how employers respond to rising healthcare pressure, not merely an increase in costs. The overall message is that passive review is being replaced by more intentional governance and decision-making.

2. Fiduciary and compliance expectations are becoming central to benefits strategy: The article says the conversation is becoming more explicit about fiduciary duty, including implementing CAA provisions and aligning processes with ERISA requirements. It presents this as a move from a pure cost-management discussion to a broader governance conversation. The author implies that employers are being pushed to formalize stronger processes and accountability in how plans are overseen. In that framing, documenting prudent decision-making becomes as important as managing spend.

3. Fragmentation and concentrated risk are driving demand for more accountable partners: The author describes a fragmented ecosystem where PBMs, TPAs, and brokers each manage parts of the system, leaving employers to “connect the dots” after costs have already occurred. The article cites external analysis that a small share of claimants drives a large share of costs and argues this makes passive oversight untenable. It also points to specialty-drug dynamics as intensifying the need to challenge default pathways before claims are paid. The proposed direction is toward specialized partners who can bridge administration and outcomes and take clearer accountability.

Benefits Committee Fiduciary Best Practices

By PlanSponsor Staff – Yes. Perhaps the most important best practice is recognizing that overseeing an Employee Retirement Income Security Act health plan is not simply a human resources or benefits function; it involves fiduciary responsibilities. While employers can delegate certain functions to brokers, consultants, third-party administrators, pharmacy benefit managers and other service providers, they cannot delegate away their responsibility to prudently select and monitor those providers. Read Full Article...

HVBA Article Summary

1. Treat health plan oversight as a fiduciary function: The article emphasizes that ERISA health plan oversight involves fiduciary duties rather than being only an HR or benefits administration task. It notes that employers may delegate operational work to outside vendors, but not the responsibility to choose and oversee those vendors prudently. This framing is presented as a foundational “best practice” for benefits committees. It also implies committees should organize their work around fiduciary standards like prudence and loyalty.

2. Establish governance, training, and document control early: A recommended starting point is forming a dedicated committee, adopting a written charter, and providing fiduciary training to members. The piece also stresses collecting and reviewing key plan documents, contracts, and required disclosures so decision-makers understand what has been agreed to and how the plan functions. It highlights the risk of relying on brokers or vendors without fully understanding underlying agreements. This approach is presented as a way to make oversight more systematic and defensible.

3. Use ongoing vendor monitoring, data analysis, and compliance routines: The article advises that vendor oversight should continue beyond renewals, including reviewing compensation disclosures, checking contracts for restrictions (such as gag clauses), and periodically benchmarking or running RFP/RFI processes. It also calls for obtaining claims, pharmacy, and utilization data, using it to evaluate performance, and documenting decisions and follow-up actions based on the data. In addition, it recommends maintaining a compliance calendar for recurring requirements (e.g., Form 5500, RxDC reporting, mental health parity, and participant disclosures). The overall message is that a repeatable process and documentation are central to fiduciary prudence.

Rising healthcare costs force employers to rethink coverage strategies

By Robin Johnson – As employers begin to evaluate benefit plans for 2027, many confront a difficult challenge: Healthcare costs continue to outpace wage growth and business budgets alike. Medical trend projections remain elevated as prescription drug spending climbs, behavioral health utilization increases and demand for high-cost specialty medications grows. At the same time, many workers are already struggling with higher deductibles and greater out-of-pocket exposure. Read Full Article...

HVBA Article Summary

1. Employers are reassessing how to offer affordable coverage: The article frames 2027 planning as a period where employers face rising healthcare expenses alongside constrained budgets. It describes how familiar cost-containment steps like higher deductibles, increased employee contributions, or less generous plan designs can reduce premiums but shift more financial exposure to workers. It also notes that this shift can lead employees to delay care or prescriptions, creating downstream health and productivity concerns. The piece presents this as a driver for exploring options beyond traditional major medical coverage.

2. Alternative benefit structures are gaining attention for certain workforces: The article highlights that industries with many hourly, seasonal, part-time, or variable-hour employees often have fluctuating eligibility and compliance challenges. It says interest is growing in pairing minimum essential coverage (MEC) for ACA-required preventive services with fixed-indemnity benefits that pay preset cash amounts for specific services. This combination is presented as potentially lower cost for employers while still offering employees a form of healthcare benefit access. The article positions these models as more practical in some environments than standard major medical plans.

3. Predictability, compliance, and advisor guidance are central themes: The piece contrasts major medical designs that rely on deductibles and coinsurance with fixed-indemnity designs that can provide scheduled benefits earlier and more predictably. It notes these arrangements are often guaranteed-issue and may avoid pre-existing condition exclusions, which can simplify access after enrollment, while also emphasizing they are not meant to replicate comprehensive major medical insurance. It stresses that ACA compliance remains critical, especially for employers managing variable-hour populations and affordability calculations. The article also argues that brokers and consultants are increasingly expected to advise on workforce-specific, compliant strategies rather than focusing only on renewal price.

CHOICE plan administrator raises $108M, emerges with $1B valuation

By Allison Bell – Thatch — a cash-for-coverage plan administrator — reported Tuesday that it has raised $108 million in capital by selling stakes to big investors. The San Francisco-based company estimated that the capital raise gives the company a total estimated market value of about $1 billion. The investor group includes venture capital firms like the General Partnership, Index Ventures, General Catalyst and Andreessen Horowitz. The investor group also includes at least two big payroll services companies: ADP's ADP Ventures arm and Paychex. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Funding round and investor mix: Thatch said it raised $108 million by selling equity to a group that spans both venture capital and payroll-services investors. Named VC backers in the article include General Partnership, Index Ventures, General Catalyst, and Andreessen Horowitz. The company also said payroll firms ADP (via ADP Ventures) and Paychex are part of the investor group. Thatch estimated the financing implies an overall company valuation of about $1 billion.

2. What Thatch offers employers and how it charges: Thatch supports employers running QSEHRA plans and custom “CHOICE plan”/individual care expense arrangements that provide employees cash to purchase individual or family major medical coverage. The company also positions itself as a worksite channel for supplemental benefits products, citing examples such as fertility benefits and weight management plans. For a standard plan covering 1 to 49 eligible employees, Thatch lists pricing of $45 per month per employee plus a $50 compliance fee. The company said it serves about 5,000 employers.

3. Market context and policy developments: The article notes that reliable, comprehensive data on enrollment in cash-for-coverage plans remains limited. It cites an estimate from the HRA Council that employers might be offering the arrangements to 500,000 people, while also pointing out continued insurer support from Centene and Oscar Health. Several states—Connecticut, Indiana, and Mississippi—are providing tax credits for plan sponsors, and Connecticut is referenced in a related story about a $1,000-per-employee credit. The article also says Trump administration officials encouraged employers to consider the strategy and rebranded “ICHRA” as “CHOICE plan.”

Humana study links pharmacy care coordination to lower costs, fewer hospitalizations for cancer patients

By Heather Landi – Humana researchers found that cancer patients who received specialty pharmacy care coordination services had fewer hospitalizations and emergency department visits, along with lower medical costs. The study, conducted by Humana Pharmacy Analytics and Consulting, analyzed health outcomes for people with cancer who are Humana Medicare Advantage members with Part D prescription plan coverage and who received medication adherence care coordination guidance, as compared to those who opted out of coordination. Humana’s CenterWell Specialty Pharmacy Oncology Center of Excellence (COE) provided the care coordination services over the course of one year. That COE program provides specialized, personalized clinical care and mail-order delivery for patients managing complex cancer diagnoses and therapies. Within CenterWell, Humana’s health care services organization, CenterWell Pharmacy serves many Humana members as a mail-order pharmacy and also serves patients who are not enrolled in a Humana plan. Read Full Article...

HVBA Article Summary

1. Study design and population: Humana Pharmacy Analytics and Consulting conducted a retrospective, observational analysis comparing outcomes for Humana Medicare Advantage members with Part D coverage who did versus did not receive medication adherence-focused care coordination. The care coordination was delivered through Humana’s CenterWell Specialty Pharmacy Oncology Center of Excellence over a one-year period. The analysis focused on people with cancer and evaluated utilization and cost outcomes tied to the care-coordination approach.

