For decades, the prices Medicare pays doctors for different medical services have been largely decided not by Medicare itself, but by a powerful industry group, the American Medical Association.
An A.M.A. committee meets in secret to determine the difficulty and time demands of each type of medical visit, test and procedure, and then recommends to Medicare how much doctors should be paid for performing them. And for decades, critics have complained that this process unfairly rewards surgeons and other specialists, at the expense of primary care physicians and other generalists. Medicare officials have been loath to change it because it has spared them from needing their own staff and budget to make such pricing decisions, along with the unpleasant politics of adjudicating conflicts between competing groups of physicians.
But a change buried inside a 1,803-page proposed regulation published last Monday suggests the Trump administration would like to move away from this longstanding system. If finalized, it could begin overturning a process that has entrenched pay advantages for certain kinds of doctors. "We're modernizing Medicare by correcting outdated assumptions in how physician services are valued," said Chris Klomp, a deputy administrator of CMS, in an email.
A lawsuit filed in federal court on behalf of the University of Pennsylvania and its health system alleges that 20 years of skyrocketing prices on drugs that treat diabetes, like insulin, can be blamed on price-fixing by the top U.S. drugmakers and Pharmacy Benefit Managers. The pharmaceutical companies named as defendants in the lawsuit, filed July 11, are Eli Lilly, Novo Nordisk and Sanofi. They are accused in court papers of colluding with pharmacy benefit managers, or PBMs, including CVS Caremark, Express Scripts and OptumRX, to inflate prices over the years.
State health insurance regulators rejected a pair of proposed hefty premium increases from major insurers and allowed six other carriers to increase rates by 7% or more, albeit at lower levels than originally sought. The Division of Insurance on Monday published final 2026 rates for the merged market, which provides hundreds of thousands of Bay Staters with health insurance through individual or small business plans.
A federal appeals court has overturned a judge's unusual decision to acquit a Maryland doctor whom a jury found guilty in a $15 million health care fraud case involving COVID-19 tests, but upheld a ruling to grant him a new trial. Dr. Ron Elfenbein was convicted in 2023 in U.S. District Court in Baltimore of five counts of healthcare fraud. Federal prosecutors alleged that Elfenbein, 51, billed Medicare too much for visits that only lasted a few minutes and submitted records detailing medical services that his clinic did not provide.
Lawyers for the accused United Healthcare CEO killer, Luigi Mangione, are up in arms over what they say were 'secret' communications between his New York prosecutors and Aetna, his former health insurer. They say prosecutors sent Aetna an 'unlawful,' back-channel subpoena seeking his confidential insurance account number and the time period for his coverage — and that in response, Aetna mistakenly sent prosecutors Mangione's entire, 120-page insurance record.