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 could face mandate to provide 6 'free' health care visits per year

By Allison Bell – Three Democrats in Congress are trying to lighten the load of high deductibles on people with commercial health coverage. The lawmakers have reintroduced the Primary and Behavioral Healthcare Access Act bill, which would require health insurers and employers' self-insured plans to cover at least three primary care visits per year before the patient had reached the deductible, and without imposing co-payment requirements, coinsurance requirements or other out-of-pocket costs on the patient. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Proposed Federal Mandate on No-Cost Visits: The legislation would require both fully insured and self-insured employer health plans to provide a set number of primary and behavioral health visits without applying deductibles or other forms of cost-sharing. Lawmakers aim to reduce the financial barriers created by high-deductible health plans. The proposal would amend federal benefits law to ensure the requirement applies broadly across employer-sponsored coverage. If enacted, it would represent a significant expansion of first-dollar coverage beyond existing preventive care rules.

2. Part of Broader Health Cost Discussions in Congress: The bill’s reintroduction comes amid multiple congressional hearings focused on rising health care costs. Lawmakers have recently signaled interest in assembling a broader health cost legislative package. The renewed push suggests sponsors believe there may be political momentum for targeted reforms. Observers may view the measure as an early component of a wider effort to address affordability concerns.

3. Debate Over High-Deductible Plan Design: The proposal highlights ongoing tensions over the role of high deductibles in employer coverage. Supporters of such plans argue they help control premiums and encourage consumer responsibility, often paired with health savings accounts. Critics contend that large deductibles can delay necessary care, particularly follow-up treatment after preventive screenings. Backers of the bill argue that covering routine outpatient services upfront could prevent more serious and costly medical interventions later.

Hacking group claims major hack of Novo Nordisk and attempted $25 million extortion

By A.J. Vicens – A cyber extortion group claimed on Tuesday to have stolen more than a terabyte of data from pharmaceutical giant Novo Nordisk (NOVOb.CO), and said it is ‌exploring selling parts of the data after unsuccessfully demanding $25 million from the company. Read Full Article...

HVBA Article Summary

1. Scope and Nature of the Alleged Breach: The hacking group FulcrumSec said it spent more than two months inside Novo Nordisk’s networks and claimed to have taken roughly 1.3 terabytes of data. According to the group, the stolen material includes proprietary information on released and unreleased drugs, trial data, internal source code and AI model information. It also allegedly contains sensitive data tied to employees, doctors and patients. Reuters reported it could not independently verify the authenticity of the posted data.

2. Extortion Attempt and Aftermath: FulcrumSec said it demanded $25 million from Novo Nordisk but did not receive payment. After the refusal, the group stated it was exploring private sales of certain drug-related and internal data, though it claimed it would withhold some employee and clinical trial information as part of a “harm-reduction strategy.” The group also indicated it might open-source some material as a deterrent to future non-paying targets. Novo Nordisk said it is aware of the claims, remains in contact with authorities and continues operating its main platforms.

3. Context and Company Response: Novo Nordisk disclosed on June 11 that it had experienced a cybersecurity incident involving unauthorized access to a limited number of internal IT systems and certain personal data. FulcrumSec told Reuters that company representatives made contact in early June and requested specific files to verify the breach. A cybersecurity researcher familiar with the group described it as generally credible in its technical capabilities and claims. The incident comes as Novo Nordisk, known for drugs such as Wegovy and Ozempic, faces heightened scrutiny over data security in the pharmaceutical sector.

GLP-1s tied to $193K in lifetime healthcare savings: 5 things to know

By Ella Jeffries – Middle-age adults who use GLP-1 medications for obesity could save an average of $192,735 in lifetime medical costs, according to a study published in June by the National Bureau of Economic Research. Read Full Article...

HVBA Article Summary

1. Education and age influence projected savings: The analysis found that financial benefits vary by demographic group. Adults ages 40 to 50 without college degrees were projected to see higher lifetime medical savings than their college-educated peers. This suggests socioeconomic factors may influence both baseline health risks and the economic return of long-term obesity treatment. The findings highlight how cost offsets may differ across populations.

2. Earlier and sustained treatment yields larger returns: Adults who start GLP-1 therapy between ages 25 and 30 could realize the highest lifetime savings, reaching up to $270,800. However, the model assumes patients remain on treatment continuously for life. It does not factor in real-world challenges such as discontinuation due to cost or adverse effects. As a result, actual savings could differ from the projections.

3. Coverage barriers and policy resistance persist: Despite evidence pointing to improved cost-effectiveness, insurance coverage for GLP-1s remains limited. A 2026 survey found that about three-quarters of health plan providers do not cover these drugs for obesity-related weight loss, and nearly half would not do so at any price. At the federal level, CMS declined to expand Medicare and Medicaid obesity coverage in its 2026 final rule, citing projected spending increases. These dynamics underscore the gap between modeled economic benefits and current payer policies.

US telehealth utilization climbs 10.1% in Q1, led by mental health visits: Fair Health

By Cailey Gleeson – Telehealth utilization increased 10.1% across the U.S. from the fourth quarter of 2025 to the first three months of 2026, a new report from Fair Health found. Telehealth utilization, measured as a percentage of medical claim lines, increased from 5.01% of medical claim lines in the fourth quarter of 2025 to 5.51% in Q1 2026. The relative increase was 12% in the Midwest, 11.8% in the Northeast, 9% in the South and 8.1% in the West, Fair Health data indicated. Read Full Article...

HVBA Article Summary

1. Telehealth Utilization Increased Nationwide: The percentage of patients with a telehealth claim rose nationally from 17.3% in Q4 2025 to 18.4% in Q1 2026, representing a 6.3% increase. All four U.S. Census regions experienced growth during the period, with the Northeast reporting the largest relative increase at 7.3%. The findings are part of Fair Health’s new Quarterly Telehealth Regional Tracker, which analyzes private insurance claims data from more than 75 contributors nationwide.

2. Mental Health Remained the Leading Telehealth Diagnosis: Mental health conditions were the top diagnostic category for telehealth visits across every age group and region in Q1 2026. Nationally, 52.1% of patients with a telehealth claim received care related to a mental health condition, though the share was lower among children ages 0–9 (26.9%) and adults age 65 and older (22%). Other leading diagnostic categories included acute respiratory diseases and infections, overweight and obesity, endocrine and metabolic disorders, and joint and soft tissue diseases.

3. Urban Areas Led in Utilization While Rural Areas Saw Faster Growth: Telehealth usage remained higher in urban areas, where 18.6% of patients had a telehealth claim compared with 10.3% in rural areas. However, growth in telehealth adoption from Q4 2025 to Q1 2026 was stronger in rural communities, increasing 7.8% versus 6.2% in urban areas. These trends suggest telehealth utilization continues to expand across geographic settings, with rural areas narrowing the gap in adoption.

New calls for workplace protections in hospitals

By Adriel Bettelheim – More reports of workplace violence in hospitals and clinics are reviving calls for a federal standard to protect nurses, social workers and others in medical settings. Why it matters: Health care workers have been among the likeliest to experience threats or be assaulted on the job since the onset of the pandemic. Read Full Article...

HVBA Article Summary

1. Unions push for a federal safety standard: National Nurses United is urging the Occupational Safety and Health Administration to establish a nationwide workplace violence prevention standard for health care and social service employers. The proposal aligns with bills introduced in Congress that would require employers to maintain prevention plans and train workers. Currently, there is no federal mandate requiring health systems to implement such measures or inform employees of their rights. Supporters argue a uniform rule would create consistent protections across care settings.

2. Survey data highlights widespread threats and violence: In a survey of more than 1,200 union members, over one-third reported an increase in violent incidents in their unit over the past year. Seven in 10 respondents said they had been verbally threatened, and many described physical assaults such as being pinched, scratched, punched, kicked or struck by thrown objects. The union also said only 6 in 10 workers reported that their employer investigates incidents after they occur. These findings point to both the frequency of violence and gaps in employer response.

3. Costs and consequences extend beyond compliance: OSHA has estimated that complying with a federal standard could cost more than $1 billion annually and would apply beyond hospitals to home health, residential and behavioral care facilities. However, hospitals already face billions of dollars in costs tied to violence, including spending on security, training and workers' compensation. Administrators say the problem also fuels burnout, staff turnover and legal risks. The debate centers on whether upfront regulatory costs could reduce longer-term financial and human impacts.

47% of US adults say corporate health insurers ‘primary drivers’ of rising health costs

By Cailey Gleeson – As healthcare costs continue to spike in the U.S., a new survey from the Coalition to Strengthen America’s Healthcare found that nearly half of Americans (47%) view corporate health insurers as the primary driver behind affordability issues. Read Full Article...

HVBA Article Summary

1. Public Blame Extends Beyond Insurers: While corporate health insurers were most frequently cited, respondents also pointed to other major players in the healthcare system. The federal government and pharmaceutical companies were each identified by more than one-third of participants as key contributors to rising costs. Hospitals, PBMs and physicians were selected less often, suggesting Americans distribute responsibility across multiple sectors. The results indicate that cost concerns are broad-based rather than focused on a single industry segment.

2. Concerns Over Insurer Influence on Care Decisions: A substantial majority of survey participants said insurers wield too much control over medical decision-making. Many respondents also expressed worry that treatments ordered by physicians are being delayed or denied by insurance companies. These perceptions highlight ongoing tensions around prior authorization and coverage determinations. The findings suggest that affordability concerns are intertwined with trust and access-to-care issues.

3. Survey Backed by Hospital-Linked Coalition Amid Cost Projections: The poll was conducted online by Morning Consult and included 2,002 U.S. adults over a three-day period in late May. It was commissioned by the Coalition to Strengthen America’s Healthcare, a hospital-backed lobbying organization, providing context for how the findings may be positioned in broader policy debates. At the same time, separate projections show commercial health costs are expected to increase significantly in the coming years. Industry groups such as the American Hospital Association have released policy proposals aimed at addressing affordability and quality concerns.

Cigna's Express Scripts sues Tennessee over PBM law

By Alan Goforth – Express Scripts by Evernorth, the pharmacy benefits manager business of The Cigna Group, late last week filed a federal lawsuit challenging a Tennessee law that prevents PBMs from also owning pharmacies in the state. The Freedom, Access and Integrity in Registered Pharmacy (FAIR Rx) Act became law in April. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Ownership Restrictions and Compliance Timeline: The FAIR Rx Act prohibits a company from owning more than 5% of a pharmacy while also operating as a health insurer and PBM in Tennessee. The law is scheduled to take effect in July 2028, giving affected companies several years to adjust. Businesses that fall under the restriction may continue operating through the end of 2028 but must demonstrate plans to divest to a separate entity. The measure is intended by state lawmakers to limit perceived anti-competitive practices and reduce drug costs.

2. Cigna’s Legal and Operational Arguments: Cigna argues the law could disrupt care for more than 180,000 Tennesseans who rely on Express Scripts pharmacies. In its lawsuit, the company claims the statute is unconstitutional and preempted by federal programs such as TRICARE, Medicare Part D and ERISA. The complaint also warns of broader operational consequences, including potential effects on its Memphis-based Accredo pharmacy, which distributed 2.3 million prescriptions nationwide last year. Company executives say the litigation is aimed at preventing patient access disruptions and pharmacy closures.

3. Broader Industry and Political Context: CVS Health filed a similar lawsuit challenging the Tennessee law, asserting that it unfairly targets out-of-state companies and could limit patient choice. In contrast, the Tennessee Pharmacists Association has publicly supported the measure, characterizing it as a stand against large PBMs and corporate influence. The legal fight mirrors developments in other states, including Arkansas, where a federal judge previously blocked comparable legislation on preemption grounds. The outcome in Tennessee could influence how states regulate vertically integrated PBMs and pharmacy ownership going forward.

MedPAC offers a look at enrollment hiccups for Medicare beneficiaries

By Paige Minemyer – Beneficiaries face a series of complex decisions in enrolling in Medicare coverage, and a key federal panel outlines some of the pain points. The Medicare Payment Advisory Commission (MedPAC) released its June report to Congress on Monday, where it notes that when an individual becomes Medicare eligible, they have to immediately make a series of decisions about coverage that may be confusing. Eligible individuals are also tasked with similar decision points at other times in the year, which adds to the complexity, per MedPAC. Read Full Article...

HVBA Article Summary

1. Enrollment Complexity and Information Gaps: MedPAC’s June report highlights how beneficiaries must navigate multiple enrollment windows and coverage options when first becoming eligible for Medicare and at other points during the year. Differences between Medicare Advantage and traditional Medicare—including premiums, network restrictions and supplemental coverage needs—can be difficult to evaluate. The commission also pointed to aggressive direct-to-consumer marketing as a factor that can further complicate decision-making. Together, these dynamics create confusion around deadlines, eligibility rules and plan features.

2. Mixed Support Infrastructure for Beneficiaries: While CMS provides tools such as the Medicare Plan Finder and official handbooks, not all beneficiaries rely solely on these resources. The federally funded State Health Insurance Assistance Program (SHIP) offers counseling, but its funding has not kept pace with overall Medicare enrollment growth, limiting its reach. Many enrollees turn to brokers for help comparing and enrolling in plans. However, MedPAC noted concerns that brokers’ financial incentives and bonus payments—currently not subject to federal limits—may influence plan recommendations.

3. MedPAC Pushes Back on Provider Margin Concerns: The report found no significant association between rising Medicare Advantage penetration and overall provider margins across hospitals, skilled nursing facilities and home health agencies. Analyses showed that hospital margins have remained relatively flat or slightly increased from 2013 to 2024 despite substantial growth in MA enrollment. Although some operational differences were observed—such as variations in length of stay and facility utilization—MedPAC characterized its findings as associative and not necessarily causal. The American Hospital Association disputed the conclusions, citing methodological concerns and arguing that MA increases administrative burdens and costs.

The Refill Encounter: Managing Medications the Modern Way

By Fred Pelzman – I vividly remember my first day in outpatient clinic as an intern more than 30 years ago, when my patient told me they needed refills for all their medications. In his incredibly thick paper chart was a list of medications, handwritten, some partially crossed out, others duplicated. We went through them and figured out what he was actually taking and needed. There were also a couple new medications he needed based on his visit that day. Read Full Article...

HVBA Article Summary

1. Electronic Prescribing Has Improved but Not Eliminated Risk: The shift from handwritten prescriptions to electronic medical records has streamlined the prescribing process and added safety features such as allergy checks, interaction alerts, and age-specific warnings. These tools have reduced some of the classic errors associated with illegible handwriting and manual workflows. However, technology alone has not solved the deeper systemic issues that arise with ongoing medication management. The author emphasizes that modern systems still require thoughtful oversight to prevent new types of mistakes.

2. Refill Requests Create Workflow and Safety Challenges: Clinicians now face a daily influx of refill requests from multiple sources, including patient portals, phone messages, and covering providers. Some requests involve patients who have not been seen for years or medications originally prescribed by specialists but later attributed to primary care. This fragmented process increases the likelihood of inappropriate refills, duplicate therapies, or continuation of medications that require closer monitoring. Without consistent standards, providers may handle similar situations very differently, adding to inconsistency and risk.

3. Clear Policies and Shared Accountability Are Needed: The author argues for standardized refill policies, such as limiting long-term refills without follow-up appointments and using system alerts to prompt reassessment. He suggests assigning medications not just to individual clinicians but to specific practices or specialties to avoid inappropriate cross-prescribing. Better alignment of practice patterns, insurance constraints, and monitoring requirements could reduce preventable errors. Overall, safer prescribing depends on coordinated systems that support clinicians in starting, maintaining, and discontinuing medications appropriately.

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 Insurers: The Other Half of the Consolidation Story

By Seth Glickman – Hospital consolidation dominates the discussion on health care costs – with good reason. There is overwhelming evidence that it raises prices. But every hospital must ultimately negotiate rates with insurers, yet the consolidation story in the health insurer market has only gotten a tiny fraction of the attention. This is a mistake. While the insurer market is not as highly consolidated as the hospital market, it is still highly concentrated by any reasonable antitrust standard, and a major (and under-estimated) driver of cost growth. Read Full Article...

HVBA Article Summary

1. Insurer Markets Are Highly Concentrated Nationwide: The author’s analysis finds that commercial insurance markets in every state meet the federal threshold for being highly concentrated. The average state-level HHI score is 4,458, and all 50 states fall into at least the “highly concentrated” category under DOJ and FTC standards. States such as Kentucky and Alabama approach near-monopoly levels, while even the most competitive states remain far above what antitrust regulators consider unconcentrated. This suggests insurers possess significant pricing leverage in negotiations with providers and employers.

2. Consolidation May Be Underestimated by Traditional Metrics: The article argues that vertical integration between insurers and affiliated entities—such as pharmacy benefit managers, physician groups, and service vendors—amplifies market power beyond what standard plan-level data captures. Large conglomerates like UnitedHealth/Optum and CVS/Aetna blur the line between payer and provider. Because much of this integration operates through complex corporate structures, existing regulatory data may not fully reflect the scope of control. As a result, policymakers may be understating insurers’ true competitive influence.

3. Local Market Dynamics Matter for Consumers: Statewide averages can obscure significant variation within metro and rural areas, where competition levels may differ sharply. In some states, dominance by a single insurer extends across both urban and rural regions, while in others, concentrated rural pockets are hidden behind more competitive metropolitan averages. The author contends that examining markets at a more granular geographic level is necessary to ensure transparency and accountability. Without that detail, consumers may have far fewer meaningful coverage options than state data alone suggests.

UnitedHealth, FTC near insulin rebates settlement

By Elizabeth Casolo – UnitedHealth Group subsidiaries and the Federal Trade Commission have reached a tentative agreement as of June 12 that would resolve allegations the companies had “created a broken rebate system that inflated insulin drug prices,” the FTC said in 2024. Read Full Article...

HVBA Article Summary

1. Tentative Settlement With UnitedHealth Subsidiaries: The FTC and subsidiaries of UnitedHealth Group, including Optum Rx and Emisar Pharma Services, have reached a provisional agreement to resolve allegations tied to insulin pricing practices. The case centered on claims that rebate arrangements contributed to higher insulin costs for patients. While the agreement marks progress in the dispute, specific terms of the Optum Rx settlement have not yet been disclosed. The matter remains subject to finalization and potential additional details.

2. Broader Crackdown on PBM Practices: The lawsuit, filed in September 2024, targeted the nation’s largest pharmacy benefit managers and their group purchasing organizations over rebate-driven pricing strategies. The FTC alleged that these entities prioritized rebates in ways that inflated insulin prices and shifted costs to patients. The investigation was part of a wider federal review of PBM business models and their impact on drug affordability. This action reflects continued regulatory scrutiny of intermediary roles in the pharmaceutical supply chain.

3. Related Agreements With Other PBMs: Other major PBMs named in the case have also moved toward resolution. Express Scripts, owned by Cigna’s Evernorth, was withdrawn from the lawsuit earlier in the year, and the FTC previously confirmed a provisional agreement with CVS Caremark. According to an FTC news release, policy changes involving Express Scripts are expected to reduce out-of-pocket drug costs by $7 billion over a decade. These developments indicate a coordinated effort to reshape rebate and pricing practices across the industry.

Health claim experts eye the new No Surprises Act boxing rings

By Allison Bell – Health insurance claim experts have had about two weeks to think about the new Trump administration interim final regulations for No Surprises Act claim fights. Providers and payers are supposed to send the claim fights subject to the act to an independent dispute resolution entity. Regulation drafters hope to bring order to the IDR boxing fights by setting up a new IDR Gateway portal. Providers and payers are now supposed to take 30 days to make a serious effort to resolve disputes through an "open negotiation" process before the IDR entities swoop in. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. New IDR rules aim to standardize and streamline disputes: The updated regulations create an IDR Gateway portal and formalize a 30-day open negotiation period before disputes proceed to independent review. Officials from the Centers for Medicare & Medicaid Services, with support from the Labor Department and IRS, designed the changes to bring more structure to the process. Supporters say requiring more detailed notices from providers could reduce errors and misdirected disputes. Some experts believe this added clarity may make the system more predictable for employer-sponsored plans.

2. Cost concerns remain central for employers and insurers: Critics argue that the current IDR system has contributed to rising out-of-network claim costs. According to Navin Nagiah of Daffodil Health, IDR entities side with providers about 88% of the time, with many awards reaching roughly 400% of Medicare payment levels. He also cited cases in which awards far exceeded what plans believed claims were worth, intensifying concerns about inflated settlements. These trends have fueled employer worries that the process is driving broader health care spending increases.

3. Experts debate whether reforms will meaningfully change outcomes: Some attorneys and health data executives suggest the clarified negotiation rules could help employers dismiss ineligible disputes earlier in the process. However, others note that certain procedural elements, such as deadline notifications, may simply formalize practices already in place rather than transform them. Observers say lawsuits or regulatory revisions could still alter implementation. Employers are being advised to coordinate with third-party administrators and review contracts to prepare for compliance and monitor dispute activity.

Elevance Health’s 3 Key Priorities for AI

By Marissa Plescia – AI is rapidly gaining traction in the health insurance industry. But according to one health insurance executive, AI shouldn’t be used for the “sake of AI,” but to empower what the health insurer is trying to accomplish. Read Full Article...

HVBA Article Summary

1. Enhancing Member Navigation Through AI Tools: Elevance Health is deploying AI to make it easier for members to understand their benefits and care options. Through a “ChatGPT-like” assistant called Sydney, members can ask detailed questions about procedures, coverage and provider options in a single interaction. The system connects benefit design, cost-sharing information and provider quality data to deliver personalized responses. The goal is to reduce confusion and help members make more informed healthcare decisions.

2. Maintaining Human Oversight in Prior Authorization: The company is applying AI to streamline administrative processes for providers, particularly around prior authorizations. AI is used to accelerate approvals, but any case that does not result in an approval is automatically routed to a human reviewer. This approach is intended to ensure that AI is not responsible for denials and that clinical judgment remains part of the process. By speeding up approvals, Elevance aims to lessen administrative burdens and allow providers to focus more on patient care.

3. Equipping Employees With Real-Time Insights: Elevance is also leveraging AI internally to support call center and service representatives. When members call, AI aggregates administrative and clinical information to give associates a comprehensive view of the member’s history and needs. This enables faster issue resolution and more personalized support. The company also analyzes post-call summaries to gauge satisfaction and proactively follow up when necessary.

The benefits leader is now an analyst, a marketer, and an advocate

By Dickon Waterfield – Earlier this year, I spent several days in Q1 with nearly 100 benefits leaders from large employers across the country. These were sustained, small-group conversations about the U.S. health care system and the challenges they're navigating every day. One theme really stood out. The role of the benefits leader has evolved so dramatically that the job would be unrecognizable to a leader 20 years ago. From the outside, it still looks like plan design, vendor management, and renewals. The leaders I spent time with described something far broader and far harder. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Benefits leaders are becoming rigorous health care analysts: Escalating medical costs, particularly in specialty areas such as cancer and musculoskeletal care, are forcing benefits leaders to scrutinize vendor claims more closely. Employers are no longer accepting marketing promises at face value and are instead demanding clear evidence of outcomes, savings, and methodology. Many are building teams with deeper analytics expertise to assess clinical performance, total cost of care, and engagement data. This shift reflects a broader expectation that benefits leaders act as disciplined purchasers of health care rather than passive plan administrators.

2. The role now blends health care expertise with marketing and communications: Beyond plan design, benefits leaders must ensure employees can navigate and actually use the solutions offered to them. That requires in-house knowledge of areas like pharmacy pricing, clinical quality, and health policy, as well as stronger communication strategies. Some organizations are adding marketing and outreach specialists to their benefits teams to drive utilization of high-quality care pathways. Leaders are also granting vendors more direct access to employees when those vendors can demonstrate measurable savings and value.

3. Employers are stepping into policy and advocacy discussions: As major purchasers within the health care system, employers increasingly recognize their influence in shaping policy debates around cost and access. Benefits leaders are beginning to voice dissatisfaction with parts of the supply chain and to hold partners accountable. Many are engaging through trade associations, local consortiums, or direct dialogue with policymakers to advocate for reforms. This evolution expands the role beyond corporate management into public-facing advocacy aimed at improving systemwide performance.

Express Scripts files suit to challenge Tennessee PBM law

By Paige Minemyer – On the heels of a legal challenge from CVS, Express Scripts has also sued to challenge Tennessee's new pharmacy benefit management law. Under the law, PBMs would be barred from also owning pharmacies in the state. In its complaint, Express Scripts says that policy would not just impact retail pharmacies but would force its parent company, Evernorth, to shutter an Accredo specialty pharmacy center based in Memphis. Closing that facility, the company said, could cost thousands of jobs. And broadly speaking, the law could lead to pharmacy deserts in rural areas, where more than a third of its residents currently live. Read Full Article...

HVBA Article Summary

1. Express Scripts warns of access and job losses: The company argues that Tennessee’s new law would require it to close its Accredo specialty pharmacy center in Memphis, putting thousands of jobs at risk. It also says the measure could disrupt home delivery and specialty pharmacy services across the state. Express Scripts reported shipping more than 2 million prescriptions to Tennessee residents last year. Company leaders contend that the law could leave hundreds of thousands of patients struggling to maintain consistent access to medications and clinical support.

2. CVS claims the law targets national chains and raises costs: CVS has filed a separate lawsuit asserting that the statute unfairly disadvantages out-of-state pharmacy benefit managers while favoring in-state independent pharmacies. The company says it operates 136 pharmacy locations in Tennessee that serve nearly 1.5 million people. According to CVS, the law could ultimately result in more than 160 pharmacy closures statewide. CVS also estimates the policy could increase annual drug costs for Tennessee employers by more than $180 million.

3. Supporters frame the law as pro-transparency and pro-competition: Tennessee’s FAIR Rx Act was signed by Gov. Bill Lee and is backed by the Tennessee Pharmacists Association. Supporters argue it is intended to increase transparency, improve fairness in the pharmacy market and bolster rural and community pharmacy access. Similar legislation in Arkansas was previously challenged in court and blocked before taking effect. The Tennessee law is part of a broader national debate over whether pharmacy benefit managers should be allowed to own or operate pharmacies.

Healthcare faces ‘watershed moment’ as costs to jump 9% in 2027: 7 things to know

By Alan Condon – Commercial healthcare costs are projected to rise 9% in 2027, the highest medical cost trend in nearly two decades, according to PwC’s annual “Health Behind the Numbers” report, published June 11. The projection reflects mounting pressure from provider reimbursement demands, pharmacy spending, behavioral health utilization, AI-driven revenue optimization and out-of-network payment disputes. PwC argued that without meaningful cost-management interventions, rising healthcare spending could strain affordability, coverage and access across the healthcare system. Read Full Article...

HVBA Article Summary

1. Cost Growth Reaches a 17-Year High: PwC projects medical cost trends of 9% for the commercial group market and 8.5% for the individual market in 2027, marking the steepest increase in nearly two decades. The firm also raised its 2026 outlook, signaling that inflationary pressures are persisting longer than previously expected. These increases are being driven by a combination of provider reimbursement demands, pharmacy spending and operational shifts within the industry. Without intervention, these trends could significantly affect premiums and plan design in the near term.

2. Multiple Structural Drivers Are Accelerating Spending: Hospital and related service inflation reached 7.59% year over year in February 2026, reflecting ongoing consolidation, labor costs and revenue optimization strategies. In addition, 70% of health plans identified AI-enabled documentation and coding tools as top cost inflators because they can increase reimbursement levels. Providers prevailed in 88% of independent dispute resolution cases in 2025, contributing to roughly 2.6 million arbitration decisions that favor higher out-of-network payments. Together, these dynamics are shifting negotiating leverage and raising claim costs for payers and employers.

3. Utilization and Pharmacy Trends Add Long-Term Pressure: Pharmaceutical spending continues to rise, with nearly 3.5 million GLP-1 prescriptions filled in December 2025—almost double the prior year’s volume. Many high-cost specialty therapies now serve broader populations and face limited market competition, reducing the effectiveness of traditional formulary controls. At the same time, behavioral health utilization has climbed 62.6% since 2018 and increased another 10% from 2023 to 2024, driven primarily by higher use rather than price hikes. These patterns suggest that both demand growth and therapeutic innovation will remain central cost drivers through the next decade.

About 67% of Employers Cover GLP-1s for Weight Management; That Could Decline in 2027

By Marissa Plescia – The high cost of GLP-1s is causing some employers to reconsider their coverage, a new survey from the Business Group on Health found. The survey received responses from 105 self-funded employers. It specifically examined GLP-1 coverage for weight management. The Business Group on Health is an advocacy organization for employers. Read Full Article...

HVBA Article Summary

1. Rising Costs Are Driving Coverage Reconsideration: The survey of 105 self-funded employers found that 80% say GLP-1 medications are increasing their healthcare costs. While 67% currently provide coverage for weight management, only 72% of those employers say they are likely to continue offering that benefit in 2027. Additionally, 10% indicated they are unlikely to maintain coverage for weight loss next year. These responses suggest that financial pressures are prompting companies to reevaluate long-term access to these drugs.