2. Outcomes associated with pharmacy-led coordination: The analysis reported that pharmacy-led care coordination services were associated with fewer hospitalizations and emergency department visits, alongside lower medical costs. The reported differences were measured as percentage reductions in utilization and costs for those who received coordination compared to those who opted out. The study also noted that results were consistent across demographic categories and geographic regions, suggesting the association held across subgroups examined.

3. Program details and publication context: The CenterWell Specialty Pharmacy COE model described in the article includes specialized clinical support and mail-order delivery for patients managing complex cancer therapies. COE care coordination is described as an optional Part D benefit supported by pharmacists, nurses and specialists, and includes follow-up, adherence support and side-effect monitoring. The research was published in Expert Review of Pharmacoeconomics & Outcomes Research, providing a peer-reviewed venue for the findings.

40% of Americans believe Medicare will pay for LTC

By Susan Rupe – Nearly 40% of middle-class Americans said they plan to use Medicare to cover their future long-term care expenses – even though Medicare doesn’t cover LTC. In addition, nearly a quarter of Americans haven’t even considered how they will pay for LTC, meaning that more than 60% of Americans are financially unprepared for health challenges as they age. Those were among the highlights of the American Council of Life Insurers’ latest Financial Resilience Index. Read Full Article...

HVBA Article Summary

1. Industry says awareness and education are needed: ACLI President and CEO David Chavern argues the life insurance industry needs to talk more directly about long-term care planning and clarify what products are available. He frames this as both a communications challenge and a product-understanding gap for consumers. His comments suggest the industry sees an opportunity to reduce confusion and encourage earlier planning. The article presents these points as guidance for how insurers can address consumers’ worries about aging-related care costs.

2. Near-term household cost worries are broad, with transportation rising: The survey indicates middle-class households are most worried about paying for daily essentials (46%), healthcare services (40%), and transportation (36%) over the next year. Transportation concerns increased from 26% to 36% compared with the prior year. The article also notes healthcare affordability concerns grow with age. It highlights a notable gap between Gen Z and millennials, with slightly more than a quarter of Gen Z concerned versus nearly two-fifths of millennials.

3. Financial resilience weakened in Q2 2026 amid wages and inflation dynamics: ACLI’s quarterly Financial Resilience Index tracks 26 variables split between cost pressures (e.g., housing, gas, childcare) and household resources (e.g., income, credit access, retirement assets). The Q2 2026 Headline Index fell 10 points from Q1 to Q2 2026, though it remained at +10, described as modestly positive relative to historical norms. The article attributes the decline to slowing wage growth and persistent inflation. It adds that inflation has outpaced wage growth since April, which the index analysis links to the Q2 drop.

Express Scripts targeted by Arkansas pharmacies in first-of-its-kind lawsuit

By Rebecca Pifer Parduhn – Under Arkansas law, PBMs aren’t allowed to reimburse pharmacies less than their cost of acquiring a drug, measured by a metric called the National Average Drug Acquisition Cost, or NADAC. NADAC is maintained by the federal government, and easily accessible by PBMs like Express Scripts — as are details like drug cost, quantity and fill date, everything the middlemen need to apply proper pricing when a drug is dispensed, according to the complaint filed Tuesday in Missouri circuit court. But Express Scripts still reimburses pharmacies well below the NADAC, the lawsuit alleges, forcing them to absorb the revenue shortfalls or invest valuable time and resources to appeal improper payments. Read Full Article...

HVBA Article Summary

1. First lawsuit using Arkansas’ new enforcement mechanism: Twelve independent pharmacies say Express Scripts underpaid them for tens of thousands of prescriptions, and they are seeking substantial damages. According to the plaintiffs’ lawyers, the case is the first brought under a state law passed last year that lets pharmacies sue PBMs for reimbursing below drug acquisition cost. The suit argues the alleged underpayments are not isolated errors but reflect how claims are adjudicated. Express Scripts, through a spokesperson, said it will defend itself and that it reimburses pharmacies at competitive rates.

2. Dispute centers on NADAC-based reimbursement standards: The complaint frames NADAC as the benchmark Arkansas uses to define whether reimbursement is below a pharmacy’s acquisition cost. It alleges PBMs have access to the necessary inputs (like drug cost, quantity and fill date) to apply compliant pricing when a prescription is dispensed. The pharmacies contend they were paid below NADAC repeatedly, leaving them to absorb shortfalls or spend time appealing. The filing characterizes the issue as a deliberate business choice rather than a technology or data limitation.

3. Broader PBM scrutiny and state-level regulation backdrop: The article notes the PBM market is highly concentrated, with three firms controlling 80% of U.S. prescriptions, which has fueled concerns about market power and pharmacy reimbursement practices. It cites FTC research alleging affiliated pharmacies may receive preferential treatment, though PBMs deny that characterization. Arkansas has taken multiple steps to regulate PBMs, including bulletins clarifying reimbursement rules and efforts to pursue per-prescription penalties from violators. The state has also pursued other first-in-kind PBM restrictions, some of which have been challenged in court.

Do Statins Still Matter in the GLP-1 Era?

By Ryner Lai – " Metabolic syndrome" — a cluster of obesity, insulin resistance, hypertension, and lipid abnormalities — long positioned obesity as one contributor to a broader web of cardiovascular risk. Statins became the cornerstone of preventive cardiology decades ago, lowering low-density lipoprotein (LDL) cholesterol and cutting cardiovascular events after entering widespread use. More recently, GLP-1 receptor agonists have shifted the conversation toward obesity and weight loss itself — somewhat detached from that broader metabolic syndrome framework. Media coverage of GLP-1 drugs has increasingly focused on their potential as transformative weight-loss treatments, with the drugs becoming unusually prominent in public discussions of metabolic health. Read Full Article...

HVBA Article Summary

1. Statins’ evidence base remains strong as GLP-1 use grows: The article reviews longstanding trial evidence supporting statins’ role in lowering LDL cholesterol and reducing major cardiovascular outcomes. It also highlights a 2026 randomized study comparing atorvastatin with placebo that reported fewer cardiovascular events in the statin arm after a median 5.9 years of follow-up. Expert commentary in the piece argues that, for patients at elevated cardiovascular risk—especially those with high cholesterol—statins are still expected to remain central to prevention. The overall framing is that GLP-1 therapies have expanded options, but they have not eliminated the need for lipid-lowering therapy.

2. GLP-1 therapies show cardiovascular benefit, but target different mechanisms: The story summarizes evidence that GLP-1–based therapies can reduce cardiovascular events, including a 2023 semaglutide trial in patients with established cardiovascular disease and overweight/obesity without diabetes. It also notes the FDA’s August 2026 approval of tirzepatide for reducing major cardiovascular events in adults with type 2 diabetes at high risk. Clinicians quoted emphasize that these benefits are additive to, rather than substitutes for, LDL-focused risk reduction in many patients. The article presents GLP-1 drugs as primarily weight- and glycemia-oriented treatments with overlapping—but not identical—cardiovascular prevention roles compared with statins.

