Below is a roundup of payer-centric news headlines you may have missed during the month of April 2025.
Leading stories
States target PBM pharmacy ownership
A coalition of 39 state attorneys general wants Congress to outlaw pharmacy benefit managers from owning or operating pharmacies.
A week later, Arkansas enacted its own law to do just that, despite vocal opposition from a leading PBM lobbying group, the Pharmaceutical Care Management Association.
In the letter, the states said, “PBMs have overtaken the market and now wield outsized power to reap massive profits at the expense of consumers.”
Tennessee audit report spotlights Express Scripts
The Tennessee Department of Commerce and Insurance released an audit (PDF) of Express Scripts for calendar year 2023.
In the report, 100% of claims to small pharmacies did not receive the mandated enhanced dispensing fee, and the company was found to reimburse its own pharmacies at higher rates, said the National Community Pharmacists Association.
Spread pricing practices withheld more than $30 million in revenue from plans and patients, the Tennessee Pharmacists Association highlighted.
“These findings are not only technical violations, but also glaring examples of the egregious practices of PBMs that jeopardize public health and drive up costs for employers, patients, and taxpayers alike,” said Tennessee Pharmacists Association CEO Anthony Pudlo.
Industry
New ACO coalition
The National Association of ACOs, Accountable for Health and America’s Physician Groups are just three of the 10 ACOs that are part of the newly formed Complex Care Alliance.
Participants are in the ACO REACH model and are advocating for the CMS Innovation Center to extend the model beyond its expiration date next year, a news release explains.
“High-needs patients require proactive, team-based care that is impossible to deliver under a fee-for-service payment system,” said Accountable for Health CEO Mara McDermott in a statement. “These organizations have proven that accountable care models deliver better care at reduced costs for this highly specialized population, and we plan to build on this success for years to come.”
Independence Blue Cross and Isaac Health
Medicare Advantage members at Independence Blue Cross can now be referred for Isaac Health services, a virtual clinic for brain health and dementia care.
Isaac offers brain health assessments with dementia specialists, neuropsychologist testing, cognitive therapy, medication management, support groups and more, according to a news release.
“Our goal is to help members who have a diagnosis of dementia address potential brain health concerns early and be connected with the appropriate resources for support,” said Luz Ramos, M.D., geriatrician and medical director at Independence Blue Cross. “This is especially important, as the National Institutes of Health estimates that the aging of our population in the U.S. is expected to cause the number of new dementia cases per year to double by 2060.”
Cone Health and Medicare Advantage
Cone Health, under the Kaiser Permanente umbrella, is now the sole owner of HealthTeam Advantage, a Medicare Advantage (MA) plan.
The company acquired Novant Health’s stake in the plan. Cone Health now owns 100% of HTA Holdings and Care N’ Care Insurance Company of North Carolina. There are more than 22,000 members on six MA plans under HealthTeam.
Providence Health Plan partnership
Providence Health Plan is partnering with Collective Health, an employee health benefits platform to "reimagine" third-party administration services.
Collective Health claims the company will slash the healthcare cost trend by 50% over five years.
“Combining PHP’s deep understanding of regional healthcare needs and trusted provider relationships with Collective Health's proven technology platform brings something unique to the market,” said President and CEO Don Antonucci in a news release.
Venteur $20M fundraising
AI-powered individual coverage health reimbursement arrangement administrator Venteur has raised $20 million during a series A funding round.
The funding round was led by Informed Ventures and American Family Ventures, and included participation from Morgan Health, Ingeborg Investments, Catalyst by Wellstar, Plug and Play, Revelry Venture Partners, Houghton Street Ventures and Techstars. The company said it has seen 21x growth in 2024.
Venteur is using the funding to develop personalized health advisors with AI to better support businesses.
eternalHealth sanctioned by CMS
Multiple eternalHealth MA-PD contracts are now under sanction (PDF) by the Centers for Medicare & Medicaid Services (CMS).
The state of Massachusetts determined in March the company could not market its services or enter into new agreements because eternalHealth “failed to meet state financial solvency requirements.”
“Because eternalHealth is not permitted to accept new enrollments under its license with the state of Massachusetts, it is non-compliant with CMS’ contract requirements,” said the CMS in the announcement.
EternalHealth is run by founder Pooja Ika, the youngest person to ever start a MA prescription drug plan, and board chair John Sculley, the former CEO of Apple.
Studies
Medicaid debate ramps up
As talk of Medicaid spending cuts overtakes Washington, D.C., more data are coming to light as how reform would change healthcare.