2. Employers Are Adding Guardrails to Manage Spending: Companies are implementing several cost-control strategies tied to GLP-1 coverage. These include verifying clinical eligibility with biometric data, restricting prescribing authority to certain providers, excluding some drugs from formularies and requiring participation in weight management programs. Most employers (83%) are also applying standard prescription cost-sharing structures rather than offering special or zero-cost benefits. Executive leadership is involved in coverage decisions at nearly 80% of organizations, underscoring the financial significance of these choices.

3. Demand Expected to Grow Despite Limited Evidence of Outcomes: More than half of employers covering GLP-1s anticipate meaningful clinical benefits, such as reduced obesity rates and fewer bariatric surgeries, although many say they have yet to see clear evidence. At the same time, 87% believe the introduction of oral GLP-1 medications will increase demand. Only 9% expect prices to decline, suggesting continued budgetary strain. Several major health plans and some state Medicaid programs have already dropped weight management coverage, reflecting broader concerns about affordability.

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)

Healthcare costs poised to jump 9% in 2027 as health plans blame AI adoption, drug prices

By Heather Landi – Health plans expect the cost of treating patients to climb in 2027, projecting the highest medical cost trend in nearly two decades with a 9% rise in commercial health costs, according to a new analysis from PwC. Payers are pointing the finger at several inflationary factors, including the increasing use of artificial intelligence tools by health systems, hospitals and medical practices. Read Full Article...

HVBA Article Summary

1. AI Adoption as a Cost Driver: Health plans report that provider use of AI-enabled documentation and coding tools is increasing billing intensity by capturing more detailed diagnoses and higher-severity codes. Seventy percent of surveyed plans ranked provider AI tools among their top three cost drivers for 2027. PwC cited research from UCSF Health showing AI scribe use was linked to higher relative value units per encounter and week without a rise in claim denials. In response, the firm recommends that payers shift payment integrity efforts upstream to validate high-risk claims before payment rather than relying primarily on post-payment recovery.

2. Pharmacy and Provider Price Pressures Intensify: Drug spending continues to outpace overall medical trends, with more than 85% of surveyed plans saying pharmacy costs are growing faster than total medical costs. Specialty medications and GLP-1 therapies are key contributors, and traditional formulary tools may not be sufficient as high-cost therapies expand to broader populations. At the same time, provider consolidation and inflationary pressures are strengthening hospitals’ negotiating leverage, contributing to higher reimbursement demands. PwC advises more disciplined contracting strategies and tighter performance monitoring to counter reimbursement drift.

3. Behavioral Health and Regulatory Impacts Add to Inflation: Utilization of behavioral health services rose 10% from 2023 to 2024 and has climbed 62% since 2018, with visit rates increasing from 828 to 1,346 per 1,000 people over that period. Prescription use has also surged, including a 53.3% increase in stimulant use and a 45.4% rise in antipsychotic use, signaling sustained demand rather than just price inflation. Meanwhile, providers prevailed in 88% of 2.6 million No Surprises Act dispute cases filed in 2025, making arbitration a reimbursement inflator. PwC recommends that payers refine out-of-network strategies and contracting approaches to better manage these mounting regulatory and utilization pressures.

2027 cost-sharing increases capped at 3.6% in Massachusetts

By Allison Bell – Massachusetts is sticking with a relatively new approach to protecting state residents against health care cost increases. The state now requires issuers of individual coverage and fully insured group coverage to limit increases in the enrollees' out-of-pocket costs to the Consumer Price Index inflation rate for the Boston area. For 2027, the cap will be 3.6%, officials announced last month. The state first began applying the out-of-pocket cost increase cap in 2026, which was initially 4.8%. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Cap Tied to Local Inflation Metric: Massachusetts links allowable increases in out-of-pocket health costs to the Boston-area Consumer Price Index, creating a formula-based limit rather than a fixed statutory percentage. By tying adjustments to a regional inflation measure, the state aims to align patient cost growth with broader economic conditions. This structure provides predictability for consumers while giving regulators a transparent benchmark for annual updates.

2. Applies to Individual and Fully Insured Group Plans: The rule covers both individual market policies and fully insured group health plans, extending protections beyond just one segment of the market. The cap affects deductibles, copayments and coinsurance, directly shaping what enrollees pay when they access care. However, self-funded employer plans are not referenced as being subject to the requirement, suggesting the policy’s reach may be limited to insured products regulated by the state.

3. Policy Trade-Offs and Market Impact: Supporters argue that limiting cost-sharing growth can shield families from sudden medical bills that may discourage them from seeking care. Critics of lower cost-sharing structures contend that requiring patients to pay more out of pocket can reduce unnecessary utilization, a concept often described as giving consumers “skin in the game.” The article notes that restraining out-of-pocket increases could shift financial pressure onto insurers, potentially contributing to higher premium growth for plan sponsors.

Drugmakers' 340B rebate fight, explained

By Ella Jeffries and Mackenzie Bean – For more than a year, major drugmakers have been pushing to replace the 340B program’s longstanding upfront discount structure with post-sale rebate models — drawing resistance from hospitals and federal regulators at every stage. What started as four lawsuits in late 2024 has since expanded into a federal pilot program, a new wave of enforcement actions, and an unresolved legal battle still working through the courts. Here is a timeline of 14 key developments since the lawsuits were filed. Read Full Article...

HVBA Article Summary

1. Manufacturers’ Shift From Discounts to Rebates: Several major drugmakers, including Johnson & Johnson, Eli Lilly, Sanofi and Bristol Myers Squibb, attempted to move 340B pricing from upfront discounts to rebate or credit-based systems. These models would require hospitals to purchase drugs at full commercial price and later seek reimbursement after submitting claims data. Hospital associations argued this approach would strain safety-net providers and violate the statute governing the program. Federal regulators initially signaled opposition, warning companies against unilateral implementation.

2. Courts and Regulators Remain Divided: Multiple federal district court rulings in 2025 upheld HRSA’s authority to oversee and require preapproval of manufacturer rebate models. At the same time, HRSA briefly reversed course by approving a limited rebate pilot tied to Medicare drug price negotiations before a Maine court blocked the initiative. The appellate courts have heard arguments in consolidated cases, but no final ruling has clarified the scope of HRSA’s authority. As a result, the broader legal question over rebate models remains unsettled.

3. Escalating Enforcement and Data Disputes: Beyond the core rebate litigation, Eli Lilly and Novo Nordisk have expanded requirements for hospitals to submit claims-level data to prevent duplicate discounts under the Inflation Reduction Act. Lilly reported that about 70% of covered entities—roughly 2,350 organizations—had complied, producing nearly 800,000 claims records since Jan. 1, and warned noncompliant hospitals of potential suspension from 340B pricing. Hospital groups contend these data demands are unlawful and have urged HRSA to intervene. The dispute reflects a growing clash not only over pricing structure but also over data transparency and program oversight.

How to keep employees safe on and off the clock

By Paola Peralta – Employees don't just want better pay and more flexible schedules, they want to know their organizations care about their health and safety. Each year, more than 2 million employees are victims of workplace violence, according to the Occupational Safety and Health Administration (OSHA), with over 5,000 of those incidents resulting in fatalities. However, by rethinking their current strategies and broadening their existing safety measures, leaders could play a role in preventing many of those occurrences from happening in the first place — and build a loyal and healthy workforce in the process. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Workplace violence remains a widespread threat: Federal data show that incidents of workplace violence affect millions of employees each year, with thousands of cases ending in death. Experts cited in the article argue that no industry is immune, reflecting broader societal tensions and safety concerns. Leaders are encouraged to rethink traditional safety protocols and adopt more comprehensive prevention strategies. A proactive approach can both reduce risk and strengthen employee trust.

2. Training and experience gaps increase injury costs: Research indicates that employees with less than one year of experience face significantly higher risks of injury, particularly from falls and equipment-related accidents. These incidents can result in substantial workers’ compensation payouts, creating financial strain for employers. Ongoing training and upskilling are positioned as essential tools for building a strong safety culture over time. Consistent education helps reduce preventable accidents and supports long-term workforce stability.

3. Psychological and cultural safety are critical components of protection: Beyond physical security, employees increasingly expect emotional and cultural safeguards, especially amid immigration enforcement actions and rising public safety fears. Surveys show that many workers feel less safe due to external factors, prompting demand for confidential reporting systems and stronger support networks. Experts emphasize that psychological safety — the ability to speak up without fear of retaliation — fosters collaboration and innovation. Organizations that address both physical and psychological risks are more likely to retain engaged and loyal employees.

Federal Fraud Watchdog Documents How Medicare Advantage Fails People When They Are Most Vulnerable

By Wendell Potter – When my mother broke her hip, I watched a Medicare Advantage plan try to cut her recovery short. I knew enough from my years in the industry to fight back — and eventually I got her out of that plan entirely and into traditional Medicare, where she could choose a quality skilled nursing facility without asking anyone’s permission. Two new federal reports released today confirm that what happened to my mother is happening to millions of people — and that the insurance companies doing it know exactly what they’re doing. Read Full Article...

HVBA Article Summary

1. High Denial Rates Followed by Frequent Reversals: Federal watchdog reports found that Medicare Advantage plans denied a notable share of prior authorization requests for post-acute care, including skilled nursing facility admissions. However, when beneficiaries appealed those denials, the vast majority were overturned in the patient’s favor. This pattern suggests that many initial denials may not withstand scrutiny and that outcomes often change when families challenge the decisions. The data raise questions about how prior authorization is being applied in practice.

2. Market Concentration Among Major Insurers: The three largest Medicare Advantage insurers — UnitedHealthcare, Humana, and CVS/Aetna — account for more than half of total program enrollment, representing over 20 million people. In many counties, a small number of insurers dominate enrollment, limiting practical choice for beneficiaries. Federal findings indicated that some of these large insurers denied certain types of post-acute care at higher rates than many competitors. The concentration of enrollment means that policies adopted by a few firms can affect a substantial portion of seniors nationwide.

3. Contractor Oversight and Vulnerable Populations: The reports highlighted the role of third-party contractors such as naviHealth, a UnitedHealth subsidiary, in processing prior authorization requests. Denial rates differed depending on whether requests were handled internally or by contractors, and a significant share of contractor-issued denials were later reversed on appeal. Particularly striking were the elevated denial rates for nursing home residents, a group the watchdog described as especially vulnerable. The Office of Inspector General called for stronger data collection and oversight from the Centers for Medicare & Medicaid Services to better monitor these practices.

Healthcare industry isn’t financially sustainable | HFMA 2026

By Ron Southwick – Nine in 10 healthcare leaders say they don’t believe the healthcare system is financially sustainable. That’s the sobering assessment of healthcare leaders, according to a survey released by Vitalic Health, which is backed by the Healthcare Financial Management Association. The report was released during the HFMA’s annual conference at the Gaylord National Resort and Convention Center. Most of those surveyed said they saw the long-term viability of the healthcare system eroding in the near future. Over three-quarters (77%) of the respondents said they thought the industry would reach an existential tipping point in the next three years. Read Full Article...

HVBA Article Summary

1. Affordability and Sustainability Are Intertwined: Ann Jordan, president and CEO of HFMA, argued that provider financial stability cannot come at the expense of patients through higher out-of-pocket costs. She emphasized that affordability has become a top concern for Americans, with families delaying or forgoing care due to rising prices. Jordan challenged executives to align institutional financial strategies with patients’ financial realities. The message was that long-term viability depends on balancing operational strength with accessible, affordable care.

2. Mixed Confidence in AI’s Financial Impact: The Vitalic Health survey found that 60% of respondents believe artificial intelligence will generate real cost savings rather than simply shifting expenses elsewhere. However, a sizable 40% are unconvinced that AI will meaningfully reduce spending. This split reflects both optimism about technology’s transformative potential and caution about overestimating its short-term financial returns. Leaders appear to see AI as part of the solution, but not a guaranteed fix.

3. Systemic Cost Drivers and Leadership Gaps: When asked about the main forces behind rising healthcare costs, half of respondents cited misaligned incentives among providers, payers and employers. Others pointed to administrative complexity (23%) and fee-for-service models that reward volume over value (20%). On the question of who should lead affordability efforts, the most common answer was that no single stakeholder can do it alone, with 33% favoring a neutral governing body and 27% pointing to the federal government. These responses suggest leaders view structural reform and coordinated action as essential to controlling costs.

ICHRA isn't a new product — it's a new role for brokers

By Stacy Edgar – I've been through thousands of individual coverage health reimbursement arrangement implementations and still remember what it felt like to not understand any of it. Not just the details — the entire concept. That's exactly where most brokers, employers and their employees are right now. And that makes sense. Group health insurance has been the only model in the employer-provided benefits space for 80 years. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. ICHRA requires a mindset shift for brokers: The author argues that ICHRA is not simply another insurance product but a fundamentally different approach to employer-sponsored benefits. After decades of relying on traditional group health insurance, brokers must unlearn long-standing habits and assumptions. Selling ICHRA demands greater comfort with ambiguity, broader carrier options and new advisory responsibilities. This transition positions brokers less as product sellers and more as strategic consultants.

2. Market conditions and infrastructure are improving: According to the article, educational resources and industry support for ICHRA have expanded significantly in recent years. The Affordable Care Act marketplace is described as more stable and competitive than in its early years, countering outdated perceptions of risk. Employers are increasingly exploring ICHRA options, creating momentum that brokers cannot ignore. Failing to proactively introduce ICHRA may result in clients hearing about it from competing advisers.

3. Successful implementation depends on preparation and cultural fit: The author emphasizes that poor rollouts can quickly erode trust if expectations are misaligned with reality. Brokers are encouraged to partner with experienced vendors and approach implementation as a collaborative learning process. Assessing workforce readiness is critical, as some employees and HR teams may prefer the familiarity of traditional group plans. When approached thoughtfully, ICHRA can provide employers with negotiation leverage and expand employee choice, but only if introduced under the right conditions.

GLP-1s Tied to Musculoskeletal Benefits in Obesity

By Javed Choudhury – In adults with obesity and without diabetes, using GLP-1s vs other antiobesity medications was significantly associated with a decreased risk for osteoporosis, major osteoporotic fractures, degenerative disk disorders, and osteoarthritis. Read Full Article...

HVBA Article Summary

1. Large Real-World Cohort Comparison: Researchers analyzed data from the global TriNetX Research Network, comparing 18,062 adults with obesity who received GLP-1 therapies to an equal number of matched patients treated with other weight-loss drugs. Participants had a mean age of 57.6 years and were predominantly women (72.76%), with an average BMI of 37.99. All patients had at least two prescriptions for their assigned medication class, and outcomes were tracked for up to 10 years with a 3-month lag to capture new events. This design aimed to strengthen comparability between groups while reflecting routine clinical practice.

2. Consistent Reductions Across Multiple Musculoskeletal Outcomes: GLP-1 therapy was associated with substantially lower relative risks for several skeletal conditions compared with non-GLP-1 medications. These included a 52% lower risk of new-onset osteoporosis (RR, 0.48; 95% CI, 0.43-0.52) and a markedly lower risk of major osteoporotic fractures (RR, 0.15; 95% CI, 0.11-0.22). Reduced risks were also observed for cervical disk degeneration (RR, 0.34), thoracolumbar disk disorders (RR, 0.36), and osteoarthritis (RR, 0.45). Subgroup analyses showed similar protective associations across age groups, sexes, BMI categories, and GLP-1 subtypes, with tirzepatide showing the greatest relative benefit.

3. Observational Limits and Data Gaps: Because the study was retrospective and observational, it cannot establish a direct cause-and-effect relationship between GLP-1 use and improved bone or joint outcomes. Diagnoses were identified through coding data, raising the possibility of misclassification or missed subclinical disease. The dataset also lacked information on bone mineral density, vitamin D and calcium intake, physical activity, and medication adherence, all of which may influence skeletal health. The authors reported no funding sources and no conflicts of interest.

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)

Do TPAs still lock up employer claims data? House hearing witness says yes

By Allison Bell – Many employers think they could do more to hold down spending at their health plans if they could get and analyze detailed, anonymized claims data. One obstacle is a tendency for health insurers and self-insured plan administrators to use indirect methods to keep the claims data out of employers' reach, according to Shawn Gremminger, president of the National Alliance of Healthcare Purchaser Coalitions. Gremminger, who leads an organization that represents employer-sponsored health plans and union plans with about 90 million participants, talked about the health plan data keepers' passive-aggressive approach to employer data requests Wednesday in Washington, at a hearing on health care cost transparency. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Indirect Barriers to Employer Data Access: Testimony at the House hearing suggested that insurers and third-party administrators often avoid outright refusals when employers request claims data. Instead, they may limit access to high-level summaries or attach significant fees to more detailed information. These tactics can make it difficult for self-insured employers to fully analyze spending patterns within their own plans. Witnesses characterized this approach as a subtle but persistent obstacle to transparency.

2. Legislative Push for Greater Transparency: Shawn Gremminger expressed support for the Patients Deserve Price Tags Act bill, arguing that it could strengthen employers’ ability to obtain meaningful claims data. The bill has bipartisan support in the House, with both Republican and Democratic cosponsors. Lawmakers at the hearing appeared receptive to proposals aimed at improving employer access to anonymized plan information. The discussion reflects ongoing congressional interest in using transparency tools to address rising health care costs.

3. Expanding the Scope of Price Disclosure Rules: Carol Skenes of Turquoise Health argued that existing federal transparency requirements are weakened by data gaps and inconsistent implementation. She urged Congress to codify certain regulatory requirements into law and broaden disclosure mandates beyond hospitals to other types of providers. Skenes also said providers should disclose prices charged to self-pay patients and stop-loss issuers, not just to insured patients. Lawmakers repeatedly questioned whether current transparency measures are effectively helping stakeholders reduce costs.

CMS received nearly 15K NSA complaints, mostly against providers

By Jacqueline LaPointe – A vast majority of the complaints CMS receives about the No Surprises Act are against healthcare providers, as payers continue to take issue with their surprise medical billing practices. CMS has accepted complaints about potential violations of the Public Health Service Act, including the No Surprises Act, since 2022. These come from information CMS receives from healthcare stakeholders, referrals from federal and local lawmakers, No Surprises Act Help Desk complaints and news articles. Read Full Article...

HVBA Article Summary

1. Most Closed Complaints Target Providers: Of the complaints CMS has closed related to the No Surprises Act, the majority were filed against healthcare providers rather than insurers. Thousands of these cases involved providers, facilities and air ambulance services. By contrast, a smaller but still notable number of complaints were directed at payers and non-federal government plans. The data indicates that provider billing practices remain a primary focus of enforcement activity.

2. Common Allegations Involve Emergency and In-Network Settings: A significant portion of provider-related complaints centered on surprise billing for non-emergency services delivered at in-network facilities, as well as for emergency services. Additional allegations involved failures to comply with the law’s good faith estimate requirements for uninsured and self-pay patients. These patterns suggest ongoing operational challenges in meeting transparency and patient protection standards. They also highlight areas where CMS may continue prioritizing oversight and compliance efforts.

3. Payer Compliance and IDR Disputes Remain Contentious: Complaints against insurers most frequently involved issues such as qualifying payment amount calculations, delayed payments following independent dispute resolution determinations and missed deadlines for initial payments or denial notices. Disagreements between providers and payers over IDR eligibility and payment calculations have contributed to dispute backlogs. In response, CMS recently finalized rule changes aimed at improving batching, communication and negotiation processes within the federal IDR system. The agency expects these updates to take effect by early September to address inefficiencies and reduce dispute volumes.

White House warns 500+ hospitals to post price information or face fines: Report

By Andrew Cass – The Trump administration has sent warning letters to 519 hospitals nationwide citing them for failing to provide transparent pricing information, the Associated Press reported June 9. The AP exclusively received a list of hospitals that have either received warning letters or requests to submit plans to provide transparency pricing since April. A senior administration official who requested anonymity told the news outlet that President Donald Trump plans to ramp up price transparency enforcement and more hospitals are likely to receive letters for failure to comply. Read Full Article...

HVBA Article Summary

1. Renewed Federal Enforcement Push: The administration is increasing scrutiny of hospital compliance with federal price transparency regulations first introduced in 2019 and implemented in 2021. A senior official indicated that additional enforcement actions are likely as the White House emphasizes stricter oversight. In February 2025, President Trump signed another executive order directing multiple federal departments to rapidly implement and enforce the rules. The broader policy agenda also calls for providers and insurers accepting Medicare or Medicaid to prominently display pricing information.

2. Geographic Spread and System Impact: Hospitals in Texas received the highest number of warning letters at 42, followed by California with 38 and Indiana with 34. Every state except Alaska had at least one hospital cited, underscoring the nationwide scope of enforcement. Large systems were also affected, including Ascension, which had 13 hospitals receive letters across multiple states. Some organizations, such as MD Anderson Cancer Center, characterized their issues as minor technical or formatting errors that were corrected after notification.

3. Compliance History and Financial Penalties: Since the transparency law took effect, CMS has issued fines to 28 hospitals for alleged violations. Enforcement activity has continued in recent years, with 10 hospitals fined in 2025 and one hospital fined so far in 2026. New rules that took effect April 1 added requirements around machine-readable files, executive attestation of data accuracy and additional reporting details. Hospital representatives say most members are complying but argue the current system could function more effectively for patients.

Trustees expect Medicare Trust Fund's reserves to run out in 2033

By Paige Minemyer – A new report suggests that the Medicare Trust Fund's reserves will run dry in 2033, leaving the program unable to pay for all scheduled benefits. The Social Security and Medicare Boards of Trustees have released their annual reports, which suggest that Medicare Part A will be able to cover 100% of benefits through the second quarter of 2033, at which point the fund's reserves will be depleted. Read Full Article...

HVBA Article Summary

1. Trust Fund Depletion Timeline and Coverage Impact: The trustees project that Medicare Part A will be able to fully pay scheduled benefits until the second quarter of 2033. After reserves are exhausted, incoming revenue would cover only 89% of benefits. Part A finances inpatient hospital services, skilled nursing, home health and hospice care, making its solvency central to core Medicare services. The updated projection moves the depletion date up by one quarter compared to last year’s estimate.

2. Drivers Behind the Worsening Outlook: The report attributes the accelerated depletion to multiple financial pressures. Trustees expect higher healthcare utilization to persist, which would increase spending from the fund. They also cite upward revisions in per capita spending for Medicare Advantage plans. In addition, lower projected tax revenue following passage of H.R. 1, the One Big Beautiful Bill Act, contributes to the weaker financial outlook.

3. Broader Fiscal Context and Other Medicare Funds: The trustees anticipate that the Medicare Trust Fund will begin running annual deficits in 2027, with medical costs rising faster than income through 2041. This contrasts with a Congressional Budget Office estimate that projects the trust fund will be depleted in 2040, reflecting differing assumptions. While Part A faces funding challenges, the report states that disability insurance is funded through at least 2100. Medicare Part B and Part D are projected to remain fully funded indefinitely.

Some US employers to drop coverage of GLP-1 obesity drugs in 2027 as use increases

By Amina Niasse – Some employers are planning to drop coverage of GLP-1 drugs for weight loss next year as more people take the medications, counteracting some savings from lower prices for Novo Nordisk's (NOVOb.CO), Wegovy and Eli Lilly's (LLY.N), Zepbound and Foundayo. Read Full Article...

HVBA Article Summary

1. Employers reassess coverage as demand grows: Surveys show that a portion of employers intend to stop covering GLP-1 weight-loss drugs in 2027, even as usage continues to climb. One employer group found that 10% of companies currently offering coverage plan to drop it, while a separate Mercer survey reported 5% of large employers expect to do the same. At the same time, coverage remains common, with 44% to 67% of large employers offering the benefit depending on the survey. The mixed data highlights how companies are balancing employee demand with mounting cost pressures.

2. Lower prices and new pills have not reduced overall spending: Although manufacturers have introduced lower-cost oral versions such as Wegovy and Foundayo at starting prices around $149 per month, overall employer spending remains elevated. Industry experts say expanded eligibility and long-term use are offsetting per-unit price declines. Oral options have also attracted new patients who previously avoided injectable treatments, further expanding the user base. As a result, aggregate costs continue to rise despite discounted pricing initiatives.

3. Transparency and purchasing channels influence employer strategy: Employers are increasingly comparing pharmacy benefit manager pricing with direct-to-consumer and government-negotiated prices offered through drugmaker websites and programs like TrumpRx.gov. Some benefits leaders say greater transparency is revealing pricing gaps and prompting employers to rethink how they provide access. Health insurer Cigna’s decision to stop covering the drugs for its own employees illustrates how companies may steer workers toward alternative purchasing options. Consultants expect overall GLP-1 coverage to decline next year as employers seek better cost control mechanisms.

Initiative looks at how caregiving impacts workplace benefits

By Susan Rupe – About 1 in 4 adults in the U.S. are unpaid caregivers to a family member or friend, and about 7 in 10 of those caregivers are in the workforce. This means that about 44 million people are juggling caregiving duties with paid employment. Caregiving is reshaping the workplace, employee benefits and long-term financial security. Read Full Article...

HVBA Article Summary

1. A National Effort to Study Caregiving’s Workplace Impact: The Employee Benefit Research Institute and Greenwald Research have launched a multi-year initiative titled Caregiving at Work. Running through 2027, the project will combine survey research, public events and digital resources. Its goal is to better understand how caregiving responsibilities influence workforce participation and the design of employee benefits. The effort reflects growing recognition that caregiving pressures are reshaping employer obligations and worker experiences.

2. Research Focused on Benefits and Return on Investment: The initiative will integrate caregiving-related questions into EBRI’s major surveys, including those focused on retirement confidence, workplace wellness and healthcare engagement. In addition, the organizations will conduct new data analysis examining the return on investment of caregiving benefits. This research is intended to measure both employer outcomes, such as productivity and financial performance, and employee outcomes, such as confidence and engagement. Findings and recommendations are scheduled for publication at the conclusion of the initiative.

3. Broad Stakeholder Dialogue on Benefit Design: Organizers emphasize the need for collaboration among employers, benefits providers and retirement service firms to address caregiving challenges. They point to demographic trends, workforce shortages in direct care and limited federal support as converging pressures. Planned activities include in-person forums, webinars and a dedicated digital platform to share resources and research insights. The initiative aims to inform policymakers and industry leaders about how caregiving affects employee stress, benefit usage and long-term financial security.

Success in self-insurance hinges on preparation

By Louis C. Bernardi – For decades, fully insured health plans have been the comfortable choice. They are familiar. Predictable. Easy to explain. When a plan sponsor renews with the same carrier year after year, there's a sense of stability in that decision, even when premiums climb and transparency remains limited. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Perceived disruption often stems from education gaps, not funding changes: The article argues that disruption in self-insured plans is less about how a plan is financed and more about confusion surrounding new administrative partners. When employers shift to independent TPAs or carve-out PBMs, providers may default to old processes and assumptions. Misrouted claims, incorrect benefit verifications and authorization delays can follow. These issues are framed as transition challenges that can be mitigated through clearer communication rather than inherent flaws in self-funding.

2. Familiar networks can mask backend changes: Many self-insured employers continue to rent established provider networks, meaning doctors and employees may see the same logos and directories. However, behind the scenes, claims administration and pharmacy management may be handled by different entities. Provider offices often rely on routine and may send paperwork or verify benefits through the wrong systems. This disconnect can create friction unless stakeholders are clearly informed about the new operational structure.

3. Proactive communication determines transition success: The most effective self-insurance transitions involve deliberate preparation before the plan’s effective date. Employers and advisers who clearly explain partner roles, contact points and verification processes help members navigate the new setup confidently. Setting realistic expectations about a short adjustment period can prevent minor issues from being perceived as systemic failures. According to the author, thoughtful preparation ultimately strengthens trust, improves member experience and supports long-term cost control and transparency.

Large Study Links GLP-1s to Lower Risk of Multiple Cancers

By Charles Bankhead – Patients taking GLP-1 receptor agonists for obesity had a 41% lower risk of obesity-related cancers as compared with patients treated with diet or exercise, a large propensity-matched cohort study showed. After 2 years of follow-up, the GLP-1 group had a cumulative hazard ratio of 0.59 for eight obesity-associated cancers. Analyses of the different cancers showed a consistently lower risk for GLP-1 users, achieving statistical significance for five of the eight cancers evaluated. The risk reduction exceeded 50% for multiple myeloma, pancreatic cancer, endometrial cancer, and colorectal cancer. Men and women alike had significant risk reductions with GLP-1 drugs. Read Full Article...

HVBA Article Summary

1. Large Real-World Cohort and Matching Methods: The study drew on the TriNetX clinical database to identify 229,467 adults with obesity but without diabetes who were treated between 2014 and 2025. After propensity matching, two cohorts of 80,899 patients each were analyzed, with a median age of 47 and a population that was predominantly female and white. Investigators required 2 years of follow-up and excluded patients with diabetes or combination therapy to better isolate the association with GLP-1 use. The primary endpoint was the cumulative incidence of 13 obesity-associated cancers.