3. Risk assessment and patient preferences complicate real-world prescribing: The article describes how rising demand for GLP-1 drugs is influencing clinical conversations, with patients sometimes favoring GLP-1s because of substantial weight-loss expectations and concerns about statin side effects. It contrasts the side-effect profiles of statins (eg, diabetes risk, liver enzyme elevations, muscle symptoms) with GLP-1 adverse effects that commonly include gastrointestinal symptoms. To guide decisions beyond weight change alone, one clinician recommends using tools like the AHA’s PREVENT equations to estimate cardiovascular risk and inform lipid-lowering therapy choices. The piece also notes that 2026 guidelines recommend initiating statin therapy and cardiovascular risk assessment earlier (beginning at age 30), potentially expanding the pool of younger high-risk patients identified for treatment.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

HHS official Klomp spars with Warren over drug pricing contracts

By Max Bayer – Top HHS official Chris Klomp had a relatively mild nomination hearing with senators on Tuesday, but he sparred with Sen. Elizabeth Warren (D-MA) over voluntary agreements with large drugmakers and what exactly the details of those agreements were. Speaking to members of the Senate Finance Committee as part of his nomination to be HHS deputy secretary, Klomp defended the Trump administration’s “most favored nation” pricing deals with pharmaceutical companies. Warren specifically asked for the exact contracts to be released, which Klomp suggested wasn’t likely to happen soon. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Questions About Drug Pricing Agreements: Senator Elizabeth Warren called for the release of government contracts with pharmaceutical companies to provide greater clarity on the terms and financial impact of negotiated drug pricing deals. She cited disclosures from Incyte and larger drugmakers indicating that the agreements were not expected to materially affect their businesses, suggesting that company profits would remain largely intact. Those disclosures prompted questions about the extent of manufacturers’ pricing concessions and how the agreements would translate into savings for patients and government programs.

2. Confidentiality During Ongoing Negotiations: Klomp argued that disclosing detailed contract terms could jeopardize ongoing drug pricing negotiations and complicate efforts to secure additional agreements. The White House and CMS have said they are negotiating with more pharmaceutical companies, alongside the administration’s broader effort to encourage other countries to pay more for medications. The exchange highlighted competing considerations around public access to pricing information and preserving confidentiality while negotiations remain underway.

3. Debate Over Disclosure Commitments: Warren referenced HHS Secretary Robert F. Kennedy Jr.’s April commitment to make the agreements available while withholding proprietary information and trade secrets. She questioned whether Klomp’s reluctance to release contract details represented a departure from that commitment and pressed for greater transparency. Limited access to the agreements leaves the public with fewer details to independently assess their pricing provisions, manufacturer obligations, and potential savings.

Enough with the Blank Checks

By Moving to Value Alliance – With U.S. healthcare costs hitting $5.7 trillion — more than $15,000 per person per year — employers are feeling the heat. Now is the time to demand payment reform from a system that assumes employers will pay double-digit premium increases because they have no choice. But employers, you have a choice. And in many cases, you have an obligation to scrutinize broker contracts and fight for the best plan for your population. Read Full Article...

HVBA Article Summary

1. A phased roadmap for employer-led health plan oversight: The article lays out a 24-month sequence that starts with governance and legal protections, then moves into contract restructuring, active procurement, and broader “ecosystem” changes. It frames healthcare spending as something employers can manage through structured purchasing practices rather than accepting renewals as inevitable. The phases are time-boxed (months 1–3 through months 16–24) to encourage prioritization and execution. The approach emphasizes treating plan management like an ongoing procurement function with defined milestones.

2. Transparency and contract terms are positioned as major levers: The roadmap calls for explicit rights to claim-level data, clinical records, and itemized billing in renewal contracts, and argues against limitations like gag clauses. It also urges review of administrative services agreements to uncover and remove hidden revenue mechanisms and fees. Pharmacy benefit and TPA arrangements are highlighted as areas where pass-through structures and auditability can change incentives and reduce opaque spreads. The overall thrust is to make vendor compensation and performance measurable and contractually enforceable.

3. Compliance and risk management are central themes: Early steps focus on forming a fiduciary committee and using counsel-led reviews to create legal privilege while examining legacy arrangements. The article also references required vendor compensation reviews tied to the Consolidated Appropriations Act framework, aiming to ensure compensation is evaluated for reasonableness. It suggests that stronger governance and documentation can reduce organizational and personal exposure under ERISA. Later steps extend this risk lens to stop-loss purchasing and to auditing practices that may inflate costs, such as upcoding.

US uninsured rate holds at 7.9% for 2025 — before the ACA subsidy cliff hits

By Stephen Owens – The Census Bureau's annual scorecard on how Americans are faring was released earlier today, and for health insurers, brokers and benefits advisers, the headline number is a strange kind of good news: the share of Americans without coverage held almost steady last year. According to the Census Bureau's Current Population Survey Annual Social and Economic Supplement, 26.7 million people, or 7.9% of the population, went without health insurance at some point in 2025. That's not a statistically meaningful shift from 2024, when 27.1 million people, or 8.0%, were uninsured, and the bureau said the rate remains near its historic lows. Read Full Article...

HVBA Article Summary

1. Coverage and poverty indicators improved in the 2025 snapshot: The same Census release reported the official poverty rate at 10.2%, described as the lowest level since the bureau began tracking it, alongside a second straight annual decline in the number of people in poverty. Median household income was reported as $87,460, with a 2.6% inflation-adjusted increase, suggesting purchasing power rose compared with the prior year. The article frames these measures as relevant to insurers because income levels and coverage rates influence plan affordability and the composition of risk pools.

2. Enhanced ACA tax credits ending changes the meaning of the 2025 uninsured rate: The article emphasizes that the CPS ASEC data reflect calendar year 2025, which was before enhanced premium tax credits for Affordable Care Act marketplace plans expired at the end of that year. It notes those subsidies had reduced costs for roughly 22 million enrollees, and cites KFF in reporting that average premiums for subsidized marketplace shoppers increased from $888 to $1,904 per year after the credits lapsed. As a result, the piece argues the 2025 uninsured rate is better interpreted as a low point rather than an expectation for subsequent years.

3. Insurers and employers are watching for shifts in where people get coverage: The article cites projections from the Urban Institute and the Commonwealth Fund that the subsidy expiration could lead to coverage losses, and it also mentions potential movement into employer-sponsored plans as individual-market premiums rise. It adds that the Census release did not yet include the full 2025 breakdown by coverage type at publication time, making upcoming detailed tables especially important for tracking direct-purchase coverage trends. The piece also flags small employers as a pressure point, arguing brokers may see more workers seeking employer coverage as marketplace plans become less affordable.

Only 46% of Gen Z, Millennial health plan members trust payers: Accenture survey

By Cailey Gleeson – Member trust in insurers is on the decline among Gen Z and Millennials, down 10.5% between 2023 and 2026, new research from Accenture found. This trust gap, according to analysts, could cost $3 billion in future member lifetime value for the largest commercial payers over the next decade. “When members don’t trust their health plan, they don’t just disengage; they route around it,” said Bracken Flynn, Accenture’s Health industry principal director, in a statement. “Our data shows that younger consumers aren’t asking for less from their insurer. They want more. They’re looking for a partner that helps them navigate care, understand costs, and make confident decisions. The insurers that earn that trust now will define what health coverage means for the next generation.” Read Full Article...

HVBA Article Summary

1. Trust is tied to perceived help navigating care and decisions: Accenture’s analysts described member trust as stemming from whether people believe their health plan will help them make good healthcare decisions and guide them to the best care. Bracken Flynn framed this as spanning both clinical and administrative “touchpoints,” emphasizing an ongoing partnership rather than a one-time transaction. The implication is that service design and day-to-day interactions can shape trust as much as pricing or benefits alone.

2. Younger members are using AI tools to make plan choices: The report cited that 62% of respondents have used artificial intelligence tools to help choose a health plan. Flynn argued that trust needs to come first, saying “Trust is the precondition for AI, not the other way around.” This positions AI as a channel that may amplify existing trust issues rather than automatically solving them.

3. Comfort with AI-powered services varies sharply by trust level: Flynn said that among younger members who trust their insurer, 69% are comfortable with AI-powered health plan services, compared with 16% among those who do not trust their insurer. He characterized this as the same technology producing very different reactions depending on whether trust already exists. The takeaway for insurers is that adoption of AI features may depend heavily on broader credibility and relationship-building efforts.

Growth of GLP-1 therapies has reshaped the market

By Denise Myshko – Nearly half of the growth in prescription drug sales now can be attributed to GLP-1 therapies. On the diabetes side, GLP-1s, including Mounjaro and Ozempic, make up a $98 billion market, with a 16.5% growth on a year-over-year basis. GLP-1 therapies for weight loss, including Zepbound and Wegovy, saw a 75% year-over-year growth and generated $55 billion in sales in the last 12 months, which is up from $2 million in 2022, said Scott Biggs, director of supplier services at IQVIA at the keynote at the Pharmacy Benefit Management Institute annual meeting in Orlando. Read Full Article...

