Health Plan Weekly

While health insurers expressed serious concerns about portions of the House budget reconciliation bill recently passed by two key committees, they used even stronger language to warn against the market-altering effects of a newly amended package passed by the full House on May 22. 

“Rather than making America healthy again, the House legislation makes Americans uninsured again,” the Alliance of Community Health Plans (ACHP) said, referencing HHS Secretary Robert F. Kennedy Jr. and President Donald Trump’s “Make American Healthy Again” slogan.  

Although UnitedHealth Group dismissed a recent Wall Street Journal article that the Dept. of Justice (DOJ) has been investigating the company since last summer for potential criminal Medicare fraud, Wall Street analysts said the report adds another headache for one of the world’s largest health care companies. UnitedHealth a day earlier had pulled its financial guidance and replaced its CEO. 

Wolfe Research analysts wrote in a May 19 note that the past five weeks have “been unprecedented for UNH from both an operational & stock price performance standpoint” and added that “we expect it will take time for both earnings and investor sentiment to begin recovering.” However, they noted “we are confident in a path to recovery” in the company’s Medicare Advantage and projected adjusted earnings per share (EPS) next year of $26, up from an anticipated $21.75 this year.

In an effort to help employers meet the “growing demand” for weight loss medications, The Cigna Group’s Evernorth Health Services on May 21 announced a deal with Eli Lilly and Co. and Novo Nordisk to cap Zepbound (tirzepatide) and Wegovy (semaglutide) copays at $200 per month for plan members, saving them as much as $3,600 per year compared to buying the weight loss medications directly from manufacturers. 

Employers will also see a lower net cost for the drug, Evernorth said. That could be an attractive option for firms that are still considering the many tradeoffs associated with deciding how to cover GLP-1s.

Even as Donald Trump’s administration seeks to significantly curtail diversity, equity and inclusion (DEI) initiatives across the U.S., a group of payers and providers in the Philadelphia-area are resolute about the work they’ve been doing to address health disparities. Speaking at the Population Health Colloquium at Thomas Jefferson University on May 9, they indicated that two programs Independence Blue Cross (IBX) helped launch in recent years continue to thrive and move forward. Those initiatives are Accelerate Health Equity, which began in March 2022, and the Regional Coalition to Eliminate Race-Based Medicine, which started in August 2023. 

Trump signed an executive order on the day he took office in January revoking federal DEI-related programs in the federal government and among federal contractors, and the ripple effect has been felt in the private sector, too. However, Rodrigo Cerda, M.D., IBX’s chief medical officer, said that “I don’t think [the order] changes the fundamental mission in public health. You do have to treat diverse populations and meet them where they are and try to ensure that everybody’s brought up.”

CMS on May 21 unveiled a “significant expansion” of its Medicare Advantage auditing efforts. The agency said it will audit all eligible MA contracts for each payment year in all newly initiated Risk Adjustment Data Validation (RADV) audits, and it will invest additional resources to expedite the completion of audits for payment years 2018 through 2024. CMS noted that it is several years behind in completing these RADV audits, as the last significant recovery of MA overpayments occurred following the audit of payment year 2007, “despite federal estimates suggesting MA plans may overbill the government by approximately $17 billion annually.” CMS uses RADV audits to ensure that diagnose codes submitted by MA plans for risk adjustment payment purposes are supported by medical records.