2. Broad and Site-Specific Risk Reductions: GLP-1 use was associated with lower incidence across multiple cancer types, including multiple myeloma, pancreatic, endometrial, colorectal, thyroid, kidney, ovarian, and breast cancers. The largest relative reductions were observed for hematologic and gastrointestinal malignancies, with statistically significant hazard ratios for several tumor types. Men experienced a greater relative reduction in overall cancer risk compared with women. Some site-specific estimates, such as kidney and ovarian cancer, did not reach clear statistical significance.

3. Differences Between GLP-1 Agents and Ongoing Research: Both semaglutide and tirzepatide were linked to reduced cancer risk, but tirzepatide was associated with a substantially larger relative reduction than semaglutide. Researchers noted that tirzepatide’s dual activity on GIP and GLP-1 receptors, along with possible anti-inflammatory effects, could help explain the difference, though this remains speculative. Investigators emphasized that the findings demonstrate association rather than causation. Prospective trials, including a newly launched breast cancer prevention study, are expected to further explore potential preventive effects.

Rising out-of-pocket costs force families to skip needed health care

By Alan Goforth – Nearly half of working-age Americans struggled to afford health care in 2025, and more than one-third said someone in their family had unmet health care needs because of high costs. "Affordability of health care is everyone's concern, not just people who are uninsured," said Katherine Hempstead, senior policy advisor at the Robert Wood Johnson Foundation. "In addition to rising premiums, higher out-of-pocket costs make many people less secure and potentially less healthy as they avoid needed care." Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Affordability Challenges Extend Beyond the Uninsured: The research found that cost pressures affect people across all types of coverage, not just those without insurance. A significant share of individuals with employer-sponsored plans reported difficulty paying for care, and the percentages were even higher among those buying coverage on their own or enrolled in Medicaid. These findings indicate that having insurance does not necessarily shield families from financial strain. The issue is systemic and cuts across coverage categories.

2. Vulnerable Populations Face Disproportionate Strain: Working-age adults with disabilities and those in fair or poor health reported especially high levels of affordability problems. People with chronic conditions such as stroke, COPD, cancer, heart disease or diabetes were also more likely to struggle with costs. In addition, more than half of Black and Hispanic adults, residents of Southern states and people in rural communities reported difficulty affording care. The data suggest that health and socioeconomic disparities are closely tied to financial barriers in accessing treatment.

3. Medical Debt and Policy Changes Could Worsen Trends: Unmet health care needs were the most common financial consequence cited, but many families also reported taking on debt or struggling to pay medical bills. Researchers warn that recent federal policy shifts affecting Medicaid and ACA Marketplace coverage could increase the number of uninsured people. They also note that if employers continue shifting rising health costs onto workers through higher premiums or deductibles, affordability pressures are likely to intensify. Together, these factors could further limit access to necessary care for working families.

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 Margin Myth: Why One of the Insurance Industry’s Favorite Talking Points is Designed to Mislead You

By Wendell Potter – When UnitedHealth Group reported its first-quarter 2026 results, it disclosed something that didn’t make many headlines: an annualized return on equity of 26.2%. That number — not the profit or operating margin — is what Wall Street uses to evaluate whether a business is making good use of the money investors have put into it. And by that measure, UnitedHealth wasn’t just profitable, it was posting returns that outpace the broader S&P 500, dwarf most of its sector peers, and rival industries that Americans actually regard as highly lucrative. So why do we keep hearing about margins? Read Full Article...

HVBA Article Summary

1. Profit Margins vs. Return on Equity: The article argues that health insurers emphasize profit margins because they appear modest when expressed as a percentage of revenue. However, return on equity (ROE) better reflects how effectively a company turns shareholder investment into profit. By focusing on margins, insurers can frame themselves as operating on thin profits, even when returns to shareholders are comparatively high. The distinction between these two metrics is central to understanding the industry’s financial performance.

2. Revenue Scale and Financial Leverage Amplify Returns: Large insurers operate with enormous revenue streams and comparatively smaller equity bases, which magnifies their ROE even if net margins seem moderate. The use of premium “float” — collecting premiums before paying claims — allows companies to generate significant investment income on funds held temporarily. This structure increases overall returns without requiring unusually high margins. As a result, modest-looking profitability ratios can translate into substantial gains for investors.

3. Policy and Regulatory Implications: The author contends that margin-based arguments are often deployed in legislative debates to resist reforms such as limits on Medicare Advantage payments or stricter medical loss ratio rules. By presenting themselves as low-margin businesses, insurers can argue they lack room for additional regulation. Yet comparative sector data show leading insurers generating returns that rival or exceed many other industries. This discrepancy, the article suggests, should factor into policymaker assessments of the industry’s financial health.

Trump administration warns over 500 hospitals to provide more price information or face fines

By Josh Boak – The Trump administration has warned more than 500 hospitals that they are failing to provide the public with basic pricing information — arguing that the lack of disclosure is keeping healthcare costs higher than they should be. Read Full Article...

HVBA Article Summary

1. Escalating Enforcement of Price Transparency Rules: The administration has sent warning letters to hundreds of hospitals and, in more serious cases, required corrective action plans. Facilities that fail to comply could face fines of up to $2 million annually. Officials say the effort builds on a 2019 executive order and signals stricter oversight ahead. More hospitals may receive similar notices as enforcement expands.

2. Political and Policy Context Around Healthcare Costs: The warnings come as affordability remains a major voter concern heading into the November midterms. Polling from AP-NORC shows relatively low public approval of Trump’s healthcare policies, underscoring the political stakes. The administration is framing transparency as a market-based way to lower costs, while critics note previous policy decisions affecting insurance subsidies. The debate highlights broader partisan differences over how to manage rising medical expenses.

3. Mixed Industry Response and Implementation Challenges: Hospital groups say most facilities are complying with federal requirements, but acknowledge the current system can be confusing for patients. Some large systems cited technical or formatting issues rather than intentional noncompliance and said corrections were made after notification. Experts note that pricing data can be difficult for consumers to interpret without specialized knowledge, limiting its immediate usefulness. Even so, policy analysts argue that improved transparency could help employers and consultants compare prices and encourage competition over time.

New House bill targets PBMs, insurers with enforceable transparency rules

By Kristen Smithberg – A new federal proposal aims to tighten oversight of health care "middlemen" and strengthen enforcement of existing transparency requirements across the health care system. Nick Langworthy, a Republican congressman from New York, has introduced the Clear Healthcare Expense Cost Knowledge (CHECK) Act, legislation designed to expand transparency obligations across pharmacy benefit managers (PBMs), third-party administrators (TPAs), insurers and health care providers, while adding stricter disclosure timelines and enforcement mechanisms aimed at improving accountability across the system. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Expanded Reporting and Anti-Gag Clause Measures: The CHECK Act would require PBMs, TPAs and insurers to provide more detailed claims, pricing, rebate and payment data to health plans. It also seeks to eliminate contractual provisions that prevent employers from accessing complete spending information. By mandating quarterly disclosures to health plans, the bill aims to give employers clearer insight into how health care dollars flow through intermediaries. Supporters argue this could improve purchasing decisions and cost oversight.

2. Stricter Billing and Patient Disclosure Requirements: The proposal would require insurers to deliver more detailed Explanation of Benefits statements within 45 days of claims processing. These statements would need to include plain-language descriptions of services, billing codes, insurer payments and patient cost-sharing responsibilities. Health care facilities would also have to provide itemized bills before attempting collections. In addition, providers would be limited in charging more than prior estimates unless medically necessary changes or patient-requested adjustments can be demonstrated.

3. Shift Toward Enforcement-Driven Transparency: Unlike earlier transparency efforts that focused primarily on disclosure, the CHECK Act emphasizes enforceability and accountability. The legislation applies broadly to ERISA-regulated plans as well as self-funded, non-federal governmental plans, expanding its reach across the employer-sponsored market. Employer groups have generally supported greater access to claims and pricing data but warn about potential administrative burdens. Meanwhile, PBMs and insurers have raised concerns about reporting complexity and the impact on negotiated pricing, while patient advocates have backed measures aimed at reducing surprise billing.

The billion-dollar blind spot in employee benefits – and why AI is finally fixing it

By Kevin Dunn – Every executive understands the importance of controlling costs. Finance teams scrutinize procurement contracts, audit expense reports and negotiate relentlessly with vendors. Across the United States, employers spend billions of dollars each year on health, dental, vision, life, disability and voluntary benefits for their employees. But few leaders realize how often the invoices for those benefits are wrong. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Widespread billing discrepancies create hidden losses: Industry audits show that between 70% and 90% of benefits carrier invoices contain at least one error. These discrepancies range from billing for terminated employees to outdated premium rates and duplicate enrollments. While each mistake may appear minor, together they can amount to substantial financial leakage. The article argues that many organizations underestimate how frequently these errors occur and how long they persist.

2. Even modest error rates can significantly impact finances: For a mid-sized employer with 500 employees and $10 million in annual benefits spending, small error percentages translate into large dollar amounts. A 5% billing error rate could mean $500,000 in annual overpayments, while a 10% rate could exceed $1 million per year. Because companies often lack systematic reconciliation processes, these overpayments may continue for years. The result is reduced operating margins, distorted forecasts and less capital available for strategic priorities.

3. AI enables more rigorous financial and compliance oversight: Traditional spreadsheet-based reconciliation struggles to manage retroactive adjustments, eligibility changes and multi-carrier rate updates. AI tools can analyze HR, payroll and carrier data simultaneously, validating invoices at the individual employee level and flagging inconsistencies quickly. This shift transforms reconciliation from a reactive administrative chore into a proactive financial control. The article also notes that stronger oversight supports ERISA fiduciary obligations and growing regulatory expectations around plan governance.

PSG report examines payers and employers’ attitudes towards GLP-1 coverage, unbundling’ PBM models

By Cailey Gleeson – Despite steady demand for obesity medications, 49% of payers who do not currently cover GLP-1s for obesity would not do so at any price, a new report from Pharmaceutical Strategies Group (PSG) found. The 2026 Trends in Drug Benefit Design report drew insights from a survey of 237 benefits leaders across employers, health plans and unions. Read Full Article...

HVBA Article Summary

1. Affordability Drives GLP-1 Coverage Decisions: The survey of 237 benefits leaders found widespread concern about the cost of GLP-1 medications, with nine in 10 respondents at least moderately worried about affordability. Additionally, 72% said discontinuation rates play a meaningful role in determining whether to offer coverage. Among those excluding obesity coverage, 45% cited overall expense, while others pointed to perceptions of the drugs as lifestyle treatments or concerns about long-term return on investment. For plans open to covering GLP-1s, the average annual amount they are willing to pay is $3,000.

2. Growing Interest in Unbundled PBM Models: The report shows that 60% of health plans and 51% of employers would consider partially or fully unbundling pharmacy benefit manager services. Respondents indicated that alternative pricing arrangements such as pass-through and cost-plus models are increasingly familiar, with 61% of payers already using pass-through pricing. Decisions about adopting these models are largely driven by their effect on total net pharmacy costs as well as member affordability and experience. Executives suggest unbundled arrangements may offer greater transparency and control over pharmacy benefits management.

3. Cost-Sharing Changes and Direct-to-Consumer Options on the Rise: Nearly 69% of respondents are weighing at least one adjustment to member cost sharing, and 43% are specifically considering higher copays or coinsurance. However, most payers view cost-transparency tools as offering only moderate value and believe relatively few members use them. Awareness of direct-to-consumer platforms is high for established players like GoodRx at 91%, though familiarity with newer options ranges from 54% to 66%. About half of payers use discount card or direct-to-consumer strategies but cite concerns such as member confusion and reduced claims visibility.

AI 411: May 2026

By Cassie McGrath – Welcome back to AI 411, a monthly roundup of tech announcements from across the healthcare industry. This month, Healthcare Brew spoke with GE HealthCare about its free program to train healthcare workers on how to use AI. We also broke down how new HIPAA rules may not be keeping pace with how quickly health tech is adopted. But that’s not all that’s happened lately. Here’s your breakdown of May news. Read Full Article...

HVBA Article Summary

1. Startup Funding and Investment Activity: Several healthcare AI companies announced new funding rounds in May, signaling continued investor interest in the sector. Basta raised a $21 million Series A to support its AI tools aimed at improving hospital workflows such as scheduling and phone management. H1 secured a $40 million investment round led by CVS Health Ventures, highlighting strategic backing from established healthcare players. These moves suggest sustained capital flow into AI solutions targeting operational and data-driven challenges.

2. Major Healthcare Companies Expand AI Training and Integration: CVS Health launched an AI Learning Academy to educate its workforce about emerging technologies, reflecting a broader push to build internal AI literacy. GE HealthCare also promoted a free training program designed to help clinicians better understand and apply AI tools in practice. These initiatives indicate that large healthcare organizations are investing not only in AI products but also in workforce readiness. The focus on training underscores recognition that adoption depends on employee competence and trust in the technology.

3. AI Applications Span Clinical Care, Wearables, and Long-Term Management: Partnerships and product launches in May showed AI being applied across diverse care settings. Oura Health teamed up with Counsel Health to connect wearable data with access to physicians, aiming to act on health insights generated by devices. Twin Health introduced a GLP-1 Stewardship Model to reduce long-term dependence on weight loss drugs using its digital twin technology, while WellSky rolled out CareQueue to streamline workflows in nursing and long-term care facilities. Together, these developments demonstrate how AI is being embedded in both direct patient care and backend operational systems.

Anubis ransomware gang claims credit as Mississippi hospital reveals attack impacted 54K patients

By Chad Van Alstin – A health system in Mississippi has revealed a December 2025 data breach of its network resulted in records on 53,888 patients being stolen by hackers. Meanwhile an infamous cybercrime cell has claimed credit for the attack, posting proof on the dark web. Read Full Article...

HVBA Article Summary

1. Scope and Reporting of the Breach: Singing River Health System reported the incident to the U.S. Department of Health and Human Services’ Office for Civil Rights after discovering unauthorized access to its network. The intrusion occurred over a three-day period in December 2025 before containment measures were deployed. An internal investigation, supported by a third-party cybersecurity firm, determined that tens of thousands of patient records were compromised. The disclosure adds the organization to the federal data breach tracker that monitors large healthcare incidents.

2. Sensitive Data and Patient Response Measures: The compromised information included highly sensitive data such as Social Security numbers, treatment details, diagnostic results, medication lists and financial information. Affected individuals were notified and advised to monitor their financial accounts for suspicious activity. The health system also offered complimentary credit monitoring services to impacted patients. In response to the breach, officials said they implemented additional security upgrades to strengthen their systems.

3. Anubis’ Claims and Broader Cybersecurity Concerns: Researchers at Comparitech reported that the ransomware group Anubis claimed responsibility for the attack, alleging it obtained 293 GB of data and more than 1.2 million files. The group posted sample materials on its dark web leak site to substantiate its claim and criticized the hospital’s security posture, referencing a previous 2023 ransomware incident that affected more than 895,000 people. Anubis has reportedly claimed 35 ransomware attacks in 2026, including 17 targeting U.S. healthcare organizations. Singing River has not confirmed the gang’s assertions, and it remains unclear whether any ransom was demanded or paid.

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Cities sue Trump administration to block final ACA rule

By Paige Minemyer – A group of cities is suing the feds to challenge recently finalized changes to the Affordable Care Act's marketplaces, which they say could lead 3 million people to lose coverage. The lawsuit is led by Columbus, Ohio; Chicago and Baltimore, alongside Pima County, Arizona. In addition, Doctors for America and the Main Street Alliance are plaintiffs in the suit. In the complaint, they argue that the effects of the final rule are "directly contrary to the landmark legislation" due to the potential coverage losses. Read Full Article...

HVBA Article Summary

1. Cities and advocacy groups challenge ACA marketplace changes: Columbus, Chicago, Baltimore and Pima County, Arizona are leading the lawsuit, joined by Doctors for America and the Main Street Alliance. The plaintiffs argue that the final rule undermines the ACA’s core mission by creating additional hurdles to obtaining coverage. They contend the changes contradict the intent of the landmark health law and could reverse progress in expanding insurance access.

2. Concerns over expanded plan flexibility and consumer risk: The final rule expands access to catastrophic and non-network plans and loosens limits on non-standard plan designs, while introducing new cost-sharing parameters in certain tiers. Industry groups have warned that these options may expose consumers to higher out-of-pocket costs or coverage gaps. Critics say the changes could destabilize a marketplace already experiencing enrollment churn and uncertainty.

3. Legal arguments focus on procedure and statutory conflicts: Beyond policy disagreements, the plaintiffs claim the rule violates federal law and was issued without proper administrative process. They allege regulators failed to adequately justify provisions or meaningfully address public comments. The lawsuit seeks to block the rule before its July 20 effective date, either by having it set aside or by securing a judicial stay, as a separate 2025 ACA rule change remains tied up in court.

Sun Life subsidiary faces lawsuits after mass data breach

By Allison Bell – A big dental insurance company is coping with a data breach that may have exposed the personal information of 2.6 million people. DentaQuest, a Wellesley Hills, Massachusetts-based subsidiary of Sun Life Financial, has warned customers and other associates about the breach in a notice posted recently on its website. "DentaQuest is actively managing a cybersecurity incident involving unauthorized access to a limited portion of our network," the company says in the notice. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Class-Action Litigation Following the Breach: At least six lawsuits have been filed in the U.S. District Court for the District of Massachusetts on behalf of affected individuals. Plaintiffs are seeking to form a nationwide class of impacted U.S. residents, excluding certain affiliated parties and court personnel. Some complainants allege that the exposed data could include highly sensitive information such as Social Security numbers, dates of birth and medical details. The litigation adds legal pressure to the company as it responds to the cybersecurity incident.

2. Role of ShinyHunters and Scope of the Data: The cyberattack group ShinyHunters posted a 234-gigabyte file in May that it claimed contained DentaQuest customer records and said the company declined to pay a ransom. The breach tracking service Have I Been Pwned reported that the file includes 2.6 million email addresses along with associated contact information. ShinyHunters has been linked to other insurance and benefits-related breaches in recent years, including incidents involving Canada Life and Kemper Corp. The group has also been associated with disruptions to U.S. college learning management systems.

3. Part of a Broader Health Care Cybersecurity Trend: The DentaQuest incident comes amid continued cyberattacks targeting health care and benefits organizations. Earlier in 2026, TriZetto Provider Solutions disclosed a breach affecting millions of patient records, underscoring the sector’s vulnerability. A related report noted that health care cyberattacks surged 55% in 2025, highlighting escalating risks. Regulators and courts are increasingly handling complex, consolidated breach cases through multidistrict litigation processes.

Eli Lilly's claims data deadline may kick off new 340B fight

By Nicole DeFeaudis – Eli Lilly’s deadline has passed for hospitals to comply with its new 340B claims data policy, and for now the pharma company is staying mum on its next steps. But just because Lilly is declining to comment doesn’t mean the issue is going away. Neal Masia, a health policy professor at Columbia who also spent almost 18 years at Pfizer, told Endpoints News on Tuesday that he wouldn’t be surprised if the issue makes it to court. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Lilly Implements New 340B Data Reporting Requirement: Eli Lilly has required hospitals participating in the 340B drug discount program to submit claims-level prescription data in order to continue receiving discounted drug pricing. The company says the policy is designed to improve transparency and help identify fraud, waste, and abuse within the program. Hospitals that fail to comply risk losing access to 340B discounts, though the number of remaining noncompliant providers remains unclear.

2. Hospital Groups Challenge Legality of the Policy: Hospital organizations, including the American Hospital Association, argue that Lilly’s requirement is not authorized under current 340B law and could create additional administrative burdens. Legal experts have also raised concerns that conditioning discounts on data-sharing requirements may establish a precedent for future restrictions. The AHA has urged the Department of Health and Human Services to block the policy, but the agency has not publicly responded.

3. Dispute Reflects Broader Debate Over 340B Oversight and Reform: Lilly’s policy is the latest development in a long-running conflict between pharmaceutical manufacturers and healthcare providers over the operation of the 340B program. Drugmakers have increasingly sought greater oversight and transparency measures, while hospitals have challenged efforts they view as limiting access to program benefits. Some stakeholders support reforms that improve accountability and visibility into how 340B savings are used, while others emphasize protecting resources intended to support patient care.

Retatrutide Data Show Dramatic Weight Loss, Other Benefits

By Miriam E. Tucker – The investigational triple GLP-1/GIP/ glucagon receptor agonist retatrutide produced significant weight loss and A1c reduction in people with type 2 diabetes (T2D), according to full data from the TRANSCEND-T2D-1 trial. And in people with obesity without T2D, the drug led to significant weight loss and improvements in osteoarthritis knee pain and obstructive sleep apnea, further results from the TRIUMPH-1 trial showed. Improvements in cardiovascular risk factors were seen in both trials. Read Full Article...

HVBA Article Summary

1. Substantial Glycemic and Weight Effects in Type 2 Diabetes: In the 40-week TRANSCEND-T2D-1 trial of 537 participants with inadequately controlled type 2 diabetes, retatrutide significantly reduced A1c compared with placebo across all tested doses. Higher proportions of treated patients achieved stringent glycemic targets, including levels below 7.0% and even 5.7%. The drug also produced double-digit percentage weight loss, with the highest dose leading to an average reduction exceeding 15% of body weight. Investigators described the magnitude of weight loss in people with diabetes as unprecedented for a phase 3 medication trial.

2. Marked and Durable Weight Loss in Obesity Without Diabetes: In the larger TRIUMPH-1 study of 2339 adults with obesity, participants receiving the highest dose experienced average weight reductions approaching 30% at 80 weeks, with further losses seen in a 104-week extension. Nearly half achieved at least 30% weight loss, and many moved below the BMI threshold for obesity. Beyond weight, nested analyses showed clinically meaningful improvements in knee osteoarthritis pain scores and reductions in apnea-hypopnea index among those with obstructive sleep apnea. These findings suggest the therapy may influence multiple obesity-related complications, not just body weight.

3. Cardiometabolic Gains and Emerging Safety Signals: Across both trials, retatrutide was associated with improvements in triglycerides, non-HDL cholesterol, systolic blood pressure, and waist circumference. Gastrointestinal side effects such as nausea, diarrhea, and constipation were common but generally mild to moderate and consistent with other incretin-based drugs. A new signal for urinary tract infections emerged, particularly among women, prompting calls for further monitoring. Experts emphasized the need for careful dosing and longer-term safety data, questioning whether maximal weight loss is necessary or appropriate for every patient.

Why health data sharing is leaving patients exposed

By Tina Reed – The push to make medical records easier to share could be opening the door for rogue companies to sell patient information to law firms and other businesses without their knowledge. Why it matters: Americans assume their medical records are only seen by doctors, nurses and others involved in their care. But the rapid growth of health tech vendors and data sharing platforms is creating security gaps — just as AI is making it easier to mine personal medical data. Read Full Article... 

HVBA Article Summary

1. Lawsuits highlight alleged misuse of patient data: Electronic health records company Epic and three health systems are suing Health Gorilla, alleging that third parties gained access to more than 300,000 medical files through its data-sharing platform. One company, GuardDog Telehealth, admitted in a consent agreement that it obtained records under false pretenses and sold them to lawyers seeking clients for class-action lawsuits. Epic also accused another provider, SelfRx, of improperly accessing over 100,000 patient records, though it later dropped claims after the company’s founder disputed the scale of access. The case underscores how patient data may be vulnerable when verification processes fail.

2. Interoperability efforts create new security challenges: Health and technology companies have spent years building systems to allow medical records to move more seamlessly across providers in order to reduce errors and inefficiencies. However, the lawsuit suggests that weaknesses in identity verification and oversight can undermine those efforts. Epic alleges some entities used fictitious websites, shell companies and sham National Provider Identification numbers to appear legitimate. These gaps raise concerns about whether current safeguards are sufficient as more organizations join data-sharing networks.

3. AI and expanding access could intensify risks: The article notes that health data concerns may grow as artificial intelligence tools become capable of navigating patient portals and health IT systems. Amazon’s One Medical recently launched an AI bot that can retrieve medical histories and answer health questions, illustrating how technology is expanding access to records. At the same time, federal regulators continue pushing interoperability and information-blocking rules to promote data sharing. The unresolved challenge is balancing easier access for care coordination with stronger protections against misuse by bad actors.

Real ROI: The case for viewing high-quality care as a cost strategy

By Dr. Daniel Stein – Traditionally, many employers have responded to rising healthcare costs by increasing member contributions and cost-sharing or turning to utilization controls such as prior authorization or medical certification to manage spending. These approaches can produce short-term savings, but they do little to address a fundamental driver of cost: the variation in quality and cost delivered by different providers. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Provider quality variation is a major cost driver: The article argues that differences in how physicians practice medicine can significantly affect total healthcare spending, even within the same network. Variations in clinical decision-making, complication rates and adherence to evidence-based guidelines often determine whether costs escalate or remain controlled. Simply negotiating lower rates does not address these underlying performance differences. As a result, employers may overlook one of the most influential levers for managing long-term healthcare expenses.

2. Aligning analytics with benefit design can change behavior: The author emphasizes that quality data must be actionable at the point when employees choose providers. When validated analytics are integrated into navigation tools and paired with financial incentives, employees are more likely to select higher-performing physicians. Data from employers covering more than 325,000 lives showed healthcare costs declined by up to 5.5% per member per year after shifting utilization toward top-performing providers. These savings were attributed to better care decisions rather than deferred or reduced care.

3. Quality-focused strategies differ from traditional cost containment: Unlike high-deductible health plans that broadly reduce utilization, a quality-centered approach aims to reduce unnecessary and avoidable care while maintaining appropriate preventive services. By making provider performance transparent, employers can influence decisions without restricting network access. This approach reframes quality improvement as a financial strategy rather than solely a clinical initiative. Over time, integrating rigorous quality measurement into benefits design is presented as a scalable and sustainable way to control costs.

New Research Reveals Addictive Design, Health Harms of Ultra-Processed Foods; Calls for Systemic Change

By Food Safety Magazine Editorial Team – A new feature section that will be published in the July issue of the American Journal of Public Health ( AJPH) presents one of the most comprehensive examinations to date of ultra-processed food (UPF) as a public health crisis shaped not only by nutrition, but by corporate practices, political influence, and regulation failures. Read Full Article...

HVBA Article Summary

1. Comprehensive Evidence of Health Risks: The AJPH feature section compiles new and existing research linking ultra-processed foods to a wide range of adverse health outcomes, including metabolic disorders, cardiovascular risks, cognitive decline, and premature death. Several studies use nationally representative U.S. datasets to strengthen the evidence base. Importantly, some findings indicate that poorer cardiometabolic outcomes persist even when overall diet quality is considered. This suggests that the degree of processing itself may play a distinct role in health impacts.

2. Industry Influence and Tobacco Parallels: The collection highlights internal corporate documents showing how tobacco companies helped shape the modern ultra-processed food industry. Philip Morris’ acquisition of major food brands in the 1980s enabled cross-industry sharing of product design and marketing strategies, including the development of Lunchables. Researchers argue that tactics such as child-targeted marketing, product engineering for hyper-palatability, and “better-for-you” branding echo earlier tobacco industry strategies. These parallels are presented as evidence that commercial practices, not just consumer choice, have shaped today’s food environment.

3. Growing Public Support for Policy Action: National polling included in the feature section shows substantial bipartisan backing for stronger government intervention on ultra-processed foods. Majorities of Americans support measures such as warning labels, advertising restrictions aimed at protecting children, and clearer definitions of what qualifies as a UPF. The issue also reviews dozens of recent federal and state policy proposals, along with the potential role of litigation in holding companies accountable. Authors collectively argue that structural reforms—rather than relying solely on personal responsibility—are necessary to address the scale of the problem.

11 large health systems growing bigger

By Alan Condon – After a brief post-pandemic lull, hospital consolidation is accelerating again, with large health systems expanding across state lines, absorbing independent hospitals and reshaping regional care markets. From portfolio resets and strategic exits to cross-market mergers and billion-dollar investments, these moves reflect how scale, capital access and geographic reach are becoming critical advantages in today’s healthcare landscape. Read Full Article...

HVBA Article Summary

1. Consolidation Is Spanning States and Care Settings: Health systems are pursuing cross-state mergers and acquisitions to broaden their geographic footprints and strengthen market presence. Transactions range from hospital purchases to expansions in ambulatory surgery centers, urgent care clinics and freestanding emergency departments. For example, Ascension’s $3.9 billion acquisition of AmSurg expands its network to 300 ASCs nationwide, while HCA Healthcare has added dozens of urgent care centers this year. These deals signal that growth strategies increasingly extend beyond traditional inpatient hospitals into outpatient and specialty care settings.

2. Scale and Capital Investment Are Central to Strategy: Many of the announced combinations involve significant financial commitments and large operational footprints. Sutter Health’s planned acquisition of Allina Health would create a $26 billion system with 39 hospitals and 88,000 employees, while RWJBarnabas Health has committed about $500 million to support Englewood Health’s outpatient and community investments. In another example, NYC Health + Hospitals’ proposed acquisition of Maimonides Health includes up to $2.2 billion in state grant funding over five years. These sizable investments highlight how access to capital is being used to modernize infrastructure, expand services and reinforce competitive positioning.

