Health Plan Weekly

While UnitedHealth Group’s stock price declined by more than 15% following the May 13 announcement that the company had replaced CEO Andrew Witty and suspended its financial guidance for this year, Wall Street analysts and other industry observers applauded the move, which they viewed as appropriate considering UnitedHealth’s dismal first-quarter performance.

“United is and always has been heavily focused on quarterly earnings,” Joe Paduda, principal of Health Strategy Associates, LLC, tells AIS Health, a division of MMIT. Profit and loss managers, he adds, “are acutely aware of their numbers and fully understand their obligation is to deliver on their forecast. It is difficult indeed to comprehend how United could have been unaware it would miss projections as badly as it did.”

After the House Energy and Commerce and Ways and Means committees passed their portions of Republicans’ domestic policy bill on May 14, it appeared as though major changes to the Medicaid program and Affordable Care Act marketplaces had moved closer to becoming a policy reality. However, conservative House members blocked the package from advancing past the Budget Committee, leaving the future of the "big, beautiful bill" uncertain.

For the private health insurers that cover most Medicaid beneficiaries and all ACA exchange enrollees, experts say the largest business headaches in the health care provisions that the GOP originally agreed upon could come from not only the cumulative weight of all the policy proposals but also the less-noticed portions of the legislation. 

Two months after announcing that it would end four payment models early and not implement two proposed models, CMS’s Center for Medicare and Medication Innovation (CMMI) on May 13 disclosed some of its priorities during President Donald Trump’s second administration, although it did not reveal any new models. Speaking at the Duke-Margolis Health Policy Conference in Washington, D.C., that same day, CMMI Director Abe Sutton and CMS Administrator Mehmet Oz, M.D., said the agency is seeking evidence-based approaches that will improve outcomes, save money and be applicable to a large number of beneficiaries.  

Oz also mentioned that CMS is “open for business,” referring to a request for information it revealed on May 13 for public input on improving health technologies that could be used to promote value-based care and other initiatives. He said that “we want to have a lot of good ideas percolating to the top, ideas that government could maybe try to do.” But he added that he believes “it’s better for the private sector to solve this” rather than the public sector. 

President Donald Trump’s administration is aiming to revive its so-called most favored nation (MFN) policy to reduce drug prices in the U.S. — a move that could lower costs for insurers but have far-reaching consequences for PBMs, experts tell AIS Health, a division of MMIT. However, some analysts are skeptical that the policy changes Trump is calling for will ever come to fruition. 

Trump’s May 12 executive order instructs HHS Secretary Robert F. Kennedy Jr., CMS Administrator Mehmet Oz, M.D., and the Assistant to the President for Domestic Policy Vince Haley to work with drug manufacturers to negotiate prices in line with those of other developed nations. If deals are not reached within 30 days of the signing of the order, the HHS secretary will turn to the rulemaking process to set MFN pricing. The order also allows HHS to set direct-to-consumer purchasing through drug manufacturers at MFN pricing. And it paves the way for importation of medications — a move that comes as the administration considers pharmaceutical tariffs. 

Commercial health plans’ use of “Z codes” to help track and understand enrollees’ social determinants of health (SDOH) has been sparse, according to a recent Health Affairs study. However, use of those codes doubled from 2016 to 2022.  

To document data on SDOH and health-related social needs, the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), introduced Z codes in 2015. The codes are used to report “factors influencing health status or reasons for contact with health services that are not classifiable elsewhere as diseases, injuries, or external causes,” according to a CMS file.