HVBA Article Summary

1. Independent pharmacies are changing their approach to dispensing GLP-1s: The article describes how retailers—particularly independent pharmacies—are more deliberately weighing whether to dispense GLP-1 prescriptions based on economics. It reports that fewer independents are declining to fill GLP-1 prescriptions than a year earlier, with different refusal levels for weight-loss versus diabetes products. This suggests pharmacies are actively adapting their business decisions as demand and reimbursement dynamics evolve. The shift also implies patient access may increasingly depend on where prescriptions are routed and which channels are willing to dispense them.

2. Dispensing channels remain retail-focused but are diversifying: The piece says retail pharmacies still account for about 80% of GLP-1 dispensing, keeping them the main point of distribution. At the same time, it notes growth in mail delivery as direct-to-consumer options gain traction. The article provides a current mail-share figure that indicates this channel is becoming more material, even if still secondary to retail. Overall, it portrays distribution as stable in its center of gravity but gradually expanding beyond traditional retail pickup.

3. GLP-1 growth is influencing diabetes treatment mix and future development priorities: The article links GLP-1 expansion to a slowdown in insulin’s role within the diabetes market, indicating substitution effects in both sales and prescription volume. It also highlights emerging demand tied to Medicare Part D’s Bridge program and offers an early claim-volume snapshot from its initial days. Beyond current use, the article outlines a large R&D pipeline (about 200 molecules) exploring additional indications such as mental health, substance use disorders, cancer risk, women’s health, and systemic inflammation. It additionally notes near-term development aims like reducing side effects, improving tolerability, and preserving muscle mass while achieving greater weight loss.

To cut healthcare costs, employers are doing their own negotiating

By Jimmy Nesbitt – For years, employers have largely relied on insurers and third-party networks to negotiate healthcare prices and manage their employees’ care. But as healthcare costs continue to climb, some benefit leaders are asking a different question: What if they negotiated more directly with the people providing the care? With healthcare costs projected to rise by as much as 9% in 2027, more large employers are looking beyond traditional health-plan networks and contracting directly with hospitals and healthcare providers. According to KFF’s 2025 Employer Health Benefits Survey, 18% of employers with 5,000 or more employees had direct contracts with hospitals or health systems in 2025, up from 9% in 2019. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Potential Savings Through Targeted Provider Agreements: Direct contracting may help employers manage spending in high-cost service categories such as musculoskeletal care, oncology, and cardiology by negotiating directly with providers on pricing and quality expectations. Bundled payments establish a single price for an episode of care, while direct primary care may support early intervention and reduce avoidable emergency department visits and hospitalizations. These arrangements can also allow employers to link reimbursement to outcomes, patient satisfaction, and evidence-based care while gaining access to claims and performance data.

2. Plan Design and Navigation Support Employee Participation: Employers can encourage employees to use directly contracted providers through lower copays, waived deductibles, and care navigation services. Dedicated coordinators or digital tools can help employees understand their options and access participating providers. Clear communication about quality, convenience, and potential out-of-pocket savings may support participation without making employees feel restricted.

3. Expansion Requires Infrastructure and Data Analysis: Direct contracting can require substantial legal, actuarial, operational, and data integration resources, particularly across multiple locations and service categories. Provider willingness varies by market, and employers may use organizations known as conveners to manage provider relationships and consolidate reporting. Before expanding, benefit leaders should identify the conditions, procedures, and geographic areas driving spending and assess where gaps in care quality exist.

State regulator sounds alarm on 'limited partner' health plans

By Allison Bell – Marketers may be selling more self-insured limited partner health plans to consumers who are seeking relief from soaring major medical insurance prices. At least 12 companies are now offering the plans in Montana, according to an advisory posted earlier this month by Montana insurance regulators. Connecticut insurance regulators counted six marketers of the limited partner plans operating in their state two years ago. A limited partner charges individual consumers for classifying the consumers as employees or limited partners of a company. The consumers face few or no work responsibilities at the company. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Consumer protection concerns and coverage limits: Montana regulators report receiving complaints from residents who thought they bought solid health insurance through limited partner arrangements but later saw medical claims denied. State officials warn that some of these plans may focus mainly on preventive services, which can leave people exposed to large bills for other care. The advisory frames low advertised premiums as a key marketing hook while emphasizing that uncovered expenses can raise out-of-pocket costs. Regulators are urging consumers to contact the state to better understand what they are buying before enrolling.

2. Regulatory ambiguity and oversight challenges: The article describes how limited partner plans are marketed as self-insured coverage backed by stop-loss insurance and presented as falling under federal oversight rather than state insurance regulation. State regulators say they can struggle to verify whether marketers truly have self-insurance arrangements and stop-loss coverage because of limited access to information. A U.S. Department of Labor EBSA letter ruling dated Jan. 24, 2020, is cited as stating EBSA did not view a limited partner arrangement as a self-insured ERISA plan. This creates uncertainty about which rules apply and how consumers are protected when disputes arise.

3. Market dynamics tied to ACA rules and potential policy responses: The piece links interest in these products to the cost of individual major medical insurance, with some consumers seeking alternatives outside Affordable Care Act requirements. It notes arguments from major medical issuers and many regulators that alternative products could worsen the ACA market through adverse selection if healthier people exit comprehensive coverage. Supporters of non-ACA alternatives counter that ACA-compliant options can involve high premiums and restrictive networks, and they present low-cost alternatives as competition. The article suggests rapid growth in limited partner plan sales could increase pressure on Congress to authorize association health plans open to individuals with added oversight.

AI is now leading driver of new cybersecurity spending

By David Jones – Artificial intelligence is now the leading driver behind new investment into cybersecurity budgets, according to a report released Tuesday from IANS and Artico Search. About seven of every 10 chief information security officers surveyed said AI was their top priority for new cybersecurity spending. Two specific areas for AI-related spending shown in the report include automating security operations and enhancing identity and access management. Overall security spending rose 5% in the current survey, which is barely ahead of the 4% spending increase in the year-ago report. AI spending priorities come at a time of relatively modest growth in overall security spending. Read Full Article...

HVBA Article Summary

1. AI is becoming the primary catalyst for incremental security budget allocations: The report positions AI-related initiatives as the most common reason organizations are adding new cybersecurity spend. It highlights that leaders are directing this spending toward practical applications rather than purely experimental efforts. Examples cited include using AI to streamline security operations and to strengthen identity and access management. This suggests organizations are trying to embed AI into core security workflows where it can measurably improve speed and scale.

2. Security leaders expect AI to reshape teams without widespread job cuts: The findings indicate many CISOs view AI as a productivity enabler over time, rather than an immediate substitute for security staff. The survey results show expectations that AI will drive demand for new roles and new skills, even as it automates parts of day-to-day work. It also notes that most respondents do not anticipate reducing headcount because of AI. Overall, the report frames AI as a workforce transformation and upskilling issue more than a downsizing trigger.

3. AI is influencing both defensive capabilities and attacker tradecraft: The article describes organizations using AI to improve vulnerability discovery and to accelerate threat detection and response. At the same time, it notes that criminal and state-linked actors are also adopting AI to increase the speed and reach of attacks, referencing prior coverage on the topic. This dual-use dynamic implies defenders may feel pressure to invest simply to keep pace with adversaries’ evolving capabilities. As AI adoption broadens, security strategy is increasingly tied to how quickly teams can operationalize AI responsibly and effectively.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

Washington Wants AI Regulation. It Should Start With Health Insurers.

By Wendell Potter – Barack Obama spent an hour last week telling House Minority Leader Hakeem Jeffries and a room of Democratic donors that artificial intelligence is “moving very fast in private hands” and that the party needs a real plan before it gets away from them entirely. He said a public framework on AI safety was urgently needed and that Democrats should make AI safety a “central agenda” in January when the next Congress is sworn in and when attention begins to shift to the 2028 elections. Read Full Article...