3. Independent and Community Hospitals Are Joining Larger Networks: Several transactions involve smaller or standalone hospitals affiliating with multistate systems. Novant Health’s acquisition of a 53-bed critical access hospital, Baptist Health’s planned addition of a 151-bed facility and Billings Clinic’s affiliation with an 88-bed Wyoming hospital illustrate this pattern. Larger systems such as Prime Healthcare, which now operates 55 hospitals across 15 states, and Sanford Health, a 58-hospital system, continue to expand through combinations with regional providers. The trend suggests that smaller hospitals are increasingly seeking the financial stability and operational support that larger systems can provide.

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 Blind Spot in Congress's Health Care Transparency Bill

By Wendell Potter – The House Energy & Commerce Subcommittee on Health will hold a hearing Wednesday on a package of bills framed around price transparency and lower costs for patients. One of those bills would require mandatory public reporting of ownership structures, mergers, acquisitions, and beneficial owner information for a broad range of health care entities — hospitals, ambulatory surgical centers, independent emergency departments, and physician practices, including those backed by private equity. Read Full Article...

HVBA Article Summary

1. Ownership Disclosure Requirements Target Providers, Not Insurers: The proposed legislation would impose mandatory public reporting on hospitals, surgical centers, emergency departments, and physician practices, including those owned by private equity. It also includes significant financial penalties for noncompliance and establishes annual audits, with public HHS reporting beginning in 2029. However, health insurers are not subject to equivalent ownership disclosure obligations under the bill. They are mentioned only in the context of potentially owning provider entities, not as entities required to disclose their own structures.

2. Potential Duplication of Existing Federal Reporting: The article argues that much of the ownership information required from providers is already collected by the Centers for Medicare & Medicaid Services as a condition of Medicare participation. Providers must report ownership stakes of five percent or more and notify CMS of mergers or acquisitions within 30 days. A December 2024 Congressional Research Service analysis found that CMS systems already capture substantial data on provider ownership and consolidation. By contrast, no comparable federal ownership disclosure framework exists for insurers, creating an asymmetry in reporting requirements.

3. Consolidation Concerns Extend to Insurer-Owned Entities: The stated goal of the bill is to improve visibility into consolidation trends that may drive up costs and reduce competition. The article highlights UnitedHealth Group as an example of a large insurance conglomerate with approximately 2,694 subsidiaries across 17 countries as of late 2024, based on state regulatory filings. Through its Optum division, the company has expanded into physician employment, urgent care, pharmacy benefit management, and data analytics. Despite this level of vertical integration, the proposed legislation would not require insurers like UnitedHealth to disclose comparable ownership information.

1 Wegovy pill script filled every 5 seconds: Novo Nordisk

By Ella Jeffries – Wegovy (semaglutide) 25-milligram tablets have surpassed 3 million prescriptions in just over five months after launching Jan. 5. The milestone equates to roughly one prescription filled every five seconds and makes Wegovy one of the strongest U.S. pharmaceutical launches by volume on record, according to a June 7 Novo Nordisk news release. The product reached 1 million prescriptions in 12 weeks, from the week of Jan. 5 to the week of March 23, and added another 2 million prescriptions in 10 weeks, from the week of March 23 to the week of June 1. Read Full Article...

HVBA Article Summary

1. Wegovy Tablets Achieve Record-Breaking Launch Growth: Leerink Partners described the oral Wegovy launch as the fastest drug launch ever after prescriptions reached approximately 26,100 by the third week on the market, representing a 42% increase from the previous week. The prescription volume significantly exceeded the early commercial launch performance of Eli Lilly’s Zepbound injectable, which recorded about 1,300 prescriptions during its first week. The rapid uptake highlights strong patient and provider interest in an oral GLP-1 weight-loss treatment option.

2. Oral GLP-1 Adoption Expands the Patient Population: More than 80% of Wegovy pill prescriptions have been filled by patients who are new to GLP-1 therapy, according to Novo Nordisk. This suggests the oral formulation is attracting additional patients rather than primarily converting users from injectable therapies. As a result, health systems may face new considerations around capacity planning, patient access, distribution, and formulary management.

3. Competition Intensifies in the Oral GLP-1 Market: Wegovy became the first FDA-approved oral GLP-1 for weight loss in December 2025, followed by Eli Lilly’s Foundayo after its April 2026 approval. Novo Nordisk has released data indicating that Wegovy demonstrated greater weight-loss efficacy than Foundayo in indirect comparisons. Both companies are competing to capture a growing segment of patients seeking oral alternatives to injectable GLP-1 therapies.

Weight-loss drug R&D pipeline threatens employers' benefits budgets

By Allison Bell – Drug researchers at a major diabetes science conference seemed to spend about as much time talking about the impact of their compounds on weight as on blood sugar. Speakers who traveled to New Orleans this weekend for the 2026 Scientific Sessions of the American Diabetes Association attracted some of the same kind of excitement normally reserved for new cryptocurrency developments or meme stocks. Eli Lilly talked about retatrutide, a "triple agonist" that combines the power of GLP-1 agonists, GIP agonists and glucagon receptor agonists. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. A crowded pipeline of next-generation obesity drugs: Multiple pharmaceutical companies are advancing new treatments that aim to improve on existing GLP-1 therapies. In addition to Eli Lilly’s retatrutide, Sciwind Biosciences presented interim data showing its drug ecnoglutide produced 35% greater weight loss than semaglutide over 20 weeks. Pfizer also reported that its monthly injectable candidate, berobenatide, led to average weight loss of about 17%. The breadth of development suggests sustained competition and continued innovation in the obesity treatment market.

2. Employers face growing financial pressure from coverage decisions: While only about 6% of participants in large employer-sponsored plans served by Benefitfocus are currently using weight-loss drugs, roughly half of Americans are obese or overweight. At the same time, about 80% of U.S. employers report that GLP-1 agonists are increasing plan costs. This mismatch between current utilization and potential demand creates concern that broader adoption could significantly expand employer health spending. Some large employers and even insurers are responding by reducing or eliminating coverage for obesity-related use.

3. Debate over economic and social value of obesity treatment: Conference discussions highlighted tension between the high upfront cost of new therapies and their broader societal benefits. Tim Dall of GlobalData argued that evaluating obesity drugs solely through a narrow budget lens may lead to underinvestment in prevention and chronic disease management. Supporters contend that improved treatment can deliver social and economic gains beyond immediate healthcare savings. For employers and benefits advisors, the next two years may force difficult decisions about balancing cost containment with long-term health outcomes.

The health plan trends that will define the next few years

By Scott King – The forces reshaping health plans over the next several years are converging fast. Across the industry, executives and clinical leaders point to three trends that will define which organizations will thrive: the rapid maturation of AI from pilot projects into core operational workflows, the intensifying pressure to make healthcare genuinely affordable, and the rising tide of consumer expectations for transparency, simplicity and personalized care. Read Full Article...

HVBA Article Summary

1. AI moving from experimentation to core operations: Multiple executives said artificial intelligence is shifting from limited pilot programs into revenue-driving and clinical workflows such as utilization management, claims and risk adjustment. Leaders emphasized that AI is increasingly embedded in day-to-day decision-making, not just back-office automation. At the same time, they stressed the importance of governance, transparency and auditability as regulatory scrutiny grows. The competitive advantage will go to plans that can deploy AI responsibly while demonstrating measurable improvements in cost and outcomes.

2. Affordability pressures intensifying across drug and care costs: Executives highlighted rising pharmacy spending — including specialty drugs, gene therapies and GLP-1 medications — as a major financial driver for plans. Behavioral health demand, chronic disease burden and shifts to outpatient and virtual care settings are also contributing to cost growth. Public program funding dynamics and downstream effects on commercial premiums were cited as additional constraints. Health plans are responding with value-based arrangements, tighter contracting strategies and cost-management initiatives aimed at improving total cost of care.

3. Consumerism and personalization reshaping plan design: Leaders said members and employers increasingly expect healthcare to function like other consumer-oriented industries, with transparent pricing, digital convenience and tailored experiences. This shift is pushing plans to offer more personalized benefit designs, clearer cost information and integrated care navigation. Employers, particularly small businesses, are also demanding solutions that make coverage more accessible and easier to manage. Plans that simplify the experience and align incentives around measurable outcomes are seen as better positioned for long-term growth and retention.

Senate HELP committee chairman seeks info on NYC Health + Hospital data breach

By Cailey Gleeson – Senate Health, Education, Labor and Pensions (HELP) Committee Chairman Sen. Bill Cassidy, M.D., R-La., is seeking information from New York City officials about a late 2025 cybersecurity breach at NYC Health + Hospitals, the largest public U.S. health system. The legislator wants answers from CEO Michael Katz, M.D., on the system’s security protocols, best practices, notified agencies and how it has responded to the incident. New York Mayor Zohran Mamdani’s administration was also cited in the June 4 letter (PDF). Cassidy is seeking responses from officials by June 18. Read Full Article...

HVBA Article Summary

1. NYC Health + Hospitals Reports Data Security Incident: NYC Health + Hospitals notified affected individuals on March 24 after discovering suspicious activity on Feb. 2 and determining that an unauthorized user may have accessed certain systems between Nov. 25 and Feb. 11. Preliminary findings suggest the access may have resulted from a security breach involving a third-party vendor. Potentially exposed information varied by individual and could include health insurance, medical, billing, biometric, Social Security, and precise geolocation data.

2. Senator Cassidy Seeks Accountability and Security Improvements: Senator Bill Cassidy cited the incident as an example of the growing cybersecurity threats facing the healthcare sector and requested additional information from NYC Health + Hospitals about its response. He asked the organization to detail remedial actions taken or planned to strengthen security protocols and explain any additional notifications or reporting it may provide beyond HIPAA requirements. Cassidy emphasized the need for stronger safeguards as healthcare organizations face increasingly sophisticated cyberattacks.

3. Incident Highlights Broader Healthcare Cybersecurity Challenges: The breach comes amid a year marked by hundreds of reported healthcare data breaches, including several incidents affecting significantly larger populations. The article notes that a breach reported by Conduent Business Services impacted approximately 62 million individuals, underscoring the scale of cybersecurity risks across the industry. The incident also aligns with ongoing legislative efforts to strengthen healthcare cybersecurity, including the reintroduced Health Care Cybersecurity and Resilience Act, which recently advanced through the Senate HELP Committee.

Is health care ignoring its own 'Big Short' moment?

By Pete Salveson – In 2005, hedge fund manager Michael Burry discovered that the nation's housing market was extremely unstable. He found that high-price tag mortgage loans were being granted to unqualified home buyers. The math didn't work, and he projected that a market collapse was statistically inevitable. When his predictions came to fruition three years later, his $1 billion investment led to a multibillion-dollar return. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Health care costs are outpacing wages and inflation: Over the past two decades, both employee and employer contributions for family health coverage have risen by more than 140%, far exceeding growth in wages. While wages have increased significantly since 2004, the share of salary devoted to premiums has climbed as well, squeezing household budgets. Out-of-pocket costs have also surged dramatically since 1999, leaving many insured individuals unable to afford actual care. The article argues that these trends mirror the kind of unsustainable math that preceded the 2008 housing crisis.

2. Opaque pricing and contract structures drive higher spending: The author contends that rising health care costs are largely fueled by escalating provider prices embedded in complex, nontransparent contracts. Employers and employees often cannot see or influence the negotiated rates, which can vary widely for identical services within the same geographic area. Nationally, employer-sponsored plans pay multiples of Medicare rates, with some states exceeding three times Medicare pricing. This lack of transparency and pricing discipline is compared to the confusing financial instruments that obscured risk before the financial crisis.

3. Reference-based pricing is presented as a potential alternative: The article highlights reference-based pricing (RBP) as one model designed to anchor payments to transparent benchmarks such as Medicare rates. By tying reimbursements to a clear formula plus a defined margin, employers can better understand and predict their health plan spending. The approach is positioned as a way to achieve meaningful cost savings and align annual increases more closely with Medicare’s lower trend growth. The author urges employers and benefits advisors to evaluate such alternatives before traditional cost structures become untenable.

AI linked to 40% of US job cuts in May: Report

By Naomi Diaz – U.S. employers announced 97,006 job cuts in May, a 16% increase from April and the highest total for the month since 2020, as AI continued to drive workforce reductions across industries, according to a June 4 report from Challenger, Gray & Christmas. Read Full Article...

HVBA Article Summary

1. Layoffs Climb for Third Straight Month: Announced job cuts have risen steadily since February, marking three consecutive months of increases. May’s total also exceeded the number recorded in the same month a year earlier, signaling persistent workforce reductions in 2026. The May figure was the highest for that month since the early pandemic period in 2020. This pattern suggests employers across sectors are continuing to adjust staffing levels amid economic and technological shifts.

2. Technology and AI Drive Workforce Reductions: The technology sector reported the largest number of layoffs in May and has posted substantial year-to-date cuts compared to 2025. AI was cited as the leading reason for workforce reductions for the third consecutive month and has already surpassed last year’s total number of AI-related job cuts. Other industries, including financial technology and pharmaceuticals, also attributed a significant share of their layoffs to AI adoption. These figures indicate that automation and AI deployment are materially influencing staffing decisions across multiple industries.

3. Sector Variations and Hiring Plans: Transportation and healthcare-related organizations have also reported notable increases in job cuts this year, while government-related layoffs have declined sharply compared to 2025 levels. Bankruptcy, company closures and restructuring were among the other primary drivers behind May’s reductions. Despite the uptick in layoffs, employers have announced slightly more planned hires year to date than during the same period last year. Technology, electronics and insurance companies are leading planned hiring activity, highlighting a mixed labor market outlook.

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)

Stop-loss cost trends are still getting worse, insurer reports

By Allison Bell – Stop-loss insurance claims increased a lot more than Tokio Marine HCC expected in 2025. The underlying trend for specific claims, or claims for individual patients with very high medical bills, was 9.5 percentage points higher than the average for the period from 2019 through 2023, the company said in a new 2025 stop-loss experience analysis. The 2025 increase compares with a 5-percentage increase in 2024. "We were undeniably surprised by these trends," analysts said in the report. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Market Tightening Expected to Continue: Tokio Marine HCC analysts indicated that the stop-loss market has already begun adjusting to higher claim trends but may need further pricing discipline to reach sustainable levels. The report suggests that renewal quotes for 2027 could resemble those seen for 2026, signaling continued pressure on employer health plan budgets. Insurers appear to be responding cautiously to persistent cost volatility rather than assuming the spike is temporary. This outlook points to an extended period of firm pricing conditions in the stop-loss sector.

2. Broad-Based Increase in High-Cost Claims: The insurer observed a rise in claim frequency across all severity levels, including catastrophic thresholds. Medical drivers cited include cancer treatments, complications affecting fetuses and newborns, and transplant-related care. Analysts also referenced external pressures such as trade tariffs, Medicare Advantage reimbursement cuts, demographic aging, expanded use of GLP-1 weight-loss drugs, and workforce shortages in health care. Together, these factors suggest that cost growth is being fueled by both clinical and systemic influences.

3. Self-Insured Employers Face Heightened Exposure: With roughly two-thirds of U.S. employers offering health benefits through self-insured plans, reliance on stop-loss coverage remains widespread. These employers depend on stop-loss insurance to shield their plans from unusually large claims, making trend volatility particularly consequential. After reduced care utilization during the COVID-19 pandemic, insurers began reporting a rebound and surge in claims starting in mid-2024. The ongoing escalation underscores the financial sensitivity of self-funded arrangements to shifts in high-cost medical utilization.

Commonwealth Fund: 21% of adults experienced a coverage denial in the past year

By Paige Minemyer – One in five adults with private insurance coverage said that they or a family member had a medical service denied in the past year, even though it was recommended by their physician. The Commonwealth Fund released its 2025 Affordability Survey and the results of focus groups on the subject, which found that 8% of coverage denials were due to denied claims, while 13% were due to prior authorization denials. One percent of the denied services fell into both categories, per the report. Read Full Article...

HVBA Article Summary

1. Prior Authorization Denials Often Cause Emotional and Care-Related Impacts: The study found that 63% of respondents who experienced a prior authorization denial reported significant worry or anxiety. Additionally, 41% said the denial delayed care for themselves or a household member, while 28% said a health condition worsened because of the delay. A smaller share (8%) reported learning about a serious medical concern later than they would have preferred as a result of the denial.

2. Denied Claims and Authorizations Can Increase Financial Burdens: Nearly one-third (31%) of respondents said a prior authorization denial ultimately cost them more money. Among those who experienced a denied claim, 69% reported higher costs and 43% said the denial contributed to medical debt. Survey results showed that many denied claims involved bills under $5,000, though some respondents faced charges exceeding $10,000.

3. Appeals Process Remains a Challenge for Many Patients: Less than half (47%) of respondents appealed a denied claim, and many who did not appeal cited uncertainty about their rights or next steps. More than half of non-appealers said they were unaware they could appeal, while others did not know whom to contact. Study authors noted that greater transparency, standardized review processes, and expanded appeal rights could help patients better navigate insurance coverage disputes.

Epic dismisses claims against SelfRx in medical record misuse lawsuit

By Emily Olsen – Epic is dismissing its claims against a defendant in a major lawsuit brought by the electronic health record alleging health data network Health Gorilla allowed several clients to improperly access patient records for financial gain. Legal claims will be dropped against chronic condition management firm SelfRx, after the company’s founder Martin Hensel denied requesting thousands of patient records from providers, according to court documents filed Wednesday. Read Full Article...

HVBA Article Summary

1. SelfRx’s Limited Record Requests: In written testimony, SelfRx founder Martin Hensel said the company requested records for only 21 patients and received data for 15 of them, totaling fewer than 100 health records. He disputed allegations that SelfRx sought more than 100,000 files and stated he did not know who accessed those records. Based on this testimony, Epic agreed to drop its claims against SelfRx. The dismissal narrows the scope of defendants in the ongoing case.

2. Broader Allegations Against Interoperability Partners: The lawsuit centers on claims that Health Gorilla and other intermediaries enabled improper access to patient data through interoperability frameworks like Carequality. Hensel said SelfRx worked with data broker Unit 387 but did not authorize it or Health Gorilla to request records on its behalf. He also claimed SelfRx never formally executed the written contract governing its participation in Carequality. Unit 387 could not be reached for comment, leaving questions about how the records were accessed.

3. Continuing Legal and Industry Debate: Epic and several health systems allege that defendants abused data exchange networks by posing as providers and monetizing patient information. Health Gorilla has countered that the lawsuit could restrict legitimate data sharing and argues it acted in good faith when vetting clients. Another defendant, GuardDog Telehealth, has admitted to improperly accessing records and said Unit 387 masked itself as a predecessor firm to obtain data. The case has become a focal point in the broader debate over balancing interoperability with data security and oversight.

How predictive analytics is stabilizing renewals

By Ali Panjwani – Every broker I talk to has a version of the same story. A client group renews its stop-loss coverage, the carrier prices it based on last year's claims and then somewhere around month eight or nine, a handful of catastrophic cases blow up the numbers. The carrier raises rates at renewal, sometimes dramatically. The broker is left explaining why the plan that looked stable 12 months ago is suddenly unaffordable. And the employer is left wondering if self-funding was the right decision at all. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Retrospective Study Highlights Risk Concentration: In a study of 19 employer groups covering nearly 17,000 members, six groups ultimately generated underwriting losses for the carrier. The platform identified four of those six as highest-risk before losses materialized, and those four groups—just 21% of the cohort—accounted for 52% of total underwriting losses. The single worst-performing group produced a $2.3 million loss and had a risk score 1.5 times higher than any other group analyzed. These findings suggest predictive models may help pinpoint a small subset of employers that disproportionately drive financial volatility.

2. Potential Financial Impact on Loss Ratios: The analysis indicated that if pricing had reflected the forward-looking risk signals, the carrier’s loss ratio could have improved from 83.6% to 55%. This implies that more precise underwriting based on predictive analytics may materially change financial outcomes for stop-loss carriers. By aligning premiums more closely with projected risk, carriers may reduce the need for broad, conservative pricing increases. The approach also suggests a pathway to stabilizing renewals for employer groups over time.

3. Shift From Reactive to Proactive Benefits Strategy: The article argues that traditional underwriting relies heavily on trailing claims data and demographics, which only describe past performance. Predictive analytics aims to distinguish between temporary high-cost events and underlying risk patterns such as chronic conditions or specialty drug exposure. With earlier insight, brokers and employers could implement preventive care initiatives, optimize provider networks and select pharmacy benefit partners more strategically. This forward-looking perspective may reduce renewal shock and support more informed decisions about whether self-funding is appropriate.

Trump signs AI cybersecurity executive order: 7 things to know

By Naomi Diaz – President Donald Trump on June 2 signed an executive order directing federal agencies to strengthen AI-enabled cybersecurity across government systems, expand protections for rural hospitals and critical infrastructure, and provide the federal government with access to the most advanced AI models up to 30 days before developers release them to other partners. Read Full Article...

HVBA Article Summary

1. Expanded AI-Driven Cyber Defenses Across Sectors: The executive order directs the Department of Homeland Security to broaden the use of AI-powered cybersecurity tools across civilian federal systems. It also extends support to state and local governments, rural hospitals, community banks and other operators of critical infrastructure. In addition, the Treasury Department is tasked with launching a voluntary cybersecurity clearinghouse to coordinate vulnerability scanning and streamline patch management. Together, these measures aim to strengthen cyber resilience beyond federal agencies and into critical community institutions.

2. Structured Oversight of Advanced AI Models: The order calls for the creation of a classified process to identify highly advanced and potentially sensitive AI systems, referred to as “covered frontier models.” Developers may voluntarily provide the federal government with early access to these systems under confidentiality and intellectual property protections. At the same time, the order explicitly prohibits using this framework to impose mandatory licensing or permitting requirements on AI developers. This approach attempts to balance national security visibility with protections for private-sector innovation.

3. Emphasis on Enforcement and Workforce Development: The attorney general is directed to prioritize prosecution of individuals who use AI tools to unlawfully access computer systems or steal data. The Office of Personnel Management is also instructed to expand cybersecurity hiring pathways through the U.S. Tech Force to bolster federal talent. The order builds on earlier cybersecurity and AI initiatives issued in 2025, reinforcing a broader strategy to integrate AI into national cyber defense. Collectively, these steps reflect a dual focus on deterrence and capacity building within the federal government.

Eli Lilly moves to cut off 340B pricing from noncompliant hospitals

By Alan Goforth – Eli Lilly and Company announced on Monday that it will end 340B discount pricing for hospitals that are not complying with the revised claims submission policy it implemented earlier this year. "A minority of entities -- led by the country's largest and best-resourced hospitals and organized through their trade associations -- continues to refuse to submit data and are recycling the same pretextual objections," the company wrote in a letter to Thomas Engels, the administrator of the Health Resources and Services Administration, which oversees the program. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Enforcement of Revised Data Policy: Eli Lilly is moving to revoke 340B pricing eligibility for hospitals that fail to comply with its updated claims submission requirements. The policy requires claims-level data for all pharmacy and medical drugs dispensed, including those handled through in-house and contract pharmacies. The company says the change is intended to increase transparency and ensure appropriate use of discounted drugs. Hospitals that do not submit the required information by the stated deadline will lose access to discounted pricing.

2. Compliance Rates and Scope of Impact: According to Lilly, about 70% of 340B participants have complied with the new reporting requirements. The company has sent two follow-up letters to roughly 1,000 covered entities that have not yet submitted the requested data. Those entities risk losing 340B pricing eligibility beginning June 8. The figures suggest that while a majority are complying, a significant number of providers could be affected.

3. Escalating Dispute With Hospital Groups: The American Hospital Association has strongly criticized Lilly’s decision, arguing that the policy is unlawful and harmful to vulnerable patients. AHA President and CEO Rick Pollack has called on the Department of Health and Human Services to intervene and prevent the company from enforcing the changes. Lilly, in turn, contends that hospital trade groups are resisting transparency measures that would reveal misuse of the program. The dispute reflects broader tensions over oversight and accountability within the 340B Drug Pricing Program.

Why migraine support needs to be part of your chronic care strategy

By Lee Hafner – Migraines are a debilitating type of headache that impact nearly 40 million Americans, resulting in reduced quality of life, missed work, and high healthcare costs. In May, Hinge Health, a digital health clinic focused on preventing and treating musculoskeletal (MSK) conditions, launched a migraine program to help employees manage their condition. Approximately 75% of those who suffer from migraine pain also have MSK pain, said Jim Pursley, president at Hinge Health. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Integration of Migraine and MSK Care: Hinge Health expanded its digital clinic to include migraine management, building on its existing focus on musculoskeletal conditions. Company leaders note that a significant overlap exists between migraine sufferers and those experiencing MSK pain, which supports a more integrated care model. The program combines a neuromodulation wearable device, AI-based trigger tracking and lifestyle interventions with access to a care team. Early participant feedback cited in the article indicates meaningful reductions in reported pain levels.

2. High Economic and Productivity Costs: Migraines are classified by the World Health Organization as one of the most disabling illnesses and can last from four to 72 hours per episode. With sufferers averaging one to two episodes per month, the condition can significantly disrupt work schedules and daily functioning. Hinge Health estimates that migraine-related care exceeds $16,000 per person annually, contributing to more than $70 billion in total yearly costs when factoring in medication, disability leave and lost productivity. These figures highlight why employers are examining migraine care as part of broader cost-containment strategies.

3. Employer Impact and Healthcare Utilization: Trinity Captive Group incorporated the migraine offering after observing that unmanaged cases were driving emergency room visits, urgent care use and reliance on specialty medications. According to early data from Hinge, participants may regain five to 10 work days over a year through improved management. Leaders at Trinity emphasize that migraine affects employees across industries and demographics, making it a broadly relevant benefit. By improving symptom control, employers may reduce downstream medical expenses while enhancing employee engagement and quality of life.

7 conditions GLP-1s may treat beyond weight loss

By Ella Jeffries – GLP-1 medications were approved for diabetes and obesity. But a rapidly expanding body of research — backed in some cases by large clinical trials and, in at least one, an FDA approval — suggests the drug class may have meaningful effects on conditions with no obvious metabolic connection. Here is a snapshot of where the evidence is strong, where it’s promising, and where it fell short. Read Full Article...

HVBA Article Summary

1. Expanding FDA approvals beyond metabolic disease: GLP-1 drugs have moved into new therapeutic territory, including obstructive sleep apnea, cardiovascular disease and chronic kidney disease. Zepbound became the first prescription medication approved for moderate-to-severe obstructive sleep apnea in adults with obesity after 52-week trials showed meaningful reductions in breathing interruptions. Wegovy earned approval to reduce cardiovascular death, heart attack and stroke risk in overweight or obese adults with heart disease, and Ozempic was cleared to reduce worsening kidney disease risk in adults with Type 2 diabetes and chronic kidney disease. These regulatory milestones signal a shift from weight management to broader chronic disease modification.

2. Mixed but promising data in cancer and other emerging areas: Multiple observational studies and analyses have linked GLP-1 use to lower risks of certain cancers, including reported reductions of 17% in overall cancer risk in one large study of 86,632 individuals and a 70% reduction in endometrial cancer risk when combined with progestin therapy. A Cleveland Clinic study of 10,225 patients associated GLP-1 use with reduced progression across several tumor types. However, a Harvard review of 48 trials involving more than 94,000 participants found no significant reduction in obesity-related cancer risk, underscoring uncertainty and the need for longer follow-up. Research is also exploring potential roles in substance use disorders and mental health, with federal regulators removing prior suicidal ideation warnings after reviewing extensive safety data.

3. Operational and clinical implications for health systems: As indications expand, health systems face more complex formulary and access decisions. Prior authorization teams must adapt to new eligibility criteria tied to each additional approval, while pharmacy leaders are increasingly involved in cross-specialty treatment decisions. Long-term data, such as research suggesting up to 14,400 fewer knee replacements annually if eligible osteoarthritis patients used GLP-1s for three years, raise potential cost and utilization impacts. At the same time, setbacks like semaglutide’s failure to slow Alzheimer’s progression in phase 3 trials illustrate that not all investigational uses will translate into clinical benefit.

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)

Payers begin pitching 2027 ACA rates: 4 updates

By Jakob Emerson – Rate season for individual market coverage in 2027 is underway, with a handful of states among the first to release insurers’ proposed premium filings. The bulk of state filings are not expected to be publicly available until later this summer. Read Full Article...

HVBA Article Summary

1. Vermont filings signal modest increases compared to other states: Vermont became the first state to post proposed 2027 rate filings, with insurers requesting average premium increases of 6.5%. Blue Cross Blue Shield of Vermont reported its requested increases as the lowest in five years, while MVP Health Care proposed higher adjustments for both small group and individual plans. Final rate decisions in the state are expected in August, following regulatory review. The early timing provides an initial benchmark for how other states’ proposals may compare.

