PBMs have been systematically underpaying small pharmacies, helping to drive hundreds out of business. The pattern is benefiting the largest PBMs, whose parent companies run their own competing pharmacies. When local drugstores fold, the benefit managers often scoop up their customers, according to dozens of patients and pharmacists. The PBMs' power comes from two main sources. First, the three biggest players — CVS Caremark, Express Scripts and Optum Rx — collectively process roughly 80% of prescriptions in the United States. Second, they determine how much drugstores are reimbursed for medications.
Humana Inc., has filed a lawsuit against CMS in response to a recent cut in crucial Medicare quality ratings. The lawsuit is an attempt to reverse the decision which has already hurt its stock value and threatens a loss of billions of dollars in incoming revenue. The company claims that Medicare acted in an 'arbitrary and capricious' manner in calculating its metrics on the health plans offered by Humana. Star ratings play a crucial role in determining bonus payments worth billions of dollars. The latest downgrade spells bad news for the 2026 earnings targets that Humana has set, and one analyst called it a 'worst-case scenario' for the Louisville, Kentucky-based insurer.
The nation's three largest Medicare Advantage insurers increasingly refused to pay for rehabilitative care for seniors in the years after adopting sophisticated technologies to aid in their coverage decisions, a Senate investigation found. UnitedHealth Group, Humana, and CVS Health targeted denials among older adults who were requesting care in nursing homes, inpatient rehab hospitals, and long-term hospitals. As of 2022, those three insurers were turning down roughly a quarter of all requests for post-acute care among their Medicare Advantage enrollees.
The emails from UnitedHealth Group managers were filled with exclamation marks and pleasantries about the weather. But the underlying message to doctors in late 2020 was persistent and urgent: Hit your targets to see more patients. We need to bring in more money. At the time, deaths from COVID-19 were surging, and no vaccine was available. But inside a UnitedHealth practice, the '#1 PRIORITY' became documenting older patients' chronic illnesses to generate more revenue from the federal government, the emails show.
Expanding Medicare coverage of costly weight loss drugs could come at a steep cost for the federal government. Allowing Medicare to cover obesity medications would increase federal spending by about $35 billion from 2026 to 2034, according to an analysis released by the CBO. The federal costs for covering those drugs would grow from $1.6 billion in 2026 to $7.1 billion in 2034, the CBO said. The analysis is all hypothetical, and comes as drugmakers and advocacy groups push for the government to expand coverage of – and give more seniors access to – the highly popular treatments. Those include GLP-1s for obesity such as Novo Nordisk's Wegovy and Eli Lilly's Zepbound, which both carry hefty price tags of roughly $1,000 per month before insurance and other rebates.
Blue Cross Blue Shield has agreed to pay $2.8 billion to resolve antitrust class action claims by hospital systems, physicians and other health providers alleging they were underpaid for reimbursements. The settlement is the largest ever for a healthcare antitrust case. BCBS denied the allegations in a statement, but said it agreed to the settlement and make operational changes to "put years of litigation behind us." The providers' lead attorneys says the proposed settlement would "transform" the BlueCard program through which providers submit claims. The agreement is subject to approval from a federal judge. The providers first sued in 2012, claiming Blue Cross and its affiliates divided the country into exclusive areas where they did not compete with each other. The lawsuit said the nationwide conspiracy increased the cost of insurance and drove down reimbursements.