HVBA Article Summary

1. Federal AI policy may miss a high-stakes use case already in practice: The article argues that insurers are already using algorithms and automated tools to shape coverage and access-to-care decisions. It contends that a national AI framework should explicitly address health insurance, rather than focusing only on broader concerns like jobs, misinformation, or abstract safety risks. The author frames this as an oversight problem because coverage decisions can have immediate consequences for patients. The piece calls for guardrails tailored to “high-stakes, industry-specific decisions,” not just general AI standards.

2. UnitedHealth’s AI spending is presented as both operational and financial strategy: The article describes UnitedHealth telling investors it plans to spend $1.5 billion on AI in 2026 and projecting a “conservative” 2-to-1 return within 12 to 18 months. It distinguishes between AI investments intended to create products to sell and investments aimed at internal processes like prior authorization and claims handling. The author notes that speed improvements (such as faster approvals) are framed positively, but also links investor messaging about AI to reduced medical spending. The piece suggests that when AI is credited for lowering medical-care outlays, patients may experience more denials alongside faster processing.

3. Lawsuits and state actions are cited as early tests of accountability: The article points to ongoing lawsuits involving UnitedHealth, Humana, and Cigna over tools used in coverage determinations, arguing that plaintiffs allege software replaced promised individualized medical review. It highlights reported details such as high reversal rates on appeal alleged for one tool and rapid review times alleged in another insurer’s system, while noting the cases are still proceeding through courts. The piece also cites state-level regulation, including Colorado’s requirements for bias audits and appeal rights, and measures in California and Texas requiring physician sign-off on certain denials. The author uses these examples to argue that federal policy lags and that patient protections can vary substantially by state.

Mental Health Parity Guidance From DOL Lacks Specifics for Sponsors

By Valentina Baez – The Department of Labor issued on Tuesday long-awaited guidance clarifying how it enforces the Mental Health Parity and Addiction Equity Act. According to Field Assistance Bulletin No. 2026-03, the DOL will continue enforcing core statutory requirements of MHPAEA, originally passed in 2008, including the obligation for health plans to prepare and maintain written comparative analyses of nonquantitative treatment limitations. In September 2024, the Departments of Labor, Treasury, and Health and Human Services issued final regulations that expanded requirements for plans to document and analyze NQTLs. Read Full Article...

HVBA Article Summary

1. Enforcement focus is being narrowed to specific risk areas: The bulletin says enforcement resources will concentrate on treatment limitations/exclusions, medical-necessity and utilization-management practices, and network adequacy. DOL frames this shift as a response to stakeholder feedback that prior enforcement created confusion and unnecessary burdens. The guidance signals what investigators may prioritize, but it does not provide detailed thresholds for what constitutes a violation in each category.

2. Plans can use proprietary clinical guidelines, but must be ready to disclose them: The bulletin indicates plans may continue applying proprietary clinical guidelines for medical-necessity decisions if they are used comparably for mental health/substance use disorder and medical/surgical benefits. It also states those guidelines must be made available to the Employee Benefits Security Administration during investigations and, upon request, to participants and beneficiaries. This places operational emphasis on documentation, consistency of application, and the ability to produce materials quickly when requested.

3. Stakeholders disagree on whether the guidance provides enough practical clarity: Parity advocates quoted argue the bulletin does not answer core questions about what specific conduct violates MHPAEA, leaving consumers and employers uncertain about expectations. Other compliance and legal experts view it as an improvement because it better signals what EBSA is looking for in comparative analyses and provides examples through an accompanying DOL resource page. The article notes that new proposed MHPAEA regulations are expected by December, suggesting further changes may be forthcoming.

J&J to hospitals: Submit claims data or lose 340B pricing

By Ella Jeffries – Johnson & Johnson will require 340B covered entities to submit claims-level data for its covered outpatient drugs starting Sept. 15, according to a notice the drugmaker sent to providers Sept. 4. Read Full Article...

HVBA Article Summary

1. Claims-level data submission becomes a condition for 340B pricing: Johnson & Johnson says it will require 340B covered entities to submit claims-level data for its covered outpatient drugs starting Sept. 15. The company outlines an escalation path that includes multiple noncompliance notices, followed by a pricing suspension after the final notice. J&J also states that pricing will be restored after compliant data is submitted, with a defined restoration timeline.

2. Policy scope and reporting timelines are broadly defined: The notice says the policy applies across covered entity types regardless of where drugs are dispensed or administered, how inventory is managed, or what payer coverage is involved. Covered entities are required to submit data within 45 days of dispensation for most drugs, with a longer window for certain oncology, autoimmune, and specialty drugs listed by J&J. J&J also says the approach continues upfront 340B pricing at purchase rather than shifting to a rebate model and that it supersedes claims-data provisions in a prior February 2023 notice.

3. Part of wider manufacturer pressure and ongoing 340B disputes: The article frames J&J’s move as an expansion of manufacturer-imposed reporting requirements, noting similar claims-data requirements by Eli Lilly and Novo Nordisk and describing reactions that included hospital-group pushback and litigation involving Eli Lilly. It also recounts J&J’s earlier attempt to move some drugs to a rebate model and the subsequent pause after HRSA warnings, followed by litigation involving HHS and HRSA and broader court scrutiny of rebate-model efforts. Provider and hospital groups argue that these types of mandates and related manufacturer policies could further strain safety-net providers.

Why ancillary benefits aren’t just ‘extras’

By Lee Hafner – As benefit leaders look for ways to help employees with life’s many challenges, ancillary and supplemental offerings “shouldn’t just be viewed as an extra; [they] should definitely be viewed as part of an overall benefits offering,” said John Feeney, vice president of group sales and market development at insurance firm Renaissance. “[Supplemental insurance like] dental, vision, life and disability help address a lot of different needs that the standard medical programs may not fully solve for. For instance, dental and vision — you go for your exams and those providers can detect there’s a potential medical problem well [before] it advances,” he said. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Supplemental Benefits Can Help Address Financial Gaps: Life, disability, critical illness, accident, cancer and hospital indemnity insurance can provide financial support when illness, injury or death creates unexpected expenses or reduces household income. Short- and long-term disability coverage typically replaces 60% to two-thirds of monthly earnings, subject to waiting periods, monthly limits and plan terms. These benefits can complement medical coverage by helping households manage ongoing bills and other financial obligations.

2. Coverage Terms Determine Payments and Flexibility: Some supplemental health plans provide payments for covered diagnoses or injuries that employees can use for medical costs, childcare or other expenses. Feeney cited Renaissance’s Supplemental Rensecure Health product as covering more than 13,000 ICD-10 diagnosis codes, with reimbursement available within 72 hours of submitting an invoice for a covered condition. Payment amounts, eligible conditions and reimbursement requirements depend on the specific plan.

3. Administration and Communication Support Benefits Use: Feeney emphasized that employers and brokers should seek vendors that provide simple administration, timely implementation and ongoing support. Clear information throughout enrollment and accessible resources afterward can help employees understand their coverage and how to use it. Supplemental benefits may help employees manage unexpected costs and reduce reliance on retirement withdrawals, although their financial value depends on coverage terms and individual circumstances.

What if workers fake HSA receipts? A fraud expert weighs in

By Allison Bell – Some employees with HSAs substantiate their requests for reimbursement with receipts they created themselves. Employers and benefits advisors should minimize that form of employee creativity by investing in recordkeeping tools and education for employees with HSAs, FSAs or other personal benefits accounts, according to Jane Gachucha. Gachucha, who bills herself as the HSA Audit Expert, is a certified fraud examiner. She tries to help employers and third-party plan administrators avoid trouble with the Internal Revenue Service by finding HSA and flexible spending arrangement problems before the IRS does. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Risk focus is on substantiation controls, not proven widespread fraud: The fraud examiner quoted in the piece says she has not found reliable, HSA-specific data showing how common fabricated receipts are. Even without prevalence data, she argues the vulnerability is real enough to merit attention from employers and plan administrators. The article frames the central issue as whether programs have adequate processes to meet IRS substantiation expectations if questioned.