2. Washington and Massachusetts see steeper proposed hikes: In Washington, 13 insurers have requested a significant average increase of 22.4% in the individual market for 2027, with regulators set to complete their review in September. Massachusetts insurers have proposed a 12.9% average increase in the merged individual and small group market. Fallon Community Health Plan submitted the largest requested increase in Massachusetts at 25.7%. These proposals highlight notable variation in premium trends across states.

3. Some insurers plan to exit the individual market: Several carriers, including Cigna, Providence Health Plan, Baylor Scott & White Health Plan and PacificSource, have announced they will fully exit the individual ACA market in 2027. Such departures could reduce plan choices for consumers in affected regions. Market exits may also shift enrollment to remaining insurers, potentially affecting competition and pricing dynamics. Regulators will likely monitor these changes closely as rate reviews continue.

Inside the Trump-backed push to bring AI doctors into American medicine

By Elizabeth Dwoskin – Last summer, Amy Gleason became a true believer in the wonders of artificial intelligence. Her daughter Morgan had spent more than a decade battling a debilitating autoimmune disorder. But when the 27-year-old uploaded 16 years of meticulously kept medical records into ChatGPT, the machine reported that Morgan was suffering from a different ailment than the one diagnosed by doctors. The new assessment granted her entry into a coveted clinical trial. Read Full Article...

HVBA Article Summary

1. Personal Story Highlights AI’s Medical Promise: The article opens with the story of Amy Gleason and her daughter Morgan, who had battled an autoimmune disorder for years. After uploading extensive medical records into ChatGPT, the AI suggested a different diagnosis than doctors had provided. That new assessment enabled Morgan to qualify for a clinical trial she otherwise would not have accessed. The anecdote illustrates how some patients see AI tools as offering fresh insights when traditional pathways have stalled.

2. Federal Backing for AI-Driven Care: The Trump administration is described as laying the groundwork for chatbots that can diagnose illnesses and prescribe medication. This signals a potential shift toward integrating AI systems more directly into mainstream medical decision-making. Such efforts could reshape how patients access care and how frontline medical advice is delivered. The policy push suggests growing federal interest in accelerating AI adoption within healthcare.

3. Physician Concerns About Risks and Limitations: Despite optimism from some patients and policymakers, physicians caution that AI systems may introduce new problems. Concerns include the reliability of diagnoses, the absence of human judgment, and the complexities of patient care that go beyond data analysis. Doctors argue that medical decisions often require context, empathy and experience that algorithms may not fully replicate. The debate underscores tensions between technological innovation and established clinical standards.

CMS officially launches $50 price tag for weight loss drugs in Medicare

By Susan Morse – Centers for Medicare & Medicaid Administrator Dr. Mehmet Oz has announced the official start of $50-a-month access to GLP-1 medications for Medicare beneficiaries. Oz gave notice of the change during a White House briefing on Tuesday. CMS said in May that $50 access was coming soon. "I want to add to that one additional insight that some of you would like to hear," Oz said, "that starting on July 1, beneficiaries on Medicare who are eligible for (GLP-1) products, weight loss products that the president speaks of frequently, will be allowed to obtain those products for $50 a month." Read Full Article...

HVBA Article Summary

1. Temporary Expansion of Coverage for Weight Loss Drugs: The new policy allows certain Medicare beneficiaries enrolled in Part D to obtain GLP-1 medications for weight loss at a capped cost of $50 per month. This access is being offered through the Medicare GLP-1 Bridge demonstration program, which runs from July 1 through December 31, 2027. Under normal Medicare Part D rules, these drugs are not covered when prescribed solely for weight loss. The demonstration therefore represents a targeted and time-limited change to existing coverage policy.

2. Cost Gap Between List Prices and Negotiated Access: GLP-1 medications typically carry list prices exceeding $1,000 per month, creating affordability challenges for many seniors. CMS leadership argues that lowering out-of-pocket costs will improve access to treatments considered medically significant for obesity and related chronic conditions. Officials also contend that broader use could reduce long-term healthcare spending by preventing diseases such as diabetes and hypertension. The program includes centralized claims and payment processes to facilitate implementation with pharmacies and providers.

3. Part of Broader Drug Pricing Strategy: The initiative aligns with the administration’s broader effort to negotiate lower drug prices with pharmaceutical manufacturers. According to Dr. Oz, most of 17 major drug companies agreed to a Favored Nation approach intended to align U.S. drug prices with those paid overseas. He projected that these efforts could generate $600 billion in savings over the next decade and noted that more than 750 medications are now listed with preferred pricing status on the TrumpRx website. The GLP-1 pricing change is framed as one component of this wider strategy to address high prescription drug costs in the United States.

The Generational Inversion in Employer Health Costs That Most CFOs Aren’t Seeing

By Mark Newman – If you run a company and offer health benefits, you have a hidden cost problem. And there is a strong chance you are attributing it to entirely the wrong cause. Across large employer populations, a consistent pattern is emerging. Employees managing a chronic condition such as diabetes, hypertension, heart disease or asthma — and who also have a mental health diagnosis — cost meaningfully more to treat for their physical illness than those with the same condition but no mental health diagnosis. Read Full Article...

HVBA Article Summary

1. Mental Health Comorbidities Drive Higher Chronic Disease Costs: Employer claims data shows that when a mental health diagnosis is present alongside a chronic physical condition, total spending on managing that physical illness is often about 20% higher. This elevated cost remains even after excluding direct behavioral health expenses such as therapy or psychiatric medications. The excess appears tied to the added complexity of managing chronic disease when mental health needs are not effectively addressed. As a result, untreated or poorly managed behavioral health conditions can indirectly inflate overall medical spend.

2. A Generational Inversion in Cost Impact: While Millennials and Gen Z report higher rates of mental health diagnoses, the associated increase in chronic disease costs for these groups is often minimal or neutral. In contrast, Baby Boomers and Gen X employees show a much larger cost differential when mental health conditions are present. Older cohorts, which make up a substantial share of many workforces, therefore drive a disproportionate share of excess spending. This inversion challenges the assumption that higher diagnosis rates automatically translate into higher downstream medical costs.

3. Organizational Silos Obscure the Root Cause: In many companies, CFOs and CHROs operate with separate datasets and priorities, making it difficult to connect behavioral health engagement with chronic disease spending trends. As a result, rising costs are frequently attributed to physical conditions alone, leading to adjustments in formularies or utilization controls that do not address the underlying issue. The article argues that integrating behavioral health screening and support into chronic disease management programs could better target the true cost drivers. Greater cross-functional alignment and generational analysis are positioned as practical next steps for employers seeking to curb healthcare cost growth.

Small businesses feel the squeeze as healthcare costs rise: Morgan Health

By Paige Minemyer – As healthcare costs continue to rise, smaller businesses are particularly vulnerable to the pressure, according to a new Morgan Health report. For example, among employers with 50 or fewer employees, 30% said that healthcare costs are worsening their business situation, compared to 22% of employers with a greater number of employees. Because these smaller firms are not required to offer coverage, they may choose to adapt to the costs by dropping benefits altogether. Read Full Article...

HVBA Article Summary

1. Smaller Employers Face Disproportionate Strain: The report indicates that the smallest firms are feeling sharper financial pressure from rising healthcare costs compared to larger counterparts. Companies with fewer than 50 employees are more likely to say costs are worsening their business conditions. Because these businesses are not mandated to provide coverage, they may weigh dropping benefits as a cost-control option. However, eliminating coverage is generally viewed as a last resort.

2. Strong Interest in Alternatives, But Hesitation Remains: Many surveyed employers believe there are viable benefit strategies they have not yet explored and say new information could influence their decisions. At the same time, a significant share worry that disruption and uncertainty tied to changing plans could outweigh potential savings. Limited transparency into current spending and alternative models contributes to this reluctance. As a result, businesses express curiosity about new approaches but remain cautious about implementation.

3. Demand for Transparency and Technology Tools: Respondents show substantial interest in digital tools and artificial intelligence to help evaluate health plan options and reduce reliance on brokers. Even so, only a small portion currently use AI-driven tools in their decision-making processes. Concerns about broker compensation transparency are also shaping employer attitudes, with many reconsidering or changing broker relationships. The findings suggest that clearer pricing data and comparison tools could play a key role in future benefit decisions.

GLP-1s drive 20% of prescription spending at large self-funded plans

By Allison Bell – Use of GLP-1 agonists and similar weight-loss drugs continued to grow at the employer-sponsored plans that Benefitfocus served in 2025. About 6% of the plan enrollees took Wegovy, Zepbound or similar drugs to control their weight, up from 5.1% in 2024, the plan administrator said in a new report. The weight-loss drugs accounted for 20.3% of the plans' prescription spending, up from 17.5% the previous year. GLP-1 usage demand partly because the U.S. Food and Drug Administration approved use of the drugs as a treatment for heart disease, and also because of "aggressive direct-to-consumer marketing that has fueled member demand," Benefitfocus analysts wrote in the report. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Large Employer Plans See Significant Financial Impact: The Benefitfocus analysis covered 316 self-insured employers with at least 1,000 full-time employees each, representing a total of 1.8 million workers. The findings indicate that GLP-1 drugs remain a primary driver of pharmacy cost growth for these large plans. Average annual spending per enrollee taking a GLP-1 reached $7,400, underscoring the budget pressure associated with broader coverage. For benefits managers, this level of per-patient expense can materially affect overall plan cost trends.

2. National Spending Could Reach Tens of Billions — or More: The report suggests that if a similar share of the 270 million U.S. adults used GLP-1s at an average annual cost of $7,400, total spending could reach roughly $120 billion in a single year. Other estimates cited in the article point to nationwide totals exceeding $50 billion annually, depending on utilization and pricing assumptions. CVS Health’s CEO previously warned lawmakers that unchecked pricing could eventually push annual spending toward $1 trillion. These projections highlight the potential macroeconomic implications of sustained high demand.

3. Multiple Data Sources Confirm Rising Utilization Trends: Separate analyses from eHealth, CBIZ and UnitedHealth Group reinforce the conclusion that GLP-1s account for a growing share of employer pharmacy claims. CBIZ estimated the drugs made up about 17% of employee pharmacy claims in 2024 among the plans it serves. UnitedHealth Group reported average per-enrollee prescription spending of about $1,600 in 2024, implying that GLP-1s represent a sizable portion of commercial drug expenditures. Together, these data points show that the trend extends beyond a single administrator’s book of business.

14 payers cutting jobs | 2026

By Jakob Emerson – Payers are continuing to trim their workforces amid financial pressures, growing medical and pharmacy utilization, Medicaid funding cuts and strategic restructuring. Below are workforce reduction efforts or job eliminations that were announced or take effect in 2026. Insurance industry layoffs in 2025 are here. The cuts follow a difficult year for the industry. The insurance sector, which includes life, health and property insurers, has shed more than 59,000 jobs since the end of 2024, according to Bureau of Labor Statistics data. Read Full Article...

HVBA Article Summary

1. Industrywide Workforce Contraction Continues Into 2026: Major insurers across the country are continuing to announce layoffs tied to financial strain, rising utilization and structural changes. Companies such as Cigna, Aetna, Optum and several Blue Cross Blue Shield affiliates are reducing headcount in the hundreds or thousands. These reductions reflect both cost-containment efforts and broader strategic shifts in response to market pressures. The trend suggests that workforce downsizing remains a key lever for payers navigating ongoing economic and regulatory challenges.

2. Restructuring, Market Exits And Contract Losses Driving Cuts: Several layoffs are directly connected to companies exiting specific markets or losing major contracts. For example, PacificSource is reducing staff following its decision to exit Montana and the individual market, while Molina and Aetna tied some cuts to contract losses. UCare is winding down operations and selling assets, affecting hundreds of employees. These examples show how business realignment decisions are translating into staffing reductions.

3. Layoffs Span National And Regional Plans: The job cuts are not limited to one segment of the industry, affecting both national insurers and regional or nonprofit plans. Organizations including Horizon BCBS New Jersey, L.A. Care Health Plan, Blue Cross of Idaho and MDwise have all announced workforce impacts. In some cases, reductions represent a defined share of total staff, such as Horizon’s approximately 8% workforce reduction and Point32Health’s 2.3% cut. The breadth of announcements indicates that workforce adjustments are widespread across different payer models and geographies.

Prior authorization adds time and costs for providers, review finds

By Kristen Smithberg – Prior authorization was designed as a cost-control tool for payers, but a new systematic review in the American Journal of Managed Care by Virginia Commonwealth University researchers finds it consistently imposes measurable time and labor costs on pharmacies and physician practices. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Significant Time Burden Across Care Settings: The review found that completing a single drug prior authorization often requires substantial staff time, particularly in physician practices where tasks can stretch well beyond half an hour. Specialty clinics and complex therapies can demand considerably longer involvement, sometimes exceeding an hour per request. Even in pharmacy-based prior authorization clinics, where workflows may be more centralized, staff still devote meaningful time to each case. Appeals and escalations further extend processing time, adding to administrative strain.

2. Measurable Financial Impact Per Authorization: Labor costs tied to prior authorization vary depending on staffing models and workflow design, but they represent a consistent expense across settings. Physician practices may incur costs spanning tens of dollars per request, especially when multiple staff members are involved or opportunity costs are considered. Pharmacy-based clinics also face variable per-authorization expenses, influenced by drug type and overhead allocation. These cumulative costs can become significant for organizations handling large volumes of authorizations.

3. Evidence Gaps and Limited Generalizability: The researchers noted inconsistencies in how studies measured prior authorization activity, with some capturing only partial workflows or excluding physician time. Most available data came from hospital-affiliated outpatient clinics, with limited representation from private practices or multisite samples. No studies evaluated costs in community, mail-order, or specialty pharmacies, despite their large role in prescription dispensing. The review also referenced prior research linking authorization requirements to delayed care and high levels of physician-reported burnout, highlighting broader operational concerns.

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)

Government Watchdog Agency Finds that Every High-Risk Acute Stroke Diagnosis Submitted by Medicare Advantage Insurers in Audit Was Upcoded

By Rachel Madley, PhD – The federal agency that investigates fraud in Medicare and Medicaid reported this week that the government likely overpaid Medicare Advantage (MA) insurers $462 million in 2021 alone due to unsupported acute stroke diagnoses submitted for risk adjustment purposes. Specifically, the Department of Health and Human Services Office of Inspector General (OIG) found that for all 97 enrollees included in a recent audit sample, MA insurers submitted an acute stroke diagnosis code that did not comply with federal requirements because the patient’s medical records did not support it. Read Full Article...

HVBA Article Summary

1. Audit Found Universal Unsupported Diagnoses in Sample: The OIG reviewed a sample of 97 Medicare Advantage enrollees and determined that every acute stroke diagnosis submitted for risk adjustment lacked proper medical record support. In many cases, records reflected a past history of stroke rather than an active acute stroke during the payment year. Because acute stroke codes carry higher payment weights, their use can significantly increase plan reimbursements. The findings point to systemic coding accuracy issues rather than isolated errors.

2. Risk-Adjustment System Creates Financial Incentives: Medicare Advantage plans receive lump-sum payments that are adjusted based on enrollees’ documented health conditions. Higher risk scores translate into higher payments, giving insurers a financial incentive to document more serious diagnoses. When diagnoses are not supported by medical records, this can distort payments and undermine the integrity of the system. The audit highlights how vulnerabilities in risk adjustment can lead to substantial taxpayer costs.

3. Policy Implications and Calls for Reform: The OIG recommended that the Centers for Medicare and Medicaid Services strengthen safeguards to ensure diagnosis codes are accurate. The article argues that stronger oversight or broader reforms may be necessary given repeated findings of excess payments tied to unsupported diagnoses. Lawmakers and regulators have the authority to modify the system, but changes have been limited despite ongoing watchdog warnings. The broader debate centers on whether current incentives in Medicare Advantage adequately protect public funds.

340B in 2026: Tracking litigation, mandates and policy shifts reshaping the program

By Ella Jeffries – The 340B Drug Pricing Program is under pressure from multiple directions: pharmacy benefit manager litigation, drugmaker contract pharmacy restrictions, and a federal rebate pilot that courts have effectively killed. For health systems, the program represents one of the most significant levers for offsetting drug costs and cross-subsidizing care for vulnerable patients — and each of these fronts carries direct financial and operational exposure. Read Full Article...

HVBA Article Summary

1. Escalating Manufacturer Data Demands and Compliance Risks: Eli Lilly has moved to enforce claims-level data reporting for in-house pharmacy dispensing, giving certain hospitals a five-day window to comply or risk losing 340B pricing on its products. The company reports that about 70% of covered entities purchasing its drugs — roughly 2,350 organizations — have already submitted nearly 800,000 claims records this year, including two-thirds of critical access hospitals. Hospital groups argue the policy is unlawful and administratively burdensome, and at least five other drugmakers are pursuing similar requirements. The expansion of these mandates suggests compliance expectations — and potential pricing suspensions — could quickly spread across the industry.

2. Legal Scrutiny of PBM and Specialty Pharmacy Reimbursement Practices: Major health systems have filed federal lawsuits against CVS Health entities, alleging a scheme that diverted approximately $250 million in 340B savings from 2020 to 2025. The complaints claim reimbursement rates for specialty drugs were reduced after 340B eligibility was identified, allowing CVS-affiliated entities to retain the difference. One system also alleges CVS refused a contractually required audit and terminated its agreement after concerns were raised. These cases highlight broader concerns about transparency and financial alignment in vertically integrated PBM arrangements.

3. Rebate Model Halted, but Contract Pharmacy Battles Intensify: Courts have blocked HRSA’s planned rebate pilot, with the 1st Circuit upholding an injunction and HHS dropping its appeal, leaving traditional up-front discounts in place for now. However, HRSA has sought stakeholder input on whether to revive a rebate-based approach, and hospital groups warn such a shift could cost providers more than $1 billion annually. At the same time, at least 13 states enacted contract pharmacy access laws in 2025, while federal courts have issued mixed rulings and the Justice Department has backed drugmakers in some cases. The resulting patchwork means hospital access to contract pharmacies now varies significantly by state and remains legally unsettled.

Brand-name drug prices climb after launch in US, fall abroad amid MFN push: report

By Ayla Ellison – In the U.S., many top brand-name drugs continue to get more expensive with age, while the same medicines often get cheaper in peer countries, according to an AARP Public Policy Institute report released Thursday. U.S. list prices for 25 top brand-name drugs have climbed an average of 81% since launch, while prices for those same medicines fell an average of 13% in 19 other high-income countries, the report found. Read Full Article...

HVBA Article Summary

1. Post-Launch Price Divergence Between the U.S. and Peer Countries: The AARP analysis found that brand-name drugs in the U.S. tend to rise in price after launch, while prices for the same medicines often decline in other high-income nations. Across the 25 drugs studied, lifetime U.S. list price changes ranged widely, from a 46% decrease to an 873% increase. In contrast, prices for 24 of the 25 drugs fell outside the U.S., producing an average decline of 13% internationally. The report attributes much of the international pricing gap to these postlaunch increases in the U.S., which compound over time.

2. Impact and Limits of Medicare Price Negotiation: The report identified six drugs that experienced significant one-time U.S. list price reductions between 2024 and 2026 after being selected for Medicare negotiation. However, an additional six drugs with negotiated Medicare prices did not show corresponding list price cuts. This suggests that while negotiation under the Inflation Reduction Act may exert pressure on some manufacturers, its effects are not uniform across all products. AARP noted that negotiated savings may not automatically extend to other payers beyond Medicare.

3. Concentration of Spending and Policy Implications: The 25 brand-name drugs analyzed accounted for more than $100 billion in Medicare Part D spending in 2024 and were used by nearly 15 million beneficiaries. The findings arrive as the Trump administration promotes “most favored nation” pricing, arguing that aligning U.S. launch prices with those abroad could generate substantial federal savings. AARP suggested that incorporating international price comparisons into Medicare negotiations and expanding eligibility for negotiation could further reduce costs. The debate highlights how pricing policy reforms could reshape future launch strategies and long-term drug spending trends.

A look at wearable adoption trends and who's using 'smart' devices: Rock Health

By Cailey Gleeson – Wearable ownership has risen 33% in the U.S. since 2015, according to a new analysis from Rock Health. Forty-six percent of respondents in the 2025 Consumer Adoption of Digital Health Survey reported owning a wearable specifically, and 57% of respondents reported owning at least one wearable or other connected device. However, the report notes that first-time wearable user growth has slowed. Read Full Article...

HVBA Article Summary

1. Device Preferences and Usage Patterns: Smartwatches remain the dominant form factor, with 43% of surveyed adults reporting ownership, while other connected devices such as smart scales and blood pressure cuffs trail behind at 13% each. Continuous glucose monitors (9%) and smart rings (8%) represent smaller but growing segments. Among users, 83% wear their devices at least five days per week, and 59% wear them nearly all the time except for charging. The most common tracked metrics are physical activity (35%), sleep (26%) and heart rate (21%), underscoring wearables’ continued focus on lifestyle monitoring.

2. Brand Loyalty and Market Leaders: Nearly half of respondents (48%) still use the first wearable brand they adopted, and 27% have upgraded within the same brand, while just 23% have switched brands. Apple leads the market with 63% of users, followed by Fitbit at 27% and Samsung at 16%, with Garmin and Oura holding smaller shares. In addition, 47% of users have been using a wearable for three or more years, suggesting sustained engagement. These figures indicate relatively strong brand loyalty and a stable competitive hierarchy among major players.

3. Demographic Gaps and Clinical Integration: Wearable ownership is concentrated among younger, wealthier, urban and commercially insured individuals who are more likely to describe their health as excellent. In contrast, people reporting moderate to poor health are less likely to own devices, highlighting a gap between potential need and adoption. Meanwhile, 59% of users have discussed their wearable data with a healthcare provider, including 30% who do so regularly, and another 20% say they want to but have not yet. The report concludes that while adoption is established, the broader impact on population health will depend on accessibility, regulatory support and how effectively data is integrated into care.

Exclusive: Cigna drops coverage of GLP-1 obesity drugs for its own employees

By Amina Niasse – Health insurer Cigna (CI.N) will stop covering GLP-1 weight-loss drugs including Novo Nordisk's (NOVOb.CO) Wegovy and Eli Lilly's (LLY.N) Zepbound in its employee health plan effective July 1, according to materials viewed by Reuters on ‌Tuesday. Details of the change in the Cigna Group Medical Plan were announced in an email to employees on June 1. Read Full Article...

HVBA Article Summary

1. Coverage Change Limited to Employee Plan: Cigna confirmed the decision in an email to staff and said the move applies specifically to its internal employee health plan. The company stated that coverage for GLP-1 drugs prescribed for type 2 diabetes will remain in place. It also emphasized that the change does not affect plans offered to external clients. The policy shift is therefore targeted at its own workforce rather than its broader insurance business.

2. Shift Toward Cash-Pay Options and Alternatives: Employees currently using the medications can continue treatment by paying out of pocket through manufacturer websites or TrumpRx, but those payments will not count toward deductibles or out-of-pocket maximums. Cigna noted that it will continue covering older generic weight-loss drugs such as phentermine and diethylpropion, which are generally considered less effective than GLP-1 therapies. Meanwhile, new oral versions of weight-loss drugs have entered the market in 2026 with starting prices at $149 per month for the lowest dose. The development reflects a broader migration of patients into cash-pay channels as employer coverage tightens.

3. Broader Employer Retrenchment Amid High Demand: The decision comes as GLP-1 drugs like Wegovy and Zepbound have surged in popularity for weight management, driven by their hormone-mimicking mechanism that promotes fullness. However, employers have increasingly scaled back coverage due to rising spending on these medications. Research cited in the article indicates that patients often regain weight after stopping treatment and that benefits can fade within two years. Cigna, which had 67,700 employees at the end of 2025 with 88% based in the U.S., is part of this wider reassessment of how such high-cost therapies are funded.

Rewriting the PBM playbook: Exposing hidden costs and empowering plan sponsors

By Simon Leung – Pharmacy benefit managers (PBMs) occupy a central position in the prescription drug supply chain, administering prescription drug benefits for most commercially insured Americans. However, a growing body of research from regulators, policy organizations and employer coalitions has highlighted the complexity and opacity of PBM revenue models, raising concerns about whether current market incentives consistently align with the financial interests of plan sponsors. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Market Concentration Amplifies PBM Influence: The U.S. PBM market is highly consolidated, with the three largest players processing roughly 80% of all prescription drug claims and generating approximately $456.3 billion in combined revenue in 2023. This scale gives them significant leverage over pricing, formularies and distribution channels. The article argues that such dominance enables profit strategies that are difficult for plan sponsors to detect or counter. As a result, employers must be deliberate in contract selection and oversight to ensure alignment with their financial and clinical goals.

2. Core Profit Drivers Shape Plan Costs: The author identifies spread pricing, manufacturer rebate retention and specialty pharmacy margins as the primary engines of PBM profitability. Spread pricing allows PBMs to retain the difference between what they charge plan sponsors and what they reimburse pharmacies. Rebate arrangements can incentivize higher-cost drugs when PBMs keep a portion of manufacturer payments. Specialty pharmacy ownership further enhances margin capture, especially as specialty drugs account for a growing share of overall spend.

3. Lesser-Known Revenue Tactics Increase Complexity: Beyond the main profit streams, the article outlines mechanisms such as repackaged National Drug Code pricing, manipulation of Maximum Allowable Cost lists and layered administrative or service fees. These practices often rely on proprietary methodologies and limited transparency, making them difficult for sponsors to audit. Because such charges can be embedded throughout contracts and reporting structures, their cumulative impact may go unnoticed. The author emphasizes the need for strict contractual definitions, comprehensive data rights and independent expertise to mitigate these risks.

More self-insured employers want to hit health care costs in the gut

By Allison Bell – Employer interest in digestive health condition management programs may be heating up. Only 8% of the 1,031 self-employed Lockton surveyed recently said they offer digestive health "buy-up" programs, beyond what their plan administrators or stop-loss insurance providers typically build into the benefits. But about 11% are considering adding digestive health programs. Digestive health condition management programs help people with conditions that affect the esophagus, the stomach, the intestines and the bowels. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Digestive Health Programs Show Emerging Momentum: While relatively few employers currently offer digestive health buy-up programs, a larger share are exploring them compared with other condition management options. This makes digestive health the only category in the survey where interest in adding coverage exceeds current adoption. The trend suggests employers are reassessing gastrointestinal conditions as a meaningful driver of employee health costs and productivity. Growing clinical evidence and vendor activity may also be contributing to heightened attention in this area.

2. Musculoskeletal and Cardiometabolic Benefits Remain More Established: Musculoskeletal programs are the most widely offered condition management option, with 32% of employers already providing them and another 14% considering them. Cardiometabolic programs, which address issues such as obesity, diabetes and heart failure, are also common, with 30% offering them and 13% considering adoption. These figures indicate that employers have historically prioritized high-cost, high-prevalence conditions. Digestive health programs, by contrast, are still catching up in visibility and implementation.

3. Cost Control Is Overtaking Talent Attraction as a Priority: Survey data show a significant shift in employer priorities since 2022, with 54% now citing cost control as their top concern compared with 19% focused primarily on attracting talent. Two-thirds of employers report using self-insured plans, and many rely on stop-loss coverage to manage catastrophic risk. The survey also found limited adoption of alternative designs such as reference-based pricing plans and ICHRAs, with only 7% of self-insured employers using the former and about 1% using the latter. Together, these findings point to a benefits landscape increasingly shaped by cost-containment strategies.

CVS Health Sued for Allegedly Withholding Funds From Hospitals

By Valentina Baez – Several U.S. hospital systems are suing CVS Health and its pharmacy companies, alleging they improperly withheld funds generated under the 340B Drug Pricing Program. Healthcare law firm Frier & Levitt LLC announced the May 18 filing of three lawsuits against CVS Health Corp., CaremarkPCS Health LLC, Caremark LLC, CVS Specialty Inc. and WellPartner LLC. Read Full Article...

HVBA Article Summary

1. Hospitals Allege Improper Retention of 340B Savings: The lawsuits claim CVS and its affiliated pharmacy benefit and specialty pharmacy businesses diverted funds generated under the federal 340B Drug Pricing Program. According to the complaints, the companies retained a portion of reimbursements tied to specialty drug claims rather than passing the full amounts to hospitals as allegedly required by contract. The hospitals estimate that about $250 million intended to support safety-net providers was improperly kept. Plaintiffs are seeking jury trials and access to CVS accounting records to assess the full scope of alleged damages.

2. Dispute Centers on Post-Sale Reimbursement Adjustments: The hospitals argue that because 340B eligibility is often determined after a drug is dispensed, claims were initially reimbursed at standard rates and later adjusted. They allege CVS reduced reimbursement amounts once claims were identified as 340B-eligible and reported the lower figures to hospitals while retaining the difference as profit. The complaints characterize this retained “spread” as part of a broader scheme spanning multiple years. CVS declined to comment on the pending litigation, stating it does not address matters subject to ongoing legal proceedings.

