Health Plan Weekly

Although PBM reform measures wound up being cut from Republicans’ newly passed budget reconciliation legislation, 11 bipartisan Congress members on July 10 introduced a package containing PBM restrictions that some industry stakeholders hope can finally get across the finish line.

The PBM Reform Act contains many of the measures that were included — but then removed — from a year-end spending bill in 2024. Some of those provisions were later included in the House’s version of the “One Big Beautiful Bill Act,” but they were left out of the legislation that cleared the Senate.

Less than a week after Centene Corp. withdrew its earnings guidance for the year and saw its stock plummet, Molina Healthcare, Inc. on July 7 revealed that its second-quarter earnings will be “modestly below expectations,” citing ongoing medical cost pressures.

Molina also lowered its full-year adjusted earnings per share (EPS) guidance to a range of $21.50 to $22.50, compared with the previous guidance of greater than $24.50. Some industry experts say Molina’s disclosure offers further evidence of the managed care sector’s mounting troubles.

The budget reconciliation bill that President Donald Trump signed into law on July 4 will have a major impact on state directed payments (SDPs) that insurers are sometimes required to make to providers serving managed Medicaid beneficiaries.

One health policy expert tells AIS Health, a division of MMIT, that the cuts may contribute to slower adoption of value-based care among managed Medicaid insurers, while a recent KFF analysis found the reduced reimbursement could potentially lead to decreased access to and lower quality of care.

While President Donald Trump has enacted or proposed numerous policy changes since beginning his second term in January, his administration has kept most of the health care antitrust rules in place, according to speakers at a July 9 Manatt, Phelps & Phillips LLP webinar.

Dylan Carson, a Manatt partner and former Department of Justice (DOJ) attorney, said that “by all appearances, antitrust enforcement in health care remains a high priority.” Still, Manatt experts suggested that this administration may be slightly more open to the idea of divestitures as a remedy for antitrust concerns than the previous administration.

The Wall Street Journal reported on July 9 that federal government officials have interviewed former UnitedHealth Group employees as part of an investigation into the company’s Medicare billing practices. Prosecutors from the Department of Justice as well as officials from the FBI and the HHS Office of the Inspector General have conducted the interviews and asked about UnitedHealth’s “efforts to encourage the documentation of certain lucrative diagnoses, including testing patients, implementing procedures to ensure the medical conditions were captured, and sending nurses to patients’ homes,” according to the Journal.

In a statement released on July 9 after the article was published, UnitedHealth said it stands “behind the integrity of our Medicare Advantage business” and noted it will implement an independent, third-party coding oversight and audit process.