2. HSA spending is mostly electronic, but documentation gaps can still emerge: The article cites Devenir’s estimate that account holders use debit cards or online systems for 97% of HSA withdrawals, with about 3% involving checks, cash, ATM withdrawals, or unknown methods. It notes that even card-based purchases may not be properly substantiated by retailers, and participants can lose records over time. The point is that digital transactions don’t automatically equal audit-ready documentation, especially years after an expense occurs.

3. IRS scrutiny may require more than a receipt and distinguishes reconstruction from fraud: The expert describes IRS expectations as showing the expense was eligible, incurred after the account was established, and not claimed as an itemized deduction, among other conditions. The article also notes the IRS may want confirmation that no other coverage or account paid the same expense. It emphasizes a distinction between poor documentation and intentional falsification, and says reconstructed records can be acceptable when supported by provider, payment, or insurance documentation (including date of service, patient name, and amount paid).

Medicare’s GLP-1 program is ‘far exceeding’ expectations, but a plateau could be coming

By Elizabeth Casolo – Pharmacies have been seeing compelling interest in Medicare’s GLP-1 Bridge program since its July launch, NPR first reported. The demonstration, designed to give eligible Medicare Part D beneficiaries access to certain GLP-1s at a fixed monthly cost, will run through 2027. Manufacturers are supplying GLP-1s at a monthly net price of $245, and beneficiaries cover $50. Unlike the proposed voluntary “Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth” — or BALANCE — model pilot, Bridge bypasses Part D sponsors. Read Full Article...

HVBA Article Summary

1. Bridge’s structure and pricing are central to the program’s appeal: The GLP-1 Bridge demonstration is intended to offer eligible Medicare Part D beneficiaries access to certain GLP-1 medications at a fixed monthly cost through 2027. The article describes a split where manufacturers provide the drugs at a set net price and beneficiaries pay a defined amount. It also emphasizes that Bridge operates differently from the proposed BALANCE model by bypassing Part D sponsors. This design is presented as a key distinction affecting how access and administration work.

2. Policy uncertainty persists despite Bridge being extended and BALANCE being paused: CMS paused the BALANCE model indefinitely for Part D while extending the Bridge program, according to the article. A CMS official indicated the agency planned to share more about Bridge insights with Part D sponsors, and CMS said it would use its data to decide whether Bridge should continue past 2027. The piece frames this as an open question for stakeholders planning around GLP-1 coverage. It also suggests that future decisions may depend on what CMS learns from the program’s data.

3. Walgreens and CVS report high prescription volume and highlight operational differences: Becker’s reports that Walgreens and CVS Health have each filled more than 100,000 GLP-1 prescriptions through Bridge to date. Walgreens’ chief pharmacy officer said uptake has been stronger than expected and predicted the program may eventually reach a plateau as patients start and stop therapy over time. The article notes that 30-day prescriptions create frequent pharmacy touchpoints, which Walgreens says can support adherence and side-effect management. CVS, meanwhile, pointed to its acceptance of discount cards and manufacturer offers for other patients and described a partnership with Novo Nordisk tied to NovoCare enrollment.

Employers brace for another year of rising health benefit costs

By Jimmy Nesbitt – More than half of employers plan to make cost-cutting changes to their health benefits in 2027, with some moves likely to push more costs onto workers, according to a new survey. Companies are under pressure to reduce expenses ahead of yet another increase in healthcare costs: Total health benefit costs per employee are expected to rise 8.2% on average next year, the highest increase since 2003, according to Marsh’s 2026 National Survey of Employer-Sponsored Health Plans. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Health Benefit Costs Face Continued Growth: Marsh projects that 2027 will mark the fifth consecutive year of elevated health benefit cost growth, following a decade of more moderate increases. Contributing factors include more expensive diagnostics and treatments, health system consolidation, and lower government funding and reimbursement that can increase charges to employer plans. Expensive therapies for cancer and rare diseases are also contributing to high-cost claims and greater budget volatility, particularly for smaller employers.

2. GLP-1 Utilization Adds to Prescription Spending: Marsh estimates that rising GLP-1 utilization will account for one percentage point of overall health benefit cost growth in 2027. According to KFF, nearly one in five large employers covered these medications for weight loss in 2025, while 66% of employers with at least 5,000 workers offering that coverage reported a significant impact on prescription-drug spending. Although negotiated prices can be substantially below list prices, some employers are choosing to drop weight-loss coverage to achieve immediate cost relief.

3. Employers Weigh Cost Controls and Employee Affordability: Marsh’s survey found that 59% of employers plan to make cost-cutting changes to health benefits next year, including higher deductibles that could increase employees’ out-of-pocket expenses. Employers are also considering approaches that manage spending without directly shifting additional costs to workers. Guiding members to higher-quality care ranked among the top three health program priorities, up from fifth last year, with 58% of large employers identifying it as important or very important.

Protecting client data in the age of AI

By Joy Dawe – Imagine your healthcare provider uploading your medical records into a public-facing artificial intelligence tool to summarize your health history. Or your accountant entering your tax returns to generate ideas on deductions. You would have concerns about those actions — and rightly so. AI tools can create meaningful efficiencies and benefits for financial professionals, but we cannot lose sight of the privacy and security protections we must uphold to ensure clients’ nonpublic personal information remains confidential. Read Full Article...

HVBA Article Summary

1. Privacy obligations still apply when using AI tools: The article argues that increased AI capability does not reduce a professional’s responsibility to protect clients’ nonpublic personal information (NPI). It emphasizes that professionals should treat AI as useful for analyzing information only when the data has been anonymized or de-identified. The piece frames privacy protection as a core duty that should not be traded away for efficiency gains.

2. Public-facing AI use can create specific compliance and security risks: The author provides examples where using public AI could expose regulated data, such as protected health information, financial details, or suitability information. It also notes that recording/transcribing calls can unintentionally place sensitive details with third parties, potentially without clear visibility into their safeguards. The article further cautions that AI outputs (including underwriting-related outputs) still need qualified human review and should not replace established processes.

3. Practical decision checks can reduce misuse and reputational risk: The article suggests asking concrete questions before using AI with sensitive information, including whether authorizations cover that use and whether the tool truly needs access to protected data. It encourages confirming whether a tool will continue protecting NPI and whether it has sufficient, accurate information to generate reliable outputs. If a professional cannot confidently answer these questions, the article warns that the action may lead to noncompliance and reputational harm.

Jake Velie, CPT Vice Chairman & President Health & Voluntary Benefits Association® (HVBA) Editor-In-Chief Daily Industry Report (DIR)

Robert S. Shestack, CCSS, CVBS, CFF Chairman & CEO Health & Voluntary Benefits Association® (HVBA) Publisher Daily Industry Report (DIR)

Half of brokers still haven't sold an ICHRA - and the gap is showing

By Mark Rosanes – More than half of benefits brokers have never sold an individual coverage health reimbursement arrangement, and after a year of watching more employers try the model, fewer of them expect adoption to grow. The TASC 2026 Broker ICHRA Survey, commissioned by Total Administrative Services Corporation, which sells ICHRA administration services, found 54% of broker respondents have still never sold an ICHRA, up from 47% in 2025. Read Full Article...

HVBA Article Summary

1. Broker experience is shaping sentiment, not just theory: The TASC 2026 survey indicates more brokers report implementation challenges after seeing ICHRAs used in real employer settings. Common issues cited include longer-than-expected employee education and enrollment, heavier administrative workloads, and individual-market network limitations. The survey also notes that some cases did not deliver the savings brokers or employers expected. These practical frictions appear to be influencing whether brokers recommend the product going forward.

2. Expectations and support levels declined year over year: The article reports that brokers’ expectations for ICHRA adoption growth fell from 65% in 2025 to 50% in 2026. It also says the share of brokers who fully support ICHRAs decreased from 48% to 29%, while outright opposition rose from 9% to 17%. The largest movement was toward conditional support, where brokers see ICHRAs as viable only for certain employers and situations. This suggests recommendations are becoming more selective rather than broadly promotional.