3. Congress Advances Related PBM and ERISA Legislation: Around the same time, the House Education and Workforce Committee advanced several bills affecting pharmacy benefit managers and ERISA-governed plans. One measure would prohibit PBMs from paying brokers or consultants to steer employer health plans toward preferred vendors, while another would require more detailed hospital billing identifiers for outpatient services. A third bill would extend the Form 5500 filing deadline and simplify reporting requirements for retirement plans. Supporters say the proposals aim to increase transparency and accountability in both the prescription drug supply chain and retirement plan administration.

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)

Microsoft, Mayo Clinic plan to build frontier AI model for healthcare

By Heather Landi – Mayo Clinic plans to develop and deploy a frontier AI model specifically designed for healthcare in collaboration with Microsoft. The strategic collaboration combines Mayo Clinic’s global healthcare expertise, de-identified clinical health data and longitudinal insights with Microsoft’s advanced AI, cloud engineering and tech capabilities, the companies announced Tuesday. The two organizations say they are developing a frontier AI model "capable of supporting the broadest scope of clinical reasoning and healthcare use cases," according to a press release. Read Full Article...

HVBA Article Summary

1. Mayo Clinic and Microsoft Partner to Develop Healthcare AI Model: Mayo Clinic and Microsoft are collaborating to build a frontier AI model specifically designed for healthcare. The model aims to synthesize diverse clinical data to support earlier diagnoses, more personalized treatment decisions, and improved patient outcomes. The partnership combines Mayo Clinic’s clinical expertise and data foundation with Microsoft’s AI engineering capabilities to expand access to advanced healthcare intelligence.

2. Mayo Clinic Retains Ownership and Clinical Oversight: Mayo Clinic will own the AI model, reflecting its commitment to patient trust, clinical rigor, safety, and responsible stewardship of clinical data and AI technologies. The model will initially be deployed within Mayo Clinic’s clinical environment, where it will be continuously tested, refined, and improved through real-world use. This approach is intended to ensure the technology aligns with healthcare standards and patient care priorities.

3. Broader Access Planned Through Microsoft Azure: Microsoft plans to make the healthcare AI model available to other organizations through Azure Foundry APIs, expanding access to advanced AI capabilities across the healthcare sector. The organizations state that the initiative will help bring Mayo Clinic’s integrated care model and medical expertise to more patients and providers. Leaders from both organizations described the collaboration as a step toward advancing “frontier medical intelligence” and accelerating innovation in healthcare.

CVS, Walgreens, Walmart opioid lawsuit dismissed by Florida judge

By Alan Goforth – A Florida judge in late May sided with three major pharmacy retailers in a lawsuit brought by 16 hospitals that accused them of violating state and federal opioid laws. The lawsuit, filed in 2021, alleged that CVS, Walgreens and Walmart improperly distributed and dispensed the drugs, which contributed to a statewide increase in opioid abuse. The plaintiffs said the pharmacies named in the lawsuit dispensed more than 21 billion opioid pills in 15 Florida counties served by the hospitals, according to Reuters. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Judge Dismisses Hospitals’ Claims Against Pharmacy Chains: A Florida judge ruled that hospitals could not recover damages from pharmacy chains for opioid-related treatment costs because their injuries were indirect. The hospitals had sought compensation for $528.3 million in unpaid opioid-related care and an additional $1.5 billion in broader medical expenses for patients who used opioids. The court found that any financial harm to the hospitals depended first on injuries suffered by patients with opioid use disorder.

2. Mistrial Followed by Directed Verdict: The case went to trial in 2025, but the jury was unable to reach a verdict after two weeks of deliberations, leading the judge to declare a mistrial. Rather than ordering a retrial, the judge issued a directed verdict, stating that the legal issues were clear and that no reasonable jury could rule in favor of the hospitals. Plaintiffs' attorneys criticized the decision, arguing that the court had previously allowed the claims to proceed.

3. Opioid Litigation Continues Despite Ruling: Pharmacy chains including CVS and Walmart welcomed the ruling, maintaining that they were not responsible for the hospitals’ alleged injuries. The decision represents one outcome in the broader wave of opioid-related litigation involving pharmacies, healthcare companies, and pharmacy benefit managers. Federal enforcement efforts also remain active, with the U.S. Department of Justice filing lawsuits against CVS and Walgreens in late 2024 and early 2025 over alleged unlawful prescribing and fraud.

The $490,000 Denial

By Wendell Potter – When Pamela Talley came home from an Arizona cycling vacation with a surgically repaired broken left wrist and elbow, she knew – as a retired family physician – that she’d be facing a tough recovery. What the 62-year-old Colorado retiree wasn’t expecting was the letter she received not long after she got home last year from her health insurer, Anthem Blue Cross and Blue Shield. It informed Talley that her hospitalization in Tucson – where they’d helicoptered her after the nasty gravel spill which left part of her broken wrist protruding through her skin – was “medically unnecessary,” and the two emergency surgeries were not covered by her policy, either. Read Full Article...

HVBA Article Summary

1. Emergency Insurance Denial Led to a Lengthy Appeals Battle: After suffering severe injuries in a bicycle accident and undergoing emergency surgeries in Arizona, retired physician Dr. Talley received notice that her insurer, Anthem, had denied nearly $490,000 in hospital charges. Despite the care being emergency treatment, the insurer cited reasons such as medical necessity, out-of-state care, and network status. The denial initiated a 13-month process of appeals, repeated phone calls, and regulatory intervention before the claims were ultimately paid.

2. Insurance Claim Denials Are Common, but Appeals Often Succeed: The article highlights that insurance claim denials affect many Americans, with one study finding that insurers initially denied 20% of claims for ACA Marketplace enrollees. Although research shows that appeals frequently result in overturned decisions, only a small percentage of patients pursue them due to the complexity, time commitment, and administrative burden involved. Talley’s experience illustrates both the challenges patients face and the potential effectiveness of persistence.

3. Consumer Advocacy and Regulatory Support Can Influence Outcomes: After exhausting Anthem’s internal appeals process, Talley sought assistance from the Colorado Department of Insurance, which helped secure coverage by citing applicable state and federal protections, including the No Surprises Act. The case underscores the value of understanding insurance policies, documenting disputes, and utilizing available consumer protection resources. The article also notes concerns that growing use of AI in claims review and increasing enrollment in high-deductible health plans could contribute to future coverage disputes.

IRS Announces Higher HSA Limits, Updated Health Plan Thresholds for 2027

By James Van Bramer – The IRS announced inflation-adjusted limits for health savings accounts and related health benefit arrangements for 2027, increasing contribution caps and updating eligibility thresholds for those enrolled in high-deductible health plans. Under Revenue Procedure 2026-24, published this week, individuals with self-only coverage under a qualifying high-deductible health plan will be able to contribute up to $4,500 to an HSA in 2027. For family coverage, the contribution limit will rise up to $9,000. In 2026, the cap on HSA contributions is $4,400; the cap for family coverage contributions in 2026 is $8,750. Read Full Article...

HVBA Article Summary

1. Higher HSA and HDHP thresholds for 2027: The IRS increased the minimum deductible requirements for high-deductible health plans (HDHPs) in 2027 to $1,750 for self-only coverage and $3,500 for family coverage. Maximum out-of-pocket expense limits also increased to $8,700 for self-only coverage and $17,400 for family coverage. These adjustments reflect annual inflation updates and affect eligibility for health savings accounts (HSAs).

2. New HSA eligibility rules for direct primary care arrangements: Starting in 2027, individuals can remain eligible to contribute to an HSA while participating in a direct primary care service arrangement (DPCSA). To qualify, monthly DPCSA fees cannot exceed $150 for an individual or $300 for arrangements covering multiple people. This change follows legislation enacted by Congress in 2025 and expands compatibility between HSAs and direct primary care services.

3. Increased employer reimbursement limits and implementation timeline: The maximum amount employers may provide through an excepted-benefit health reimbursement arrangement (HRA) will rise from $2,200 to $2,250 for plan years beginning in 2027. The IRS guidance implements both inflation adjustments required by tax law and provisions from the One Big Beautiful Bill Act enacted in 2025. The updates are intended to keep tax-advantaged health benefit limits current while providing clear guidance for taxpayers, employers, and health plan administrators.

What will new Medicaid work rules mean for employee benefits plans?

By Allison Bell – Medicaid program managers in Washington want to require many adults who have Medicaid coverage to work or engage in work-like activities at least 80 hours per month. The Centers for Medicare & Medicaid Services — the U.S. Department of Health and Human Services agency that oversees Medicaid — has posted an interim final rule that shows how the new work requirements would work. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Medicaid Work Requirements Could Affect Millions of Enrollees: New Medicaid community-engagement requirements would apply to able-bodied adults and could be met through paid employment, volunteer work, participation in government work programs, or school attendance. Exemptions would be available for individuals serving as caregivers for young children or adults with disabilities. Policy analysts estimate that between 4.4 million and 5.4 million Medicaid enrollees could be affected by the requirements and moved into qualifying engagement activities.

2. Debate Continues Over Coverage and Healthcare Cost Impacts: Supporters argue that the requirements could help low-income individuals connect with employment opportunities and improve long-term economic outcomes. Critics contend that the policy could increase the number of uninsured individuals if some beneficiaries lose Medicaid coverage. Analysts remain divided on whether any increase in uninsured rates would lead to higher costs for employer-sponsored health plans through healthcare provider cost-shifting.

3. Potential Employer and Workforce Implications Remain Uncertain: Some policy analysts predict that the requirements could increase job applications from Medicaid-covered individuals seeking lower-wage employment, particularly in areas with large Medicaid populations. Because many of these workers may retain Medicaid coverage rather than rely on employer-sponsored health benefits, employers could experience lower benefit-related hiring costs. However, some experts note that if these workers have higher rates of chronic health conditions, employers could face increased workers’ compensation, disability, and life insurance claim costs, though the extent of these effects remains speculative.

The obesity drug race moves beyond weight loss

By Tina Reed – The obesity-drug race is becoming less about losing weight and more about keeping it off. Why it matters: As more GLP-1 drugs deliver eye-popping results, the next winners may be determined by convenience, affordability and whether patients keep taking them long enough to benefit. That means reducing side effects, focusing on lifestyle changes and making the pricey drugs affordable. "Keeping the weight off is going to be the next big challenge," said Tim Blackstock of Citeline, a biopharma intelligence services firm. Read Full Article...

HVBA Article Summary

1. Debate Shifts Beyond Maximum Weight Loss: Eli Lilly’s experimental obesity drug retatrutide achieved nearly 30% average weight loss after 80 weeks, approaching results typically seen with bariatric surgery. While this exceeds the performance of many currently available GLP-1 medications, analysts and clinicians are increasingly questioning whether additional weight loss beyond current standards provides meaningful benefits for all patients. Experts note that many individuals may not need to lose more than 15% of their body weight to achieve important health improvements.

2. Greater Weight-Loss Efficacy Raises Safety and Support Considerations: More powerful GLP-1 therapies can be associated with gastrointestinal side effects as well as risks such as muscle loss, reduced bone mass, and gallbladder complications linked to rapid weight reduction. Healthcare leaders emphasize that nutritional guidance, lifestyle interventions, and muscle-preservation strategies become increasingly important as treatment effectiveness improves. The discussion is shifting toward balancing clinical benefits with long-term patient safety and treatment tolerability.

3. Focus Expands to Long-Term Outcomes and Treatment Selection: As obesity medications demonstrate benefits beyond weight loss—including reductions in cardiovascular events and other health risks—drugmakers are investing in combination therapies and improved treatment approaches to help patients remain on therapy. Industry participants are seeking ways to differentiate products through factors such as tolerability, convenience, and patient fit rather than weight-loss magnitude alone. Future adoption of retatrutide may also depend on pricing decisions, which could influence whether it is positioned as a premium option for patients requiring greater weight loss or a broader treatment choice.

Post-pay recovery spots millions in hidden reimbursements

By Laura Hescock – With CEOs and CFOs keeping a close watch on rising medical costs, there is new urgency for self-funded employer health plans to evaluate every dollar of healthcare spending. Yet benefits leaders are overlooking one of the most powerful tools they have. Post-pay reimbursement through subrogation offers plans a way to recover medical expenses they have already paid when another party or insurance policy is legally responsible for those costs. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Traditional Subrogation Methods May Limit Recoveries: Most health plans identify subrogation opportunities by reviewing injury-related medical claims and then contacting members for additional details through questionnaires and phone calls. The article argues that claims data alone often cannot determine whether a third party is financially responsible for an injury, while member outreach frequently generates low response rates and delays. As a result, some reimbursement opportunities may be missed or identified too late to pursue effectively.

2. Data-Driven Liability Detection Offers an Alternative Approach: The article describes a newer recovery model that begins with external data sources such as accident reports, liability claims, lawsuits, and insurance policy information rather than relying solely on health plan claims. By connecting these external liability signals with paid medical claims, plans can identify potential reimbursement opportunities earlier in the process. The approach is also presented as a way to reduce or eliminate the need for member questionnaires and follow-up calls.

3. Subrogation Is Increasingly Viewed as a Financial Performance Lever: The article notes that third-party recoveries can represent a meaningful source of reimbursement for health plans, potentially amounting to millions of dollars annually for large organizations. Rising healthcare costs, faster legal settlements, and growing expectations for seamless member experiences are increasing the importance of timely and accurate recovery efforts. The author contends that plans that modernize their subrogation programs may capture more recoverable funds than those that continue to rely on traditional, member-dependent processes.

Prescription Drug Monitoring Programs Shape Care. Our Patients Should Know.

By Sarah Cady – For many patients, taking a controlled medication feels like any ordinary medical decision. You're prescribed something for sleep, anxiety, ADHD, or pain. You're counseled on risks and side effects. You pick it up from the pharmacy and assume the transaction ends there. What patients are not routinely told is that once that prescription is filled, it becomes part of a state-run monitoring system that tracks controlled medication use across prescribers and pharmacies, information that can shape how clinical encounters unfold. Read Full Article...

HVBA Article Summary

1. PDMPs Provide Clinicians Early Access to Prescription Histories: Prescription Drug Monitoring Programs (PDMPs) are state-run databases used by clinicians to review patients’ controlled substance prescription records, including medications, dispensing dates, prescribers, pharmacies, quantities, and payment methods. The article notes that clinicians often access this information before discussing a patient's history, which can influence initial impressions and shape the clinical encounter before patients provide their own context. This creates a shift from relying primarily on patient disclosure to incorporating preexisting prescription data into care decisions.

2. Privacy Expectations May Differ From How Information Is Shared: Patients may assume they control when and how sensitive treatment information is disclosed, particularly regarding substance use disorder treatment. However, the article explains that medications such as buprenorphine can appear in PDMPs once prescribed and dispensed, making that information accessible to authorized prescribers even when patients have not voluntarily disclosed it. This can create a gap between patients’ expectations of privacy and the realities of how prescription information is shared in clinical practice.

3. PDMPs Improve Safety but May Influence Care Beyond Their Intended Purpose: The article acknowledges that PDMPs help identify unsafe prescribing patterns, prevent harmful drug interactions, and improve coordination among healthcare providers. At the same time, prescription data viewed without full clinical context may affect how patients are perceived and influence decisions related to prescribing, monitoring, or treatment access. The author argues that greater transparency about the existence and use of PDMP data could help patients better understand how information is incorporated into their care.

Hi Everyone,

You’re invited to join SAVVI Financial for an upcoming HVBA webinar:

Stop Pushing Benefits
The Link Between Decision Intelligence and Better Outcomes

📅 Thursday, June 4, 2026
⏰ 1:00 PM – 1:30 PM ET

Low participation isn’t an employee motivation problem. It’s a guidance gap.

When employees can’t connect their benefits to their real financial lives, they disengage. The result is flat participation, weaker renewals, and brokers increasingly being treated like vendors instead of strategic partners.

That’s why this conversation matters.

Join SAVVI Financial to learn how their Decision Intelligence engine helps drive better outcomes for employees, employers, and brokers.

During this 30-minute webinar, we’ll discuss:

✅ Why the system does not need to be more complicated, it needs to be simplified
✅ What Decision Intelligence is and why it matters
✅ How coordinated guidance can create better employee engagement
✅ How brokers can use data and guidance to become stronger strategic partners
✅ How better decisions lead to better outcomes for employers and employees

Stop pushing benefits. Start guiding better decisions.

We hope you’ll join us for this important conversation.

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 surprise billing fix may not reduce disputes

By Maya Goldman – A new bid to fix the process for resolving surprise billing disputes may not make a dent in the massive backlog of cases. Why it matters: Providers and insurers have been sparring over how to settle claims for out-of-network services almost from the moment Congress protected privately insured patients from getting stuck with huge, unexpected costs. - More than 5 million claims have gone to arbitration since 2022, and many remain unresolved. Driving the news: The Trump administration last week finalized a plan to streamline arbitration by expanding which disputed items and services can be lumped together. Read Full Article...

HVBA Article Summary

1. Streamlined Arbitration Process May Increase Disputes: The new plan aims to make arbitration more efficient by allowing more claims to be grouped together and lowering administrative fees. However, analysts predict these changes could actually lead to a higher volume of disputes rather than reducing the existing backlog. This is because the process becomes more accessible and less costly, encouraging more providers to enter arbitration.

2. Mixed Reactions from Stakeholders: Providers and some analysts believe the changes could benefit smaller and independent medical practices by making dispute resolution more attainable. On the other hand, insurance industry representatives argue that the rule favors providers and could drive up overall health care costs. There are concerns that private-equity-backed practices and middlemen may exploit the system, potentially leading to higher payouts and increased costs for patients.

3. Unresolved Issues and Future Uncertainty: The plan does not address how to calculate the median in-network rate, a key benchmark in negotiations, which remains under judicial review. Some details of the new process are yet to be clarified and may be subject to future guidance or legal challenges. Stakeholders are watching to see if the changes will ultimately reduce the backlog or if further reforms will be necessary.

CMS outlines new Medicaid work requirements, exemptions and $600M tech investment

By Chad Van Alstin – New work requirements for Medicaid established as part of last year’s One Big Beautiful Bill Act are set to go into effect in 2027, and now the details are being finalized. The new rules will impact state Medicaid programs funded by the federal government. All new barriers to Medicaid entry will go into place on Jan. 1, unless states decide to opt into them earlier. Broadly, the new requirements for Medicaid eligibility will impact all adults in the U.S. from age 19-34, who are not pregnant and deemed able-bodied to work. Read Full Article...

HVBA Article Summary

1. New Medicaid Work Requirements: Beginning in 2027, adults aged 19-34 who are not pregnant and are considered able-bodied will be subject to new work requirements to qualify for Medicaid. These changes are part of the One Big Beautiful Bill Act and will be implemented across state Medicaid programs that receive federal funding. States have the option to adopt these requirements earlier if they choose.

2. Exemptions and Reporting Changes: The new rules include exemptions for individuals who are disabled, frail, or otherwise unable to work, as well as for half-time college or trade school students. States will face updated reporting requirements to ensure compliance with the new eligibility standards. The Centers for Medicare & Medicaid Services (CMS) is providing support to states through advancements in data technology to streamline these processes.

3. $600 Million Technology Investment: CMS is allocating $600 million to upgrade health IT systems, aiming to improve efficiency and transparency in Medicaid eligibility and appeals processes. The new data infrastructure is expected to be operational by 2028, providing patients with greater insight into their eligibility and simplifying paperwork submission. CMS leadership has emphasized the importance of safeguards for technology vendors and a balanced approach to reducing fraud while maintaining access for those in need.

Individual HSA contribution limit to rise 2.27% in 2027

By Allison Bell – The Internal Revenue Service says important numbers at the heart of personal health benefit account programs will rise by about 2% to 3% in 2027. The IRS announced the new, inflation-adjusted parameters for health savings accounts and some health reimbursement arrangements in Revenue Procedure 2026-24. For individual contributions to HSAs, for example, the annual contribution limit will increase to $4,500, from $4,400, and the minimum deductible will increase to $1,750, from $1,700. For some types of health reimbursement arrangements, the maximum employer contribution will increase to $2,250, from $2,200. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. IRS Announces Modest Increases for 2027: The IRS has set new contribution and deductible limits for health savings accounts (HSAs) and certain health reimbursement arrangements (HRAs) for 2027, reflecting inflation adjustments. These increases are based on the Chained Consumer Price Index for All Urban Consumers, which rose by 2.19% overall, while the medical care component increased by 2.77%. The changes mean that individuals and employers will be able to contribute slightly more to these accounts, but the growth is modest compared to rising health care costs.

2. Impact on Account Holders and Health Care Costs: While the limits for HSA and HRA contributions are rising, the rate of increase is not keeping pace with the growth in medical expenses. Workers who maximize their contributions may still find it challenging to cover increasing health care costs, as the annual out-of-pocket maximums and deductibles are also climbing. This underscores the ongoing pressure on consumers to manage health care spending despite tax-advantaged savings opportunities.

3. Direct Primary Care and Legislative Updates: The IRS notice for 2027 also clarifies how much HSA funds can be used for direct primary care (DPC) membership fees, a provision enabled by the One Big Beautiful Bill Act of 2025. For 2027, HSA owners can spend up to $150 for individuals and $300 for families on DPC memberships without incurring penalties or extra taxes. This development offers more flexibility for HSA holders seeking predictable costs for routine health care services.

Biologics Continue to Transform Psoriasis Care, Giving Physicians and Patients More Options

By Damian McNamara, MA – Biologics continue to transform the treatment of psoriasis. Dermatologists use terms such as “night and day,” “profoundly different,” and “amazing” to describe the biologics era compared with treatment before biologics became available. Despite these advances, however, challenges remain, with few patients facing high treatment costs, inequitable access, or a lack of response to a particular biologic, whereas few experience an initial benefit that starts to wear off over time. And regardless of their effectiveness in treating psoriasis, an unanswered question remains: How long do patients need to stay on biologic therapy to maintain their response? Read Full Article...

HVBA Article Summary

1. Biologics Have Dramatically Improved Psoriasis Outcomes: The introduction of biologic therapies has significantly changed the landscape of psoriasis treatment, offering rapid and effective disease control for many patients. Dermatologists report that these treatments can induce remission in a majority of moderate-to-severe cases, a stark contrast to the limited and often toxic options available in the past. This shift has led to improved patient quality of life and increased demand for advanced therapies.

2. Multiple Biologic Options and Ongoing Research: There are now several classes of biologics available, including IL-17 and IL-23 inhibitors, which have shown high efficacy in clinical studies. Comparative research indicates that some biologics outperform others in achieving near-complete skin clearance, and ongoing studies are exploring even longer-acting agents and new oral therapies. The field continues to evolve, with both injectable and oral targeted treatments expanding the range of options for patients.

3. Challenges Remain Regarding Access, Cost, and Long-Term Management: Despite their effectiveness, biologics can be expensive and access may be limited by insurance formularies and administrative hurdles. Some patients may lose response over time or require ongoing therapy to maintain remission, raising questions about optimal treatment duration. Researchers are working to address these issues by developing therapies with longer dosing intervals and by investigating strategies to sustain remission with less frequent treatment.

Alternative health plans: The expectation of familiarity and the execution gap

By Al Rogers – Employers aren't exploring alternative health plans out of curiosity. Rising healthcare costs continue to strain budgets, and traditional models leave little room to manage that pressure. Employers face a 9% increase in healthcare costs this year, forcing many organizations to reevaluate whether their current approach is sustainable. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Rising Costs Drive Interest in Alternatives: Employers are increasingly considering alternative health plans as a response to escalating healthcare expenses and the limitations of traditional insurance models. The pressure of rising costs is prompting organizations to seek solutions that offer more control and predictability in their benefits spending. This shift is not driven by a desire for novelty, but by necessity and the need for sustainable cost management.

2. Operational Execution Is Critical for Success: While alternative health plans may promise cost savings and flexibility, their success largely depends on reliable operational infrastructure. Employers and employees expect these plans to function with the same dependability as traditional options, including timely payments and clear processes. When operational issues arise, such as delays or confusing workflows, the perceived risks can outweigh the theoretical benefits, making adoption less attractive.

3. ICHRAs and Infrastructure Shape the Future: Individual Coverage Health Reimbursement Arrangements (ICHRAs) are gaining traction, with significant year-over-year growth among larger employers. However, the long-term viability of ICHRAs and similar models will be determined by their ability to deliver familiar, stable experiences and integrate seamlessly with existing systems. The article emphasizes that innovation in health benefits must be matched by operational maturity to earn employer trust and achieve lasting adoption.

Patients with treatment-resistant depression are costing Medicare big

By Anastassia Gliadkovskaya – A patient with treatment-resistant depression (TRD) costs Medicare 21%, or $8,000, more annually than a patient with depression that is controlled. So finds a new report from Health Management Associates (HMA), a health policy consulting firm. The report aimed to quantify the direct economic impact of the condition, looking at Medicare claims data from 2022 and 2023 for its analysis. The firm identified major depressive disorder claims that included at least one inpatient encounter or at least two hospital outpatient claims within a year. Read Full Article...

HVBA Article Summary

1. Significant Financial Burden on Medicare: Treatment-resistant depression (TRD) leads to substantially higher costs for Medicare compared to controlled depression. The majority of these expenses are attributed to increased hospitalizations, prescription medications, and more frequent physician visits. This highlights the need for targeted strategies to manage TRD more effectively within the Medicare population.

2. Intensive and Costly Interventions: Patients with TRD often require advanced treatments such as transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT), which are associated with much higher annual costs. These interventions not only increase direct medical spending but also reflect the complexity and severity of managing TRD. The report underscores that these therapies, while beneficial for some, contribute significantly to the overall economic impact.

3. Call for Innovative Solutions: The analysis points out that TRD remains a challenging and underserved area in mental health care, with current interventions being both expensive and not universally effective. The consulting firm emphasizes the need for scalable, long-lasting solutions that can improve both symptoms and daily functioning for TRD patients. Policymakers, clinicians, and researchers are encouraged to prioritize this issue to achieve better outcomes and reduce the economic strain on the healthcare system.

AI-driven change is intensifying mental health needs. Leaders may not be ready.

By Ryan Golden – Employers already faced significant challenges in addressing employees’ mental health issues, but the rapid pace of workplace transformation seen throughout 2026 seems all but certain to further intensify a thunderous storm. Recent surveys of workers have borne out those concerns. The first quarter of the year marked a 65% increase in burnout reported by Glassdoor users compared to the same point in 2025. A separate May report by Monster found that 59% of employee respondents said their job actively hurts their mental health. Read Full Article...

HVBA Article Summary

1. AI’s Dual Impact on Mental Health: The integration of artificial intelligence in the workplace is a major driver of both anxiety and opportunity for employees. While some workers are energized by AI’s potential, many experience fears of job displacement and skill erosion, which can negatively affect their focus and well-being. The way organizations implement AI—including transparency, ethical guidelines, and reskilling efforts—will ultimately determine whether its impact on mental health is positive or negative.

2. Leadership Readiness and Organizational Culture: Many current leadership behaviors, such as relentless work habits and constant availability, may unintentionally undermine mental health initiatives. Experts suggest that promoting resilience, empathy, and psychological safety among leaders is crucial for creating a healthier work environment. Without these qualities, even well-intentioned mental health policies and benefits may fall short if day-to-day management practices do not support employee well-being.

3. Structural and Holistic Approaches Needed: Addressing mental health in the workplace requires more than just offering benefits or awareness campaigns. Organizations are encouraged to adopt structural changes like flexible scheduling, clear communication, and support for caregivers, as well as leadership training focused on psychological safety. Recognizing that employees’ work and personal stressors are interconnected, companies should strive to create environments where energy can be replenished and high performance is sustainable.

About 8% of the country lacked health insurance in 2025, new data shows. That could rise next year

By Mike Stobbe and Al Swenson – The proportion of Americans without health insurance held steady at around 8% of the population in 2025, according to new findings from the U.S. Centers for Disease Control and Prevention. The national survey results, released Thursday, show the all-ages uninsured rate has stayed significantly down from where it was several years ago, but the ranks of the uninsured could soon expand as the Trump administration’s sweeping changes to the health landscape begin to take hold. Massive changes to Medicaid, the government’s safety-net health program for low-income Americans, passed into law last year could result in 10 million more uninsured individuals over a decade, according to Congressional Budget Office estimates. Read Full Article...

HVBA Article Summary

1. Uninsured Rate Remains Stable but May Increase: The share of Americans without health insurance remained at about 8% in 2025, maintaining a lower rate compared to previous years. However, policy changes such as Medicaid cuts and the end of certain Affordable Care Act subsidies are expected to drive the uninsured rate higher in the near future. These changes could reverse recent progress in expanding health coverage.

2. Policy Shifts Could Affect Millions: Congressional Budget Office estimates suggest that recent Medicaid changes could lead to 10 million more uninsured people over the next decade. The expiration of ACA subsidies is also projected to result in around 5 million fewer people enrolling in marketplace plans in 2026 compared to 2025. These figures highlight the significant impact that federal and state policy decisions can have on health insurance coverage.