3. Employer interest may depend heavily on adviser recommendations amid federal momentum: A July 2026 EBRI and Morgan Health study cited in the article found more than 80% of companies worry individual-market out-of-pocket costs could be too high for some workers. The same study found about three-quarters of employers would be more likely to adopt an ICHRA if their broker, benefits consultant, or a peer business recommended it, based on nearly 1,000 benefits decision-makers. Meanwhile, CMS and the SBA have rebranded ICHRAs as CHOICE Arrangements, signaling continued federal interest without changing the underlying rules. The article frames this as a potential mismatch: growing policy visibility and employer adoption data alongside more cautious broker confidence.

Employer, consumer groups urge lawmakers to reform No Surprises Act's IDR

By Paige Minemyer – Employer and consumer organizations are urging lawmakers to address "loopholes" in the No Surprises Act. In a letter (PDF) submitted to House and Senate leaders on both sides of the aisle, nearly 70 groups representing employers, patients and labor unions argue that while the law has successfully averted millions of surprise medical bills, flaws in its processes are driving up healthcare costs. They particularly point to the independent dispute resolution, or IDR, process, which has seen a growing contingent of critics. IDR is a baseball-style arbitration that is designed as a second level for resolving a claim if a payer and provider cannot come to an agreement in negotiation. Read Full Article...

HVBA Article Summary

1. Broad coalition is asking Congress to change how disputes are resolved: Nearly 70 employer, patient and labor groups are pressing lawmakers to revise parts of the No Surprises Act they view as exploitable. They argue the law’s patient protections can remain intact while curbing downstream cost growth. Their focus is on how payment disputes between insurers and providers are handled after negotiations fail. The letter frames the issue as a cost and process problem rather than a rollback of surprise-billing protections.

2. IDR volume and participant behavior are central concerns: The groups contend that the independent dispute resolution (IDR) system is being used far more often than originally anticipated. They also point to concentrated usage patterns, describing “flooding” by a relatively small set of provider organizations and the rise of intermediary firms that specialize in IDR. In their view, these dynamics contribute to higher awards and reinforce continued reliance on arbitration. The letter suggests that as long as the economics favor frequent filings, the incentives to change behavior are limited.

3. Proposed reforms emphasize benchmarks and predictability, with potential premium implications: The signatories urge replacing the current baseball-style arbitration approach with a benchmarking model they describe as more predictable and transparent. They also call for a “fair, market-based” payment methodology intended to reduce gaming and prevent excessive reimbursement. While patients are protected from being directly billed for covered surprise out-of-network services, the groups warn that rising system costs can still show up indirectly. They argue insurers and employer plan sponsors may respond to higher IDR-related expenses by raising premiums or taking other cost-management steps.

5 states finalize 2027 ACA rates

By Elizabeth Casolo – ACA insurers requested a median rate increase of 15% for 2027, according to a Peterson-KFF Health System Tracker analysis. However, some states are pushing back — while others are abiding by those requests — as they finalize increases. The set rates precede open enrollment, beginning Nov. 1. Read Full Article...

HVBA Article Summary

1. State regulators are adjusting insurer requests in different ways: Several states approved increases that were lower than what insurers initially sought, indicating some level of regulatory pushback during rate review. New York’s final approvals reduced requested increases substantially compared with what insurers filed for in both the small group and individual markets. Other states, such as Washington, made only slight adjustments from requested levels, suggesting limited change during the approval process.

2. Approved 2027 ACA-market rate changes vary widely by state and market segment: The updates show that finalized changes span from low single-digit increases in some places to increases above 20% elsewhere. The article also distinguishes between the individual and small group markets, where the approved changes can differ within the same state. This variation suggests local market dynamics and regulatory decisions are playing a major role in what consumers and small employers may face.

3. Market participation and enrollment context are part of the 2027 picture: Beyond rate levels, the article notes at least one planned insurer exit from a state’s ACA market for 2027 (Centene’s Ambetter in Delaware). It also provides enrollment context in some states—such as New York’s covered lives across individual and small group plans and Vermont’s impacted residents—highlighting that these rate decisions affect sizable populations. The timing matters as well, since these finalized rates come ahead of the Nov. 1 open enrollment start.

Plan Sponsors Increase Focus on Health Plan Fiduciary Roles

By Elizabeth Harris – As plan sponsors grapple with how to establish best practices for their role as health plan fiduciaries, consultant Jamie Greenleaf, founder of Greenleaf Advisors and co-founder of Fiduciary In A Box, is hearing frequent queries about the subject. “Plan sponsors are still struggling to understand everything they need to do,” says Greenleaf, based in Red Bank, New Jersey. “The questions that they’re asking tend to be ‘Who can help me with this?’ and ‘How come nobody told me about this?’” Read Full Article...

HVBA Article Summary

1. ERISA health-plan fiduciary oversight is becoming more structured: Attorneys and advisers quoted in the piece describe plan sponsors paying more attention to creating and following prudent fiduciary guidelines for health plans. A key driver is anticipation of federal guidance that could clarify expectations around pharmacy benefit manager (PBM) fee disclosure and oversight. The article frames this as an evolution similar to what occurred previously in retirement plan governance, where process and documentation became central. The emphasis is on turning general concern into repeatable governance practices that can be demonstrated if challenged.

2. PBM contracts and RFPs are positioned as the main leverage point for financial controls: The experts argue that the best time to address fiduciary risk is before signing, by negotiating contract terms and running competitive request-for-proposal processes. Specific oversight tools discussed include audit rights, access to claims data, benchmarking fees, and scrutinizing how rebates and pricing mechanisms are handled. The piece also highlights interest in reducing or eliminating practices that can obscure true drug costs, such as spread pricing, by requiring transparency and reconciliation. Overall, the message is that plan sponsors can strengthen oversight capabilities primarily through upfront contracting and ongoing monitoring provisions.

3. Litigation risk and upcoming compliance deadlines are shaping sponsor priorities: The article points to prohibited-transaction and fiduciary-breach lawsuits as a cautionary backdrop, including attention to a PBM-related case involving J.P. Morgan. It also notes looming policy and regulatory changes affecting PBM accountability and ERISA-related duties, which encourage sponsors to revisit existing agreements rather than wait. The guidance offered centers on demonstrating that arrangements meet plan needs and that compensation is reasonable, supported by documentation and periodic reviews. Sponsors are encouraged to set up committees, keep minutes, document vendor reviews, and retain evidence of a prudent decision-making process.

Hartford to compete harder for small-employer benefits sales

By Allison Bell – Hartford Insurance sees selling life, disability, dental and vision plans to employers with fewer than 500 plan participants as a top strategic priority. Beth Costello, the insurer's chief financial officer, talked about the company's benefits strategy Thursday in New York at the KBW Insurance Conference. Hartford is one of the top issuers in the market for group life and group disability benefits for employers with more than 500 plan participants. "We feel very good about the scale that we have," Costello said. "It's allowed us to develop very strong capabilities across the board." Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Strategic shift toward smaller employers: Hartford is signaling that growth in benefits will increasingly come from employers with fewer than 500 plan participants, after emphasizing larger-case group life and disability. The comments were delivered by CFO Beth Costello at the KBW Insurance Conference, indicating this is an executive-level priority. The move suggests Hartford is looking to broaden distribution and relevance in segments where it has had less share. It also implies more direct competition for carriers already entrenched in the small-group space.

2. Equitable acquisition as a distribution and tech lever: Hartford expects its announced agreement to acquire a benefits business from Equitable to help it compete more effectively in the smaller-employer market. Costello highlighted that the acquired business includes a digital platform designed to support quoting and case installation workflows, which could improve speed and ease of sale. The deal also brings dental and vision products, which Hartford views as important in the lower end of the market. Together, the added technology and product breadth are positioned as enablers for expanding small-employer reach.