3. Coverage Trends Influenced by Demographics and Legislation: While most Americans over 65 are covered by Medicare, younger populations rely on a mix of public and private insurance, making them more vulnerable to policy changes. Historical data shows that uninsured rates have fluctuated with legislative actions, such as the Affordable Care Act and pandemic-era protections. Experts agree that future uninsured rates will depend heavily on decisions made by lawmakers and agencies at both the federal and state levels.

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)

‘A missed opportunity’: Payers lash out against surprise billing final rule

By Rebecca Pifer Parduhn – On Thursday, the Trump administration finalized a widely supported rule addressing shortcomings in the system through which providers and payers settle disputes over surprise medical bills. But insurers think regulators should have done a lot more. Payers are saying the Trump administration missed the mark by not cracking down on alleged provider abuse of the dispute resolution process set up by the No Surprises Act, a watershed consumer protection law passed in 2020 to shield consumers from surprise medical bills. No Surprises has largely been successful in that goal, preventing millions of Americans from being hit with unexpected out-of-network charges. Read Full Article...

HVBA Article Summary

1. IDR Process Drives Higher Provider Payments: The article highlights concerns that the No Surprises Act's Independent Dispute Resolution (IDR) process has evolved into a significant source of increased payments for some providers. Providers filed approximately 1.2 million arbitration disputes in the first half of 2025 alone, far exceeding original government projections. Critics argue that frequent provider victories and awards often exceeding in-network rates by three to four times have created incentives for extensive use of the arbitration system.

2. Payers Raise Concerns About Arbitration Incentives and Costs: Insurers, employers, and unions argue that flaws in the arbitration process may encourage the submission of ineligible disputes and contribute to disproportionately high provider awards. They contend that arbitrators may face incentives to accept more cases because providers initiate the vast majority of disputes, while decisions are final and cannot be appealed. These stakeholders warn that higher arbitration payouts can increase healthcare costs, which may ultimately be reflected in insurance premiums and employer-sponsored health plan expenses.

3. New Rule Introduces Incremental Reforms with Broad Support: The final rule aims to improve the IDR process by reducing ineligible disputes, standardizing communication between payers and providers, and enhancing the federal arbitration portal. While payer groups sought stronger oversight of arbitrators, including audits and conflict-of-interest reviews, many stakeholders view the changes as a positive step toward greater efficiency and transparency. Provider organizations have also welcomed portions of the rule, particularly measures that lower filing costs and improve access to the arbitration process for smaller medical practices.

Employer stop-loss could break free from state, federal health insurance rules

By Allison Bell – The Self- Insurance Protection Act bill could free employers' stop-loss insurance policies from federal health benefits rules as well as from state health benefits mandates, according to analysts at the Congressional Budget Office. Employers with self-insured health plans use stop-loss insurance to protect their plans against catastrophic losses. The SIPA bill would exclude stop-loss insurance from the definition of health insurance coverage given in the Employee Retirement Income Security Act of 1974, according to the CBO analysts. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. SIPA Bill Would Limit Regulatory Oversight of Stop-Loss Insurance: The Self-Insurance Protection Act (SIPA) would prevent states from restricting group health plans from obtaining stop-loss insurance and would exclude stop-loss policies from certain ERISA insurance-related regulations. The legislation is intended to preserve access to stop-loss coverage for self-insured employers, including smaller employers that increasingly use these arrangements. If enacted and interpreted as the Congressional Budget Office (CBO) expects, employers using stop-loss insurance would remain subject to ERISA, while stop-loss policies themselves would not be treated as health insurance coverage under ERISA.

2. Bill Addresses State Efforts to Regulate Small Self-Insured Plans: The proposal comes amid growing use of stop-loss insurance by small employers seeking to self-insure and potentially avoid some state health benefit mandates. In response, several states have implemented requirements such as minimum employer size thresholds or small-group insurance rules for stop-loss arrangements. SIPA seeks to limit states' ability to impose such restrictions while still allowing states to regulate the availability and coverage terms of stop-loss insurance.

3. Minimal Federal Budget Impact Could Aid Legislative Efforts: The CBO and Joint Committee on Taxation concluded that implementing SIPA would have little or no effect on federal spending or revenue. States would continue to oversee the solvency of stop-loss insurers, but neither states nor the U.S. Department of Labor could apply health insurance benefit mandates to stop-loss providers in the manner addressed by the bill. The measure advanced out of the House Education and Workforce Committee on a party-line vote, and its negligible budget impact could improve its prospects under congressional procedures that favor fiscally neutral legislation.

CMS grants Elevance Health a reprieve from Medicare Advantage sanctions

By Paige Minemyer – Elevance Health has earned a reprieve from potential federal sanctions on its Medicare Advantage plans. The Centers for Medicare & Medicaid Services sent a letter (PDF) to the company Friday, saying that it has completed key steps to remedy the agency's concerns. CMS was set to suspend enrollment in Elevance's MA plans on March 31 if the insurer did not comply. In March, CMS said that the company had consistently failed to use the agency's official channels to correct data on diagnostic codes found to be unsupported by medical records. Read Full Article...

HVBA Article Summary

1. CMS Temporarily Lifts Sanctions Threat: The Centers for Medicare & Medicaid Services (CMS) has paused its planned sanctions against Elevance Health's Medicare Advantage plans after the company took steps to address compliance concerns. Elevance submitted the required data through official channels and made a wire transfer for overpayments, though the exact amount was not disclosed. This action prevented the immediate suspension of new enrollments that was scheduled for March 31.

2. Ongoing Compliance Requirements Remain: Despite this reprieve, Elevance Health is still required to complete additional corrective actions by June 30 and resolve any outstanding issues by July 31 to avoid future sanctions. If these steps are not met, CMS has stated that sanctions could be implemented as early as July 1 or August 1, depending on the status of compliance. The company remains under close regulatory scrutiny until all requirements are fulfilled.

3. Background of Noncompliance and Market Impact: CMS's concerns stemmed from Elevance Health's repeated failure, since at least November 2018, to submit corrected risk adjustment data through the agency's designated electronic systems, instead using encrypted USB drives. The company revised its practices in April 2023 following federal guidance, but the issue affected claims predating that change. News of the potential sanctions previously led to a significant drop in Elevance Health's share price, highlighting the financial and reputational risks associated with regulatory noncompliance.

CHAI releases AI governance guidance for health systems

By Emily Olsen – The Coalition for Health AI released a series of governance resources this week that aim to help health systems safely roll out artificial intelligence tools. The playbooks, developed through community workshops and work groups that included more than 150 clinicians and health AI leaders, provide examples and guidance on implenting AI, including resources on setting up AI policies, managing third party developers and assessing risks. The goal is to provide a standardized, but flexible framework that health systems can use to deploy AI tools, regardless of their size or available resources, CHAI said. Founded in 2021, CHAI is a network of more than 3,000 organizations — including health systems, technology startups and patient advocacy groups — that aims to develop guidelines on responsible AI use in healthcare. Read Full Article...

HVBA Article Summary

1. Comprehensive AI Governance Resources: The Coalition for Health AI (CHAI) has released governance playbooks designed to help health systems implement artificial intelligence in a safe and responsible manner. These resources were developed with input from over 150 clinicians and AI leaders, ensuring a broad perspective on best practices. The playbooks address key areas such as policy creation, risk assessment, and third-party developer management.

2. Standardized Yet Adaptable Framework: CHAI's guidance is intended to serve as a standard framework that can be adapted by health systems of varying sizes and resource levels. The materials emphasize flexibility, allowing organizations to tailor governance structures and oversight committees to their unique needs. This approach aims to make responsible AI deployment accessible to a wide range of healthcare providers.

3. Ongoing Evolution and Sector Expansion: CHAI plans to continue refining its guidance based on feedback and the evolving landscape of AI governance. The coalition also intends to expand its playbooks to include other sectors within healthcare, such as payers. This iterative process reflects the rapid pace of AI adoption in healthcare and the need for governance frameworks to keep up with technological advancements.

Walmart, Telahealth partner to expand virtual care nationwide

By Alan Goforth – The nation's largest virtual care provider is teaming up with the nation's largest retailer. Teladoc Health announced on Thursday that its services are now available through Walmart's Better Care Services platform. The collaboration brings Teladoc Health's suite of offerings -- including virtual urgent care, dermatology and nutrition services -- to customers seeking both insured and cash-pay options. This is the latest in a series of steps the company has taken to expand access to care by integrating with established platforms. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Strategic Expansion of Virtual Care: The partnership between Walmart and Teladoc Health aims to make virtual health services more accessible to a broader population by leveraging Walmart's extensive customer base. By integrating Teladoc's offerings into Walmart's Better Care Services platform, customers can now access a range of virtual health options, including urgent care and specialty services. This move reflects a growing trend of major retailers entering the telehealth space to meet evolving consumer expectations.

2. Affordability and Convenience for Consumers: The collaboration introduces both insured and cash-pay options, with a set cash-pay price of $89 per visit for Walmart customers. This pricing structure is designed to make virtual care more affordable and transparent, potentially reducing financial barriers for those without insurance. The convenience of accessing care through a familiar retail platform may encourage more people to seek timely medical attention.

3. Implications for Employers and Workplace Benefits: The article highlights that telehealth services, such as those offered through this partnership, can benefit employers by reducing healthcare costs and improving employee productivity. Employees may experience increased job satisfaction due to the flexibility and immediacy of virtual care, which can be accessed around work schedules. As telehealth becomes more integrated into employer-sponsored health plans, it may contribute to a more positive workplace culture and help retain talent.

Judge dismisses BCBS Texas’ surprise billing lawsuit against HaloMD

By Rebecca Pifer Parduhn – The No Surprises Act has protected millions of Americans from surprise medical bills since taking effect in 2022. While the law has shielded consumers, it’s also created major headaches for insurers and providers that find themselves at odds over how to resolve out-of-network disputes, and for regulators looking to fairly referee the process. Over the last few years, providers have emerged on top in arbitration determinations from No Surprises, a process known as independent dispute resolution or IDR. The lion’s share of disputes have been settled in favor of providers — a whopping 88%, according to the most recent data — and providers are often awarded three or four times above comparable in-network rates when they win. Read Full Article...

HVBA Article Summary

1. Judicial Limits on Surprise Billing Disputes: The federal judge's dismissal of Blue Cross Blue Shield of Texas’ lawsuit against HaloMD reinforces that courts do not have the authority to overturn arbitration decisions made under the No Surprises Act. This ruling aligns with three other recent federal court decisions, collectively signaling a judicial reluctance to intervene in independent dispute resolution (IDR) outcomes. The courts have emphasized that such disputes should be resolved within the arbitration framework established by the law, not through additional litigation.

2. Provider Success and Insurer Concerns: Data shows that providers have been prevailing in the majority of No Surprises Act arbitration cases, often receiving awards significantly higher than comparable in-network rates. Insurers, including BCBS Texas, have argued that some providers and billing companies are exploiting the arbitration process to maximize payouts, leading to increased costs for payers. Despite these concerns, the courts have thus far declined to address allegations of improper awards, leaving insurers to seek other avenues for recourse.

3. Ongoing Legal and Regulatory Tensions: While several lawsuits challenging IDR outcomes have been dismissed, some cases in other states remain active, indicating that legal battles over the No Surprises Act are not fully resolved. The persistence of these disputes highlights ongoing tensions between insurers, providers, and billing intermediaries over the implementation and impact of the law. Regulatory agencies and industry stakeholders continue to grapple with balancing consumer protections against potential system abuses and escalating arbitration costs.

Lilly's Foundayo and Zepbound to gain CVS coverage, lifting sales outlook

By Max Bayer – Eli Lilly’s flagship obesity medications will be included in CVS Caremark formularies, likely boosting sales in the most competitive commercial drug market. The company announced Thursday that its oral drug Foundayo will join CVS commercial plans beginning June 1, while its injectable product Zepbound will have coverage broadened across CVS templates by Oct. 1. The expansion opens the door for more people to buy the drugs with a $25 monthly co-pay instead of higher cash-pay prices. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. CVS Expands Access to Lilly Weight-Loss Drugs: CVS Caremark added Lilly’s oral weight-loss medication as a preferred option and reinstated Zepbound as a preferred injectable alongside Wegovy. Investors responded positively, sending Lilly shares up about 4% on expectations that broader formulary access could increase utilization. The change gives Lilly greater exposure to CVS’s approximately 90 million members and may strengthen its position in both the oral and injectable obesity treatment markets.

2. Competitive Dynamics Shift Between Lilly and Novo Nordisk: Novo Nordisk’s oral Wegovy entered the market first and has maintained a lead in prescriptions, while Wegovy has also been CVS’s sole preferred injectable option for roughly a year. The addition of Lilly’s products to preferred coverage introduces greater competition, particularly for Zepbound in the injectable category. Analysts noted that the change could benefit Lilly while potentially creating a headwind for Novo, which may have previously benefited from more exclusive formulary positioning.

3. Affordability Efforts Expand Through CVS and Medicare Programs: CVS stated that ongoing negotiations with drug manufacturers are focused on improving affordability and access for members. In addition, a Medicare bridge program remains on track to launch July 1, allowing eligible participants to obtain weight-loss medications for $50 per month. Originally intended as a temporary measure, the program has been extended through 2027 due to concerns surrounding treatment costs and utilization rates.

As AI identifies more at-risk patients, health systems face a capacity challenge

By Giles Bruce – Healthcare AI solutions tout their ability to identify more at-risk patients and irregularities imperceptible to physicians, all while keeping a human in the loop. But are there enough humans to handle all this additional demand brought on by AI? That’s a question healthcare leaders are grappling with as the technology expandsacross the industry. “You don’t want to be, say, implementing something that’s going to scan every patient for a particular disease, which costs you a lot of money if you can’t do anything about it, because you don’t have the appointments downstream to actually manage that,” said Michael Pfeffer, MD, senior vice president and chief information and digital officer of Palo Alto, Calif.-based Stanford Health Care, at Becker’s 16th Annual Meeting in April. Read Full Article...

HVBA Article Summary

1. AI Increases Clinical Demand: As AI tools become more adept at identifying at-risk patients and subtle health irregularities, healthcare systems are experiencing a surge in the number of cases requiring follow-up. This increased detection can strain existing clinical resources, especially if systems are not prepared to handle the additional workload. Leaders emphasize the importance of evaluating whether there are enough staff and appointment slots to manage the influx before deploying new AI solutions.

2. Human Oversight Is Not Always Feasible: While the concept of keeping a human in the loop is often promoted as a safety measure for AI in healthcare, experts note that relying on humans to review every AI-generated alert or summary is not sustainable. Physicians are increasingly trusting AI outputs and may not have the capacity to verify each recommendation. The human role becomes most critical in situations where direct clinical intervention is required, rather than in constant algorithm monitoring.

3. Workflow Integration Is Essential: Successful implementation of AI in healthcare requires a holistic approach that considers the entire patient care workflow. Simply adding AI tools without addressing downstream processes—such as scheduling additional tests or follow-up appointments—can create bottlenecks and inefficiencies. Health systems are encouraged to assess and adjust their workflows and staffing needs in advance to ensure that AI-driven insights can be acted upon 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)

CMS finalizes changes to No Surprises Act dispute resolution process

By Paige Minemyer – A new federal rule aims to overhaul the No Surprises Act protocols, particularly as large volumes of disputes are pushed to arbitration. The rule, finalized jointly by the Departments of Health and Human Services, Labor and Treasury as well as the Office of Personnel Management, would reduce the administrative fees on disputes from $115 to $15, which the feds argue will make it easier to participate while "maintaining a self-sustaining program." The agencies will allow for multiple claims to be resolved in a batch, which would both lower costs and accelerate the resolution timetable, per an announcement from the Centers for Medicare & Medicaid Services. Read Full Article...

HVBA Article Summary

1. CMS Launches IDR Gateway to Centralize Dispute Management: CMS announced plans to introduce the IDR Gateway, a centralized platform that will allow users to initiate disputes, track case status, and manage dispute-related activities in one location. The platform will be rolled out in phases beginning this year, with mandatory payer registration designed to help providers identify the correct parties and reduce errors. CMS also plans to add features such as in-portal navigation over time to further reduce unnecessary dispute filings.

2. Rule Aims to Improve Transparency and Efficiency in Out-of-Network Disputes: The final rule would require payers to use standardized claims codes when communicating about out-of-network care, making it easier for providers to determine whether claims are eligible for IDR. CMS said the changes are intended to improve transparency, streamline dispute resolution, and reduce administrative burdens. Agency officials described the reforms as part of a broader effort to make the process more efficient and accountable.

3. Stakeholders Remain Divided on IDR Reform Impact: The changes come as the IDR process has handled more than 5 million disputes since its launch in April 2022, significantly exceeding original expectations that most cases would be resolved through negotiation. Provider organizations largely praised the rule, citing benefits such as clearer payment information, stronger oversight, and reduced administrative burdens. Insurer groups acknowledged the reforms as a positive step but argued that additional measures are needed to address concerns about high arbitration volumes and large award amounts.

Unlocked Repost: Curing U.S. Health Care, Part II

By Paul Krugman – On March 23, 2010 President Barack Obama signed the Patient Protection and Affordable Care Act — usually referred to either as the Affordable Care Act or as Obamacare — into law. Joe Biden, then the vice president, could be overheard whispering “This is a big fucking deal.” And it was. The ACA, which went into full effect in 2014, created a system of subsidies and regulations designed to make health insurance available to many Americans who had previously been left out. It worked: In 2010 there were 47 million uninsured people in America, but by 2016 this number had dropped to 27 million. Read Full Article...

HVBA Article Summary

1. Historical Barriers to Universal Coverage: The United States has a long history of failed attempts to implement universal health care, often due to opposition from powerful interest groups and political factions. Efforts by presidents such as Truman and Clinton were stymied by resistance from the medical industry and concerns about government overreach. Racial and economic factors also played a significant role in shaping the fragmented nature of the U.S. health care system.

2. Impact and Limitations of the Affordable Care Act: The ACA significantly reduced the number of uninsured Americans and expanded Medicaid coverage, especially in states that chose to participate in the expansion. However, the law maintained the existing employer-based insurance system and did not achieve universal coverage, leaving millions still uninsured. Political compromises were made to avoid industry backlash, resulting in a complex system that improved access but did not fully resolve disparities.

3. Recent Policy Changes and Future Risks: Actions taken by the second Trump administration, such as ending enhanced subsidies and cutting Medicaid funding, are projected to reverse much of the ACA's progress in expanding health insurance coverage. These changes could result in millions losing coverage and increased financial strain on hospitals and individuals. The article suggests that unless these policy shifts are reversed, the U.S. may face a significant rise in the uninsured population and renewed challenges in health care access.

Lilly's Foundayo and Zepbound to gain CVS coverage, lifting sales outlook

By Max Bayer – Eli Lilly’s flagship obesity medications will be included in CVS Caremark formularies, likely boosting sales in the most competitive commercial drug market. The company announced Thursday that its oral drug Foundayo will join CVS commercial plans beginning June 1, while its injectable product Zepbound will have coverage broadened across CVS templates by Oct. 1. The expansion opens the door for more people to buy the drugs with a $25 monthly co-pay instead of higher cash-pay prices. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. CVS Expands Coverage for Lilly Weight-Loss Drugs: CVS Caremark has added Lilly’s oral weight-loss drug Foundayo to its preferred formulary and reinstated injectable Zepbound as a preferred option alongside Wegovy. The move is expected to improve affordability and access for approximately 90 million CVS members. Investors responded positively, with Lilly shares rising about 4% as the company strengthens its position in the competitive obesity treatment market.

2. Competitive Impact on Lilly and Novo Nordisk: Oral Wegovy remains the prescription leader in the oral weight-loss category, while Lilly has gained significant market share in injectable treatments with Zepbound. Analysts believe expanded CVS coverage could drive higher utilization and revenue for Lilly’s products. Conversely, Novo Nordisk may face increased competitive pressure as Wegovy loses its status as the sole preferred injectable weight-loss medication under CVS coverage.

3. Medicare Access Program Extended Through 2027: Eligible Medicare beneficiaries are expected to gain access to discounted weight-loss medications through a bridge program launching July 1, with costs set at $50 per month. The initiative was originally intended as a temporary measure through the end of the year while insurers expanded coverage. However, concerns about affordability, demand, and utilization rates have led the administration to extend the program through 2027.

After Eric Tennant’s Death, West Virginia Takes Aim at Prior Authorization

By Wendell Potter – The death of Nataline Sarkisyan became a defining moment in America’s debate over prior authorization. In 2007, her insurer initially denied coverage for a potentially lifesaving liver transplant, only reversing course after public outrage but when it was already too late. Nearly 20 years later, the same fights are still playing out. West Virginia lawmakers recently passed a new law aimed at easing prior authorization burdens after the death of Eric Tennant, a coal mining safety instructor whose cancer treatment was delayed for months after his insurer deemed it “experimental and investigational.” By the time approval finally came, Tennant’s condition had deteriorated so badly that he was no longer eligible for the procedure. Read Full Article...

HVBA Article Summary

1. West Virginia's Legislative Response: In the wake of Eric Tennant’s death, West Virginia enacted a new law to reduce the burden of prior authorization for state employee health plans. The law allows patients to switch to an alternative, medically appropriate treatment of equal or lesser cost without restarting the entire prior authorization process. This aims to prevent harmful delays in care that can occur when insurers require repeated approvals.

2. Inconsistencies in Prior Authorization Requirements: Recent research has revealed significant variation in how major insurers determine which medical services require prior authorization. A study found that out of thousands of services, only a small fraction had overlapping requirements among large insurers like Aetna, Humana, and UnitedHealthcare. This fragmentation can create confusion and administrative challenges for both patients and providers.

3. Ongoing National Debate and Limited Federal Action: The Affordable Care Act expanded insurance coverage but did not address the complexities of prior authorization, leaving insurers with considerable power over medical decision-making. As a result, patients and physicians continue to face administrative hurdles and delays. The persistence of these issues has led to increased calls for reform at both the state and federal levels.

Aging Care Crisis

By Caitlin Owens – Senate Democrats recently committed to tackling one of health care's most under-the-radar dilemmas: how to accommodate the long-term care needs of the fast-aging U.S. population. Why it matters: The elder care infrastructure isn't ready for the demographic change heading its way. Between the lines: This isn't the stuff that typically lights up a debate stage. But the math suggests that more and more American families are going to be confronted with a broken status quo and no easy solutions. Read Full Article...

HVBA Article Summary

1. Long-Term Care Affordability Crisis: Long-term care is a growing challenge because most seniors will eventually need assistance with daily activities, yet many cannot afford care on their own. The average person who turns 65 is expected to incur about $130,000 in long-term care costs, while private long-term care insurance covers only a small percentage of older adults. Public support is largely limited to Medicaid, which often requires individuals to exhaust their assets before qualifying for benefits.

2. Caregiver and Workforce Shortages Threaten Access: Unpaid family members and friends currently provide the majority of long-term care, often at significant financial and personal cost. As the population ages, demand for care is expected to increase while the number of available caregivers declines, creating additional pressure on families and the workforce. At the same time, shortages of paid long-term care workers and low wages in the sector raise concerns about whether enough caregivers will be available to meet future needs.

3. Policy Solutions Involve Trade-Offs: Policymakers are debating whether to expand government-funded long-term care benefits or encourage individuals to save and plan for care privately. Proposals range from expanding Medicare and Medicaid home-care services to promoting private insurance, savings accounts, and home equity as funding sources. Washington state's WA Cares program, which provides limited long-term care benefits through a payroll tax, is emerging as a closely watched example of a potential alternative approach.

Employers are facing a new threat to workers' oral health

By Allison Bell – Employers are facing a new threat to workers' oral health, and overall oral health: workers' terror of routine cleanings leading to follow-up visits for "deep cleaning" services that may or may not be necessary. Most workers with employer-sponsored dental plans expect to pay $100 or less for the cleanings, according to Jordon Comstock, the founder and chief executive officer of BoomCloud, a dental practice software firm. When dentists recommend deep cleanings, those extra cleanings can cost $1,000 or more, and the patient's share of the bill could be $150 to $300. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Rising Skepticism Toward Dental Recommendations: Many employees are increasingly wary of dental providers' recommendations for costly procedures, particularly deep cleanings, which can lead to avoidance of both necessary and routine dental care. This skepticism may stem from a lack of understanding about when such treatments are truly needed. As a result, some workers may forgo preventive care, potentially worsening their oral health over time.

2. Employer and Plan Design Implications: Employers and benefits advisors are encouraged to address these concerns by incorporating education about dental procedures and preventive care into their plan designs. By proactively informing employees about the necessity and costs of various treatments, employers can help reduce confusion and mistrust. Additionally, emphasizing preventive measures like regular brushing and flossing can support better oral health outcomes and reduce the need for more expensive interventions.

3. Provider Benchmarking and Communication Strategies: Dental insurers, such as MetLife, are responding by increasing transparency and benchmarking provider practices to identify those who focus on prevention versus those who perform more costly procedures. Programs that highlight high-performing, prevention-oriented dentists have shown success in reducing unnecessary treatments, as evidenced by a 65% reduction in fillings among a group of providers. Enhanced communication between insurers, dentists, and patients is seen as key to building trust and ensuring appropriate care.

HHS watchdog finds 6 Part D plans accounted for 82% of 2023’s $276B gross federal spend

By Ella Jeffries – HHS’ Office of Inspector General has found that patients in vertically integrated Medicare Part D plans pay substantially higher out-of-pocket drug costs — and that data gaps are preventing a full picture of how consolidation affects pharmacies, according to a May 19 report. OIG also found that just six out of 11 health plans accounted for roughly 82% of the $275.9 billion in gross Part D spending in 2023, a level of concentration consistent with prior findings from the Federal Trade Commission and the House Oversight Committee. Read Full Article...

HVBA Article Summary

1. Market Concentration in Medicare Part D: The report highlights that a small number of health plans dominate the Medicare Part D market, with six plans responsible for the vast majority of gross spending. This concentration raises concerns about competition and the potential for these plans to influence pricing and reimbursement practices. Such dominance may also impact the choices available to consumers and independent pharmacies.

2. Higher Out-of-Pocket Costs for Patients: Patients enrolled in vertically integrated Part D plans are paying significantly more out-of-pocket for their medications compared to those in other plans. Although these plans may offer lower monthly premiums, the savings are largely attributed to increased rebate flows rather than more efficient drug pricing. This suggests that the structure of these plans may not always benefit patients financially, particularly those without additional financial assistance.

3. Data Gaps and Impact on Independent Pharmacies: The Office of Inspector General identified substantial data limitations that hinder a comprehensive understanding of how vertical integration affects independent pharmacies. While vertically integrated sponsors appear to reimburse their own pharmacies less at the point of sale, it is unclear how much is ultimately paid after accounting for various fees and concessions. These data gaps make it difficult for regulators and stakeholders to fully assess the impact of consolidation on pharmacy operations and patient access.

GLP-1 Response Clues: Can Clinicians Predict Outcomes?

By Mauricio Wajngarten, MD, PhD – GLP-1 receptor agonists (RAs) are widely used to promote weight loss. Independent of their effects on body weight, GLP-1 RAs also provide metabolic benefits and reduce cardiovascular and renal risks. However, responses to GLP-1 RAs vary substantially among individuals, both in weight-loss outcomes and in the occurrence of adverse effects. Understanding the factors underlying this variability may help clinicians better manage patient expectations, reduce adverse effects, and make informed treatment decisions. Read Full Article...

HVBA Article Summary

1. Patient Characteristics Influence GLP-1 RA Response: Factors such as sex, ethnicity, age, and initial BMI can affect how individuals respond to GLP-1 receptor agonists. For example, women and those of European descent tend to experience greater effectiveness, while older adults may face increased risks of adverse effects like dehydration and sarcopenia. Tailoring monitoring and dose titration to these characteristics can help optimize outcomes and minimize risks.

2. Clinical and Genetic Factors Affect Efficacy and Safety: The presence of type 2 diabetes, chronic kidney disease, and gastrointestinal intolerance can alter both the efficacy and tolerability of GLP-1 RAs. Additionally, genetic variants in GLP-1 and related receptors have been linked to differences in weight loss and the likelihood of side effects such as nausea. Recognizing these factors may allow clinicians to better predict which patients will benefit most and who may be at higher risk for discontinuation.

3. Individualized Treatment and Dose Adjustment Are Essential: Higher doses and longer treatment durations are associated with greater metabolic and cardiovascular benefits, but also with increased adverse events, particularly gastrointestinal issues and biliary tract disease. Discontinuation rates due to side effects can be significant, especially outside of clinical trials. Careful, individualized dose selection and titration, considering both phenotypic and genotypic predictors, are crucial for improving adherence and advancing precision medicine in obesity and diabetes care.

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)

Drug Channels News Roundup, May 2026: My $0.02 on Optum Rx’s Transparency, Must-Read 340B History, PBM Unbundling Update, PA Delays, and Vegas Fun

By Adam J. Fein, Ph.D. – Summer unofficially kicked off last weekend. So fire up the grill and enjoy these noteworthy delicacies, seared to perfection on the Drug Channels barbeque… Read Full Article...