3. Broader market competition and deal activity: The article frames Hartford’s push as part of intensifying competition in non-medical employer benefits like disability, dental, and vision. It notes other insurers’ expansion ambitions, including Principal’s recent acquisition of a dental benefits provider and Prudential leadership discussing a return to the U.S. dental and vision market. The piece also points to brokerage and consulting consolidation and capital-markets activity—Hub International’s IPO preparations and acquisitions involving Aon/USI and Grant Thornton/CBIZ—that could reshape distribution dynamics. These developments collectively suggest increased competitive pressure across carriers and intermediaries in the benefits ecosystem.

Cancer still dominates pharma R&D. Obesity is gaining ground.

By Alexandra Pecci – Cancer still dominates pharma pipelines by a wide margin, but its share slipped for the second year in a row with its pipeline numbers shrinking by 4.6% from the year before. But cancer is far from alone. There are fewer drugs in the pipeline altogether this year, marking the first drop since the mid-1990s, according to the Pharma R&D Annual Review 2026, a Norstella report drawn from Citeline clinical data. Read Full Article...

HVBA Article Summary

1. Overall pipeline has declined, with caveats about data changes: The review reports a year-over-year drop in the total number of drugs in development, described as the first decline since the mid-1990s. Citeline also notes that changes to its data system likely made the apparent decline look larger than it really is. Taken together, the report suggests caution in interpreting the magnitude of the downturn while still recognizing that the pipeline did not expand this year.

2. Oncology remains the largest area despite easing growth: The report highlights that oncology continues to represent the biggest share of newly identified drug candidates, even as the number of oncology drugs in development fell for a second consecutive year. It also indicates cancer dominates the top disease/indication rankings, with multiple cancer types occupying most of the top positions. The article uses recent examples from companies like Amgen and BioNTech to illustrate continued activity in lung cancer development alongside the broader trend.

3. Obesity and rare diseases are expanding focus areas within R&D: Anti-obesity development increased sharply, with the category growing 30.7% to 588 drugs and obesity moving into the top 10 indications for the first time. Rare diseases similarly represent a sizable portion of development: while the number of drugs targeting at least one rare disease dipped 1.3% to 7,618, their share of the overall pipeline rose from 32.3% to 33.2%. The article also points to recent regulatory and trial outcomes—both positive and negative—as signals of sustained attention and risk in rare-disease programs.

Beyond ransomware: 5 healthcare cyber risks to know

By Naomi Diaz – Recent cybersecurity warnings and incidents are highlighting risks for healthcare organizations that extend beyond ransomware, including cloud authorization abuse, voice phishing, brand impersonation, third-party access and publicly exposed information. Read Full Article...

HVBA Article Summary

1. Cloud app permissions are a growing attack path: The FBI flagged “OAuth consent phishing” as a method that can yield account access through user-approved permissions rather than stolen passwords. The scheme relies on links that lead to legitimate cloud-provider permission screens, which can make it harder for users to spot as malicious. If users authorize the request, attackers may gain access via an authorization token to email and other data. The American Hospital Association circulated the FBI alert to its member hospitals, underscoring sector-wide relevance.

2. Social engineering and brand impersonation continue to target patients and staff: Health-ISAC reported voice phishing and domain impersonation activity associated with ShinyHunters, including pressure tactics around multifactor authentication approvals. Separately, health systems warned patients about phishing that impersonates MyChart and promotes fake “kits” or “packages” directing people to fraudulent sites. The FTC received 166 complaints over the past five years that reference MyChart, with multiple complaints tied to the current campaign. Epic stated the campaign does not come from a MyChart breach and that the platform’s security is unaffected.

3. Third-party and exposure risks can involve real patient data even without major outages: Veradigm disclosed an incident involving credentials obtained from a third-party vendor environment, which were used to access an API and download personal information for a small number of customers. The company said the incident did not involve clinical/medical data, did not provide access to its broader network, and did not disrupt operations, though Social Security numbers were included in some cases. In a separate issue, nearly 50 hospitals and health systems had publicly accessible webpages linked to QGenda pages that exposed clinician schedules and sometimes cellphone numbers. The report characterized this as publicly accessible information rather than a cyberattack or breach of QGenda, and at least 10 organizations restricted access after being contacted.

The Villages’ Medicare Advantage Saga Now Has a $541 Million Bill

By Joey Rettino – Last time we checked in on The Villages’ Medicare Advantage (MA) soap opera, it actually had something resembling a happy ending. The retirees got to keep their doctors; Humana and UnitedHealthcare stopped fighting; retirees could go back to their, well, retirements. Read Full Article...

HVBA Article Summary

1. Federal settlement claim tied to alleged coding practices: Federal prosecutors say the company formerly behind The Villages Health reached an agreement with the government after allegations involving unsupported or invalid diagnosis codes. The codes were allegedly sent to multiple insurers, which then submitted them to Medicare. The alleged effect was higher payments associated with Medicare Advantage’s risk-adjustment approach. The settlement is structured as a claim in bankruptcy rather than a straightforward repayment from an operating company.

2. How the payment chain works in this case: The article describes a multi-step flow in which a provider supplies diagnosis codes to insurers, insurers pass those codes to Medicare, and payments then move back through insurers to the provider. The government alleges that invalid diagnoses led to inflated payments at multiple points in that chain. The piece contrasts this structure with traditional Medicare, emphasizing that the private-plan intermediary role changes how incentives and money flow. It also notes that the diagnoses at issue were said to be unsupported in records or tied to improper record amendments.

3. Implications for Medicare Advantage incentives and accountability: The article frames the episode as an example of a broader policy concern: payments increase when beneficiaries are coded as sicker, which can create incentives around coding intensity. It raises uncertainty about how much money will ultimately be recovered, especially given the bankruptcy context. The author suggests that any insurer repayments to CMS could offset what the government seeks from the bankrupt estate. The piece signals that future transparency about final recoveries may be limited.

Plan Sponsors Face Challenges to Providing Mental Health Parity

By Beth Braverman – It’s been nearly two decades since the passage of the federal Mental Health Parity and Addiction Equity Act, mandating that health plans that offer mental health and substance use disorder benefits cover them on par with medical and surgical care. “We have seen a lot of housekeeping over the year by plans to clarify their terms and make clear their message that they, the plan, do not have any intent to be restricting access in their provision of mental health [benefits],” says Elena Lynett, a senior vice president in Segal’s national health compliance practice group. “That really leaves us now with the muddier question of what the regulators want to see.” Read Full Article...

HVBA Article Summary

1. Compliance is operationally complex, not just a checkbox: Sources quoted in the piece say parity compliance is difficult because mental health and medical/surgical benefits are structured differently, making direct comparisons challenging. The article emphasizes that compliance now often hinges on demonstrating parity for nonquantitative treatment limitations (NQTLs), such as prior authorization and formulary design. It also notes that plan changes on the medical/surgical side can trigger rework of parity analyses on the mental health side, which can slow or complicate benefit updates. As a result, sponsors frequently rely on outside vendors or consultants to manage the documentation and analysis workload.

2. Provider-network limitations and payment dynamics constrain real-world access: The Department of Labor is described as focusing on network adequacy as an NQTL issue, but the article says a shortage of in-network mental health providers makes parity difficult to achieve in practice. It cites the American Medical Association’s Mental Health Parity Index reporting that mental health and substance use disorder treatment reimbursement rates are 16% to 59% lower than physical healthcare rates. The article links these lower payments to providers choosing to stay out of insurance networks and instead take direct private payments. It also highlights that administrative friction can influence whether providers decide to join a plan’s network.

3. Point solutions and engagement measurement create new challenges for employers: The article reports that many sponsors are adopting “point solutions” such as remote programs and app-based tools, partly to expand access and address network gaps. However, it says managing multiple solutions can increase administrative complexity and make data tracking harder for employers. It cites EBRI survey findings (2025) that 47% of employers reported employees lacked awareness of mental health benefits, 43% cited stigma, and 40% pointed to confidentiality concerns affecting uptake. It also references an analysis from Path Forward, based on EBRI data, indicating fewer than half of employers offering mental health coverage measure whether benefits deliver timely, effective care.