HVBA Article Summary

1. Optum Rx’s Move Toward Transparent Pricing: Optum Rx is shifting its business model to offer clients a transparent, fee-based pricing structure that is independent of drug list prices and prescription volumes. This approach aims to eliminate spread pricing and increase clarity around fees and manufacturer payments. The change reflects broader industry trends toward transparency and may challenge the sustainability of rebate-driven models.

2. 340B Program’s Historical Evolution and Policy Implications: Recent research highlights that the 340B Drug Pricing Program was originally intended as a narrow solution to specific Medicaid pricing issues, but has since expanded well beyond its initial scope. The eligibility criteria, such as the disproportionate share hospital threshold, were set for political reasons rather than scientific or policy-based rationale. Understanding this history is crucial for stakeholders engaged in current debates over the program’s future direction.

3. Challenges in PBM Unbundling and Prior Authorization Delays: Blue Shield of California’s attempt to unbundle pharmacy benefit management (PBM) services across multiple vendors has not yet delivered the anticipated cost savings, with administrative costs offsetting reported savings. Meanwhile, a study of prior authorization (PA) processes found that a significant portion of brand-name drug prescriptions face delays or are never approved, particularly affecting complex cases and certain patient groups. These findings underscore persistent inefficiencies and access barriers within the healthcare system.

Uptick in subrogation lawsuits raises concerns

By Bruce Shutan – A new wave of health plan litigation could sweep over benefit brokers and advisers who aren't careful about the vendors they recommend to employer clients. Phia Group chief legal officer Ron Peck has noticed an uptick in lawsuits filed by group health plan sponsors and members against administrators and advisers over failure to enforce cost-recovery strategies like subrogation. Indeed, a 2025 ERISA litigation review by law firm Willkie Farr & Gallagher LLP noted that "copycat" lawsuits that included failure to recover overpayments and improper claims processing have been filed "at a rapid pace." Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Fiduciary Concerns Around Subrogation Recovery: Subrogation allows insurers to recover medical costs from third parties responsible for a member’s injuries, helping reduce financial strain on self-funded health plans. When these recoveries are not pursued, the costs may shift back to employers and plan members through higher contributions, potentially creating fiduciary concerns. Peck argues that fiduciary responsibilities ultimately center on transparency, prudent decision-making, protecting confidential information, and acting in the client’s best interest.

2. Increased Legal Scrutiny of TPAs and Fiduciary Status: The article highlights that many small and midsized employers rely on TPAs and brokers to manage complex benefit plans because they lack the resources of larger organizations. Courts are increasingly examining whether TPAs can be considered fiduciaries based on how much control they exercise over plan assets and claims decisions, regardless of contractual language. A recent case involving Blue Cross Blue Shield of Michigan and Tiara Yachts Inc. demonstrated how claims-handling practices and recovery fee arrangements can lead to fiduciary breach allegations.

3. Cross-Plan Offsetting and Conflict-of-Interest Risks: Cross-plan offsetting is identified as a major issue in which TPAs may recover an overpayment by underpaying claims tied to another plan or line of business. Peck argues that this practice disregards the independence of individual self-funded plans and may demonstrate fiduciary control over plan assets. He recommends that advisers implement strong payment-integrity measures, effective recovery programs, and objective fee structures to reduce conflicts of interest and avoid perceptions of self-dealing.

Rising healthcare costs impact 401(k) accounts

By Donnell Stidhum – For decades, the 401(k) was a single-purpose vehicle: Money goes in during working years, stays untouched and comes out during retirement. That compact has quietly broken down. Medical bills are one of the leading reasons Americans raid their retirement accounts early. And the people doing it aren't reckless spenders; they are ordinary workers who simply cannot make the math work anymore. Read Full Article...

HVBA Article Summary

1. Healthcare Costs Outpace Retirement Planning: The article highlights that most Americans significantly underestimate the amount they will need for healthcare in retirement, with costs rising steadily each year. Many retirees face expenses that far exceed their initial expectations, and these figures do not include long-term care or other uncovered services. This gap in planning leads to financial strain and increased reliance on retirement accounts for medical bills.

2. 401(k) Withdrawals for Medical Expenses Are Increasing: There has been a notable rise in hardship withdrawals from 401(k) accounts, with medical expenses being a primary reason. The frequency of these withdrawals has more than tripled compared to pre-pandemic levels, and the trend has continued for several consecutive years. Early withdrawals not only reduce retirement savings but also incur taxes and potential penalties, compounding the long-term financial impact.

3. Alternative Savings Tools Remain Underutilized: Health Savings Accounts (HSAs) are designed to help individuals save specifically for medical expenses, offering tax advantages and flexibility. Despite their benefits, only a minority of Americans contribute to or invest their HSA funds for retirement healthcare needs. The lack of professional guidance and awareness about these tools means many people continue to rely on 401(k)s for expenses they were not intended to cover, putting their overall retirement security at risk.

Employers Can Drive 529 Engagement Across Income Levels

By Emily Boyle – Federal 529 college savings plans are powerful tools to help fund higher education, but employees with low to moderate incomes face barriers to understanding and adopting the vehicles, according to new research from Commonwealth. Parents with household incomes greater than $100,000 held 37% of their college savings in a 529 account, while parents with annual income between $35,000 and $100,000 utilized the same vehicle for only 17% of their college savings, according to a 2018 study cited in Commonwealth’s report. Read Full Article...

HVBA Article Summary

1. Growing Interest and Expansion of 529 Plans: Interest in 529 education savings accounts is increasing, particularly among low- to moderate-income families, with 79% of parents earning between $25,000 and $80,000 annually saying they would consider opening their first 529 account if offered through their employer. Total assets in 529 plans reached $569 billion across 17.1 million accounts in the first quarter of 2026, reflecting continued growth in adoption. Recent federal legislation has also expanded eligible uses for 529 funds, including trade schools, apprenticeships, workforce certifications, and up to $10,000 annually for K-12 tuition.

2. Employers Positioned to Expand Access to Education Savings: Commonwealth’s report suggests that employers can help increase participation in 529 plans by offering payroll-deducted savings options alongside retirement and health benefits. Researchers found that many families still rely on cash savings or retirement accounts to pay for education expenses, with 41% of surveyed families reporting withdrawals from retirement savings for college costs. Integrating 529 enrollment during onboarding, after the birth or adoption of a child, or alongside retirement benefit elections may create a more accessible and low-friction pathway for employees across income levels.

3. Technology and Integrated Savings Tools May Improve Participation: The report highlights that artificial intelligence and integrated financial tools could help families better manage both emergency and education savings goals. A 2024 Commonwealth study found that 57% of respondents living on low to moderate incomes reported improved financial well-being after using an AI chatbot for financial guidance. In a separate pilot program combining emergency savings accounts with PA 529 plans, participants increased contributions to education savings while maintaining emergency savings levels, and most users reported positive experiences with the integrated tool.

Eli Lilly to acquire three vaccine developers for nearly $4B

By Alan Goforth – Eli Lilly and Company has agreed to acquire three vaccine developers in separate deals valued at nearly $4 billion, the drugmaker announced on Tuesday. The acquisitions of Cuerevo, LimmaTech Biologics and Vaccine Company will expand Eli Lilly's research and development efforts in infectious diseases. "These acquisitions reflect a deliberate strategy to prevent disease at its source rather than treat its consequences," said Daniel M. Skovronsky, M.D., Ph.D., chief scientific and product officer and president of Lilly Research Laboratories. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Strategic Expansion in Infectious Disease Prevention: Eli Lilly's acquisition of Cuerevo, LimmaTech Biologics, and Vaccine Company is a significant move to broaden its vaccine research and development portfolio. The company is shifting focus from treating diseases to preventing them at their source, aligning with a growing industry emphasis on proactive healthcare. This approach is intended to address both immediate and long-term health risks associated with infectious diseases.

2. Addressing Unmet Needs in Vaccine Development: Each acquired company brings unique technologies and vaccine candidates targeting critical health challenges. Cuerevo is developing a shingles vaccine aimed at improving tolerability and increasing vaccination rates, while LimmaTech Biologics focuses on bacterial pathogens with rising antimicrobial resistance. Vaccine Company contributes proprietary nanoparticle technologies to enhance immune responses, collectively aiming to fill gaps in current prevention strategies.

3. Broader Industry Implications and Recent Activity: These acquisitions are part of a larger trend of consolidation and investment in the biopharmaceutical sector, as evidenced by Eli Lilly's other recent deals, including purchases of Kelonia Therapeutics and Centessa Pharmaceuticals. The focus on vaccines and advanced therapies reflects the industry's response to evolving threats like antimicrobial resistance and the need for innovative solutions. Eli Lilly's expanded capabilities may influence future research directions and competitive dynamics in the vaccine market.

WTW: Employers aiming to bulk up AI use for health and benefits

By Paige Minemyer – Employers are set to significantly increase their use of AI in health benefits, a new survey shows, even as they continue to face barriers to rolling out the tech. WTW polled 312 employers with about 4.6 million workers for the 2026 AI Use in Health and Benefits Survey, and found that 72% of those surveyed plan to embed AI into their benefits programs in the next two years. By comparison, only 20% said they are currently doing so. Read Full Article...

HVBA Article Summary

1. AI Expected to Improve Benefits Operations: Employers identified communication, data insights, and personalization as the top areas where AI could support workplace benefits operations. Survey findings showed that 68% believe AI can improve communication, 59% see value in analytics and data insights, and 57% expect greater personalization. WTW leaders stated that these functions represent practical areas where AI can help benefits teams make decisions and better support employees.

2. Employers Face Readiness and Resource Challenges: The survey highlighted a gap between employer interest in AI adoption and organizational readiness to implement it effectively. Seventy-one percent of benefits teams reported having limited or no access to the internal skills and resources needed to deploy AI, even when expertise may exist elsewhere in the organization. In addition, only 1% of employers said they currently have a fully developed AI governance framework or roadmap specific to benefits, although 56% said one is being developed.

3. Early Adopters Show Importance of Governance and Expertise: Employers cited several concerns tied to AI implementation, including data privacy and security, AI errors, and legal or fiduciary risks. Specifically, 70% identified privacy and security as major concerns, while 66% cited AI inaccuracies and 64% pointed to compliance exposure. WTW found that early adopters, representing about 16% of employers, are more likely to have established governance structures, clearer AI strategies, and partnerships with external experts to support implementation and risk management.

Gen X health risks could drive up corporate benefits costs

By Allison Bell – Employers should look to see whether the workers in Generation X are getting checkups and taking their blood pressure pills. That's the advice of Businessolver, a company that helps employers and benefits advisors communicate with employer plan participants about benefits and wellness programs. Members of Generation X were born from 1965 through 1980, and they are now ages 45 through 61. "Gen X stands out as a cohort to watch closely," the Businessolver analysts say in the new report. "They report the lowest levels of self-rated health, with only 50% describing themselves as healthy." Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Gen Xers Face Notable Health Challenges: Generation X workers, currently aged 45 to 61, report lower self-rated health compared to other generations, with only half considering themselves healthy. This group is also more likely to be preparing for surgery and to be taking multiple prescription medications. These health issues could lead to higher health plan claim costs for employers if not addressed proactively.

2. Benefits Literacy and Engagement Are Mixed: Gen X workers scored an average of 47% on a benefits literacy survey, which is slightly higher than boomers but still indicates room for improvement. They are more likely than other generations to opt into text-message reminders for benefits programs, suggesting a willingness to engage with employer communications. However, the overall moderate literacy score highlights the need for clearer benefits education and outreach.

3. Employers Encouraged to Support Preventive Care: Analysts recommend that employers and HR leaders focus on removing barriers to preventive care for Gen X employees. Proactive outreach and nudges toward regular checkups and medication adherence could help mitigate future health costs. By supporting this age group before health issues escalate, companies may be able to better manage their benefits expenses and improve workforce well-being.

Five Things to Know About Weight-Loss Drugs and IBD

By Randy Dotinga – As gastroenterologists seek better therapies for inflammatory bowel disease (IBD), they're closely watching the evolving data on GLP-1 receptor agonists. Could drugs like semaglutide (Ozempic, Wegovy) and tirzepatide (Mounjaro, Zepbound) turn the tide against ulcerative colitis and Crohn's disease? Read Full Article...

HVBA Article Summary

1. GLP-1 Drugs Show Potential but Are Not Yet Approved for IBD: Early research suggests that GLP-1 receptor agonists, commonly used for obesity and type 2 diabetes, may have beneficial effects for patients with IBD, including reduced need for corticosteroids, hospitalizations, or surgery. However, experts caution that these drugs should not be considered standard therapy for IBD at this time. Their use is currently limited to patients with approved indications, and more evidence is needed before broader recommendations can be made.

2. Safety Profile in IBD Patients Appears Comparable to General Population: Gastroenterologists report that adverse effects from GLP-1 drugs, such as gastrointestinal side effects and risk of bowel obstruction, do not seem to be more frequent in IBD patients compared to others. Most side effects are mild and manageable with dose adjustments. Nonetheless, caution is advised for patients with certain risk factors, such as severe gastrointestinal disease, history of pancreatitis, or those at risk of malnutrition.

3. Ongoing Clinical Trials Will Clarify Role of GLP-1 Drugs in IBD: Several prospective studies are underway to determine whether GLP-1 drugs can improve outcomes for patients with Crohn's disease or ulcerative colitis who are also overweight or obese. These trials will compare GLP-1 drugs to standard care and are expected to provide more definitive answers by 2028. Until these results are available, clinicians are advised to use GLP-1 drugs in IBD patients only when there is a clear, approved indication.

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)

Innovation Summit in San Antonio with Strategic Board Meeting, Industry Collaboration, and Business-Driving Partnerships

By HVBA – The Health & Voluntary Benefits Association (HVBA) officially kicked off its 2026 Innovation Summit in San Antonio with a full strategic board meeting, setting the tone for a high-impact event focused on leadership, innovation, meaningful networking, and partnership development across the health and voluntary benefits industry. The San Antonio Innovation Summit brought together HVBA board members, sponsors, brokers, carriers, solution providers, and industry leaders for a curated experience designed to move beyond traditional conference networking. The event created an environment where attendees could engage in real conversations, explore case studies, ask thoughtful questions, and identify new opportunities to bring innovative benefit solutions to employers and their employees. Read Full Article...

HVBA Article Summary

1. HVBA Innovation Summit Focuses on Strategic Connections: The HVBA Innovation Summit in San Antonio was designed to prioritize meaningful business relationships, collaboration, and measurable outcomes rather than simply maximizing attendance. Organizers emphasized curated networking opportunities that brought together brokers, carriers, solution providers, and benefits professionals for focused conversations and partnership development. The event highlighted how smaller, targeted industry gatherings can create strong value for both attendees and sponsors.

2. Event Highlights Education, Innovation, and Industry Insights: Attendees participated in discussions centered on industry trends, benefit innovation, broker differentiation, and flexible solution offerings that can support employer clients. The summit also showcased the importance of reviewing case studies, data, and real-world applications to help benefits professionals make more informed strategic decisions. Sponsors and speakers provided direct access to emerging ideas and solutions shaping the voluntary and health benefits marketplace.

3. Strong Momentum Builds for Future HVBA Events: Feedback from attendees reflected enthusiasm around the networking experience, new business opportunities, and continued collaboration following the summit. Many participants left with actionable next steps, meaningful introductions, and plans to expand partnerships moving forward. The success of the San Antonio event has already generated anticipation for the next HVBA Innovation Summit taking place on August 20, 2026, in Tampa.

   
   Get Your VIP Pass at HVBA’s Next Innovation Summit in Tampa, Thursday, August 20th

CVS sues to challenge Tennessee's new PBM law

By Paige Minemyer – CVS has filed suit to challenge a Tennessee law that would bar pharmacy benefit managers from owning pharmacies in the state. Republican Gov. Bill Lee signed the Freedom, Access and Integrity in Registered Pharmacy, or FAIR Rx, Act into law last week, making the Volunteer State the latest to enact a law in this manner. In a statement, the Tennessee Pharmacists Association argues that the law brings greater transparency and fairness to the market. Read Full Article...

HVBA Article Summary

1. Tennessee Lawmakers and Independent Pharmacies Support S.B. 2040: Tennessee officials and independent pharmacy advocates say S.B. 2040 is intended to protect patients, healthcare providers, and community pharmacies from the influence of large pharmacy benefit managers (PBMs). Supporters, including the Tennessee Pharmacists Association, argue the law will strengthen rural and community pharmacy access while preserving patient choice. Advocates also believe the measure will help maintain the long-term viability of local pharmacies serving underserved areas.

2. CVS Challenges Law as Unconstitutional and Anti-Competitive: CVS Health argues that the legislation unfairly targets national and out-of-state pharmacy companies while favoring independent in-state pharmacies. The company says the law could force the closure of its 136 Tennessee pharmacy locations and contribute to the shutdown of more than 160 pharmacies statewide. CVS also contends that the measure would reduce competition, limit access to medications, and negatively impact the millions of Tennesseans who rely on its pharmacy services.

3. Debate Centers on Patient Access and Healthcare Costs: Supporters of the law say the measure is designed to improve pharmacy access and protect community-based care, particularly in rural areas. CVS counters that widespread pharmacy closures would have the opposite effect by reducing convenience and limiting treatment access for patients. The company also estimates the law could increase prescription drug costs for Tennessee employers by more than $180 million annually, underscoring broader concerns about affordability and healthcare access.

Cigna's president expects stop-loss price hikes to ease after 2027

By Allison Bell – Employers' medical stop-loss insurance premiums could start to stabilize after 2027. Brian Evanko, the president of Cigna, talked about the possibility recently in Las Vegas, at a health care conference organized by Bank of America Securities. Stop-loss premiums started climbing in late 2024, after stop-loss insurers began to report seeing a big, unexpected surge in claims. That year "was a difficult year for us, where claim costs exceeded our expectations rather meaningfully," Evanko said. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Cigna Stop-Loss Pricing Reset Extends Through 2027: The Cigna Group said rising stop-loss claim costs that emerged in 2024 were not fully reflected in 2025 pricing, making 2025 a transitional year for the business. Company leadership stated that sizable premium increases were implemented for 2026, with 2027 expected to complete the stop-loss repricing and margin recovery process. Executives also noted that customer retention has remained strong despite higher-than-historical rate increases.

2. Stop-Loss Market Conditions Align Across Major Insurers: Cigna executives said the company is the largest overall stop-loss issuer, generating approximately $8 billion in annual stop-loss premiums. Industry peers including Sun Life Financialand Voya Financial have reported similar experiences, citing elevated claims costs in 2024 followed by expectations that 2026 pricing assumptions are now more aligned with current claim trends. The comments suggest broader stabilization across the stop-loss insurance market after a period of significant cost pressure.

3. Employer Health Plan Trends Show Modest Overall Growth: During the conference, incoming CEO Brian Evanko said prescription utilization is increasing at a natural rate of approximately 1% to 2% annually, while enrollment in employer-sponsored health plans overall has been growing about 0% to 1% per year. However, smaller employer-sponsored plans with 50 to 500 participants are experiencing stronger enrollment growth, reaching mid- to high-single-digit increases in some cases. The discussion indicates that smaller employer groups may represent an expanding segment within the commercial health insurance market.

How voluntary plans close coverage gaps for women

By Melanie Cannon – HR and benefits professionals know that women are increasingly the primary benefits decision-makers for their households, especially among lower-income workers, but they're also carrying heavier burdens without adequate support. Research from The Standard shows that 72% of women earning less than $50,000 hold the benefits for their families compared to 62% of higher earners. At the same time, women shoulder a disproportionate share of caregiving responsibilities. They dedicate nearly twice as much time to family caregiving as men, according to the Bureau of Labor Statistics. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Women Report Lower Satisfaction With Benefits Support: Payroll Integrations’ 2025 Employee Financial Wellness Report found that women feel significantly less supported by employer financial wellness programs and benefits packages than men. Only 32% of women said they feel completely supported by financial wellness offerings compared to 56% of men, while just 36% said their benefits fully meet their needs versus 48% of men. The article suggests that many women, who are often primary caregivers and household decision-makers, are navigating complex benefits systems without adequate support or resources.

2. Employers Are Encouraged to Simplify and Personalize Benefits Communication: The article argues that traditional enrollment materials and annual meetings may not effectively reach hourly workers, front-line employees or caregivers with limited time to review complicated information. It recommends more accessible communication strategies, including in-person enrollment support, plain language explanations, mobile-friendly materials and real-life caregiving scenarios rather than technical insurance terminology. Segmenting communication by life stage, income level and caregiving responsibilities may also improve employee understanding and engagement.

3. Voluntary Benefits May Help Address Caregiving-Related Coverage Gaps: The article highlights voluntary benefits such as critical illness, accident and disability insurance as tools employers can use to better support employees with caregiving responsibilities. These benefits may provide financial protection for employees caring for children or aging family members, often without increasing direct employer costs. The article concludes that improving benefits alignment and communication could strengthen retention, increase benefits utilization and improve overall employee satisfaction.

Hospital stays, specialty drugs drive high-cost claims

By Alan Goforth – Secondary (comorbid) conditions, long inpatient hospitalizations and injectable drugs are the biggest drivers of expensive claims, according to the latest High-Cost Claims and Injectable Drug Trends report from Sun Life U.S. Other contributing factors include congenital anomalies, complicated surgeries and gene therapies, an analysis of more than 70,000 high-dollar claims medical claims from self-funding employers found. Some of the most common conditions resulting in claims greater than $3 million include orthopedic/musculoskeletal (MSK) conditions, premature birth and cancer. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Orthopedic/MSK Conditions Join Top Drivers of High-Cost Claims: Orthopedic and musculoskeletal (MSK) conditions have recently emerged alongside cancer and premature births as major contributors to million-dollar and multimillion-dollar health claims. The report suggests that rising claim severity and advancements in therapies and treatments are contributing to higher costs. Orthopedic/MSK conditions and cancer are also among the most common diagnoses associated with short-term disability claims.

2. Comorbidities Increase Complexity and Health Care Costs: The report highlights how comorbid conditions can complicate treatment plans, worsen primary diagnoses, and extend recovery times. Strong connections were identified among cancer, cardiovascular disease, chronic kidney disease, and orthopedic/MSK conditions, which share common risk factors such as obesity, diabetes, aging, and inflammation. The findings emphasize the importance of whole-person care approaches that recognize the interconnected nature of many high-cost conditions.

3. Specialty Treatments and Preventive Care Shape Cost Trends: Health care costs continue to rise due to increased use of specialty medications and gene therapies, including multimillion-dollar treatments for rare and complex diseases. Million-dollar-plus claims rose 46% between 2022 and 2026, while expensive treatments such as Elevidys and blood cancer therapies significantly increased overall spending. The report also notes that employers may have opportunities to reduce long-term costs by expanding preventive care initiatives, including GLP-1 coverage and support programs focused on cancer and MSK conditions.

UnitedHealth’s PBM names CFO

By Jakob Emerson – Optum Rx has named Jon Bosland as its next chief financial officer. “The PBM space is at an inflection point with rising utilization, accelerating cost pressures, and a technology landscape that is genuinely reshaping member expectations and how value gets delivered,” Mr. Bosland wrote May 22 on Linkedin. “The scrutiny of the industry is real, and so is the opportunity to lead differently.” He most recently served as CFO of the electrification software segment at GE Vernova from November 2023 to December 2025. Before that, he spent more than 16 years at Dell Technologies, holding a variety of financial leadership roles. Read Full Article...

HVBA Article Summary

1. Leadership Transition at Optum Rx: Jon Bosland has been appointed as the new chief financial officer of Optum Rx, UnitedHealth Group’s pharmacy benefit manager. His background includes significant experience at GE Vernova and Dell Technologies, where he held various financial leadership roles. This transition comes at a time when the pharmacy benefit management sector is facing increased scrutiny and evolving market dynamics.

2. Industry Challenges and Opportunities: The pharmacy benefit management industry is currently experiencing rising utilization rates and cost pressures, alongside rapid technological advancements. Bosland acknowledged these challenges in his public statement, emphasizing the need for innovative leadership and adaptation to shifting member expectations. The industry’s transformation presents both obstacles and opportunities for companies like Optum Rx to redefine value delivery.

3. Recent Strategic Moves by Optum Rx: Optum Rx maintained a 23% share of the U.S. prescription claims market in 2025, consistent with the previous year. Recently, the company announced a shift in its fee structure, moving away from group purchasing organization fees tied to drug prices to a flat, per-member monthly fee model for plan sponsors, with full implementation expected by the end of 2027. This change reflects broader efforts to increase transparency and align incentives within the pharmacy benefit management sector.

GLP-1s are closing the gap with bariatric surgery. Here’s what the research shows.

By Ella Jeffries – Eli Lilly’s new obesity drug is posting weight loss results that rival — and in some cases exceed — gastric bypass surgery, long considered the only effective treatment for most patients with severe obesity. Lilly announced May 21 that its investigational triple agonist retatrutide produced up to 30.3% body weight loss at two years in the Triumph-1 Phase 3 trial, surpassing any obesity drug currently on the market. The drug targets three hormones — GLP-1, GIP and glucagon — compared to the one or two targeted by existing treatments. Read Full Article...

HVBA Article Summary

1. GLP-1 Drugs Show Impressive Weight Loss in Trials, but Surgery Still Leads in Real-World Results: Clinical trials for new GLP-1 drugs like retatrutide have demonstrated weight loss outcomes approaching those of bariatric surgery, with some patients losing over 30% of their body weight. However, real-world studies indicate that bariatric surgery still results in greater and more sustained weight loss compared to GLP-1 medications. The difference is especially notable when considering long-term adherence and the durability of weight loss outcomes outside controlled trial settings.

2. Durability and Adherence Remain Key Challenges for Medications: While GLP-1 drugs are effective during active treatment, many patients regain weight after discontinuing the medication, highlighting a dependency on continued use. In contrast, bariatric surgery induces more permanent physiological changes, though a significant minority of surgical patients also experience weight regain or do not achieve expected results. This has led to increased use of GLP-1s as a supplementary therapy for post-surgical patients facing weight regain.

3. Cost and Access Influence Treatment Choices and Trends: Bariatric surgery is generally less expensive than ongoing GLP-1 therapy over a two-year period, but fewer patients qualify for or choose surgery. Meanwhile, GLP-1 prescriptions have surged, reaching a broader population, including those not eligible for surgery. Despite the higher up-front cost of surgery, the expanding use of GLP-1s reflects shifting preferences and greater accessibility, though both options face barriers related to cost, insurance coverage, and patient eligibility.

Unpacking the mental health parity index

By Michelle Quist Ryder – Mental health parity is a case in point. For more than a decade, federal law has required that mental health and substance use disorder (MH/SUD) benefits be comparable to physical health benefits. By statute, parity exists. And yet, for many employees trying to access care, that parity can feel more theoretical than real. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Persistent Gaps in Mental Health Access: Despite federal laws mandating parity between mental and physical health benefits, many employees still encounter significant barriers when seeking mental health care. The Mental Health Parity Index (MHPI) reveals that access to in-network mental health clinicians is consistently more difficult compared to physical health clinicians, and reimbursement rates for mental health providers are often lower. These disparities can result in longer wait times, narrower provider networks, and increased reliance on out-of-network care.

2. MHPI as a Data-Driven Tool for Employers: The MHPI provides employers, advisers, and policymakers with real-world data to better understand and address disparities in mental health care access. By quantifying differences between mental and physical health services, the index enables more informed decision-making during plan selection and renewal processes. This approach shifts the conversation from mere regulatory compliance to a strategic focus on improving employee well-being and reducing compliance risks.

3. Evolving Expectations and Opportunities for Change: There is a growing emphasis from regulators, employees, and the labor market on not just documenting parity, but ensuring it is implemented in practice. The MHPI encourages employers to move beyond assumptions and use data to identify and address gaps in care, ultimately supporting a healthier and more resilient workforce. While the index does not solve all parity issues, it increases transparency and provides a foundation for ongoing improvement in mental health benefit design.

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)

House Committee Advances 3 Bills Affecting ERISA Plans

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

HVBA Article Summary

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

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

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

Health insurers point fingers over affordability woes

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

HVBA Article Summary

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

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

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

Retatrutide Delivers Unprecedented Weight Loss in Phase 3

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

HVBA Article Summary

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

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

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

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

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

HVBA Article Summary

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

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

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

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

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

HVBA Article Summary

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

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

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

Caregiving as a business risk

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

HVBA Article Summary

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

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

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

The Medicare rules agents would repeal tomorrow

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

HVBA Article Summary

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

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

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

Brokers face a new reality in voluntary benefits

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

HVBA Article Summary

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

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

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

This holiday serves as a reminder of the courage, dedication, and selflessness of those who gave their lives to protect the freedoms we enjoy every day. We extend our deepest gratitude to our fallen heroes and to the military families who carry their legacy forward.

On behalf of the Health & Voluntary Benefits Association, we wish you and your families a safe and meaningful Memorial Day weekend. May we all take a moment to reflect on the true significance of this day and honor those who served with courage and distinction.

Thank you for being part of the HVBA community.

With gratitude,
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)