About 1 million people received medication treatment for opioid use disorder through Medicaid in 2022, and 60% of Medicaid enrollees receive the treatment through Medicaid expansion, a report from the U.S. Congress Joint Economic Committee — Minority explains. If funding drops below a threshold in “trigger” states, at least 110,000 people will lose access to treatment.
Building off an Urban Institute report finding 5 million adults would lose coverage if work requirements are enacted, at least 10,000 adults would lose coverage in nearly every expansion state, finds the Robert Wood Johnson Foundation.
Cuts to funding could restrict the coverage of 2.6 million individuals in Michigan and $2 billion in fewer funds, warned Gov. Gretchen Whitmer’s office. She instructed the Michigan Department of Health and Human Services to prepare a report of how federal proposals would impact the state.
MA health risk assessments
Six in 10 Medicare Advantage enrollees are offered a reward for completing a health risk assessment.
Insurers use HRAs to collect health status information and can be completed as part of an annual wellness visit. HRAs are used to help calculate an individual’s risk score, and MA plans received $15 billion in 2023 due to diagnoses from HRAs, explained the KFF. Independent watchdogs and news publications have found health plans are receiving higher federal payments than they should because of HRAs.
Almost all Centene, CVS Health and UnitedHealthcare members receive an award for completing an HRA.
Pat Ryan Optum report
Rep. Pat Ryan, D-New York, released a report following a community inquiry into Optum-owned Hudson Valley medical practices and submitted the results to the Department of Justice, the Department of Health and Human Services and the Federal Trade Commission.
He'd received responses from more than 1,800 Optum patients and “several providers” detailing inadequate conditions.
About 36% of respondents reported customer service issues affecting the ability to obtain care, and 25% of respondents noted they experienced inaccurate or double billing. Nearly half said it was difficult to get an appointment, and 41% noted the quality of care has decreased over time.
“The volume of responses, the specificity of issues and the frankly heartbreaking stories involved are unlike anything I’ve seen in my time in Congress,” said Ryan in a statement. “I’ve heard from disabled children unable to get treatment. Mothers waiting almost a year for a cancer diagnosis. Families sent into debt because of overcharges for treatments never even received. All so the largest health care company in the world can continue to make record breaking profits.”
Jonathan Kanter on healthcare platforms
Dedicate antitrust enforcement to healthcare companies with the same focus as toward big tech platforms, argues Jonathan Kanter, former Department of Justice assistant attorney general, and Martin Gaynor, Ph.D., a Carnegie Mellon University professor of economic and public policy, in a Health Affairs viewpoint.
Platformization, they say, is when the largest companies encompass every aspect of the healthcare system under just one owner. Oftentimes, these companies provide products and services to multiple parties on opposite ends of the equation, so they always come out on top.
“Consolidated health markets have failed to deliver better care, lower prices, increased access or improved population health,” the authors write. “Evidence on the decadeslong experiment with consolidation in healthcare in the U.S. shows that concentrated markets have led to higher consumer prices and spending, without improvements in quality or gains in efficiency.”
The authors suggest the largest insurers should be broken up, if necessary.
“We may be witnessing the march to single-payer healthcare, but a private, profit-seeking single payer without oversight or competition to constrain it is not the kind of single payer anyone imagines or wants,” said Kanter and Gaynor.
A recent letter (PDF) from Reps. Lloyd Doggett, D-Texas, and Greg Murphy, R-N.C., pinpointed how Medicare Advantage Organizations must spend at least 85% of revenue on healthcare, but the companies circumvent these requirements. They asked the Government Accountability Office to provide a report on all relevant ownership structures.
MA coding practices
An Arnold Ventures-funded study in the Annals of Internal Medicine found Medicare Advantage (MA) plans are paid more for sicker members.
MA plans received $33 billion in additional payments in 2021, with nearly $14 billion going to UnitedHealthcare.
The authors found the average MA risk score was 0.19 higher than if traditional Medicare coding were identical.
Quick hits
- CBS News breaks down the Medicaid scandal engulfing Gov. Ron DeSantis, his wife Casey DeSantis and her nonprofit Hope Florida, and Centene in this TV report.
- Health tech company Zelis Healthcare—along with Aetna, Cigna, Elevance Health and Humana—have been sued by doctors and other healthcare professionals in an antitrust lawsuit (PDF).
- The Department of Justice has accused a Florida insurance executive of enrolling ineligible people into Affordable Care Act plans to obtain federal subsidies to the tune of $133 million. He is also accused of bribing low-income individuals.
- California Insurance Commissioner Ricardo Lara has used a shell campaign committee to pay for nearly $30,000 in meals and drinks, The San Francisco Standard revealed. He also took 11 taxpayer-funded trips to foreign countries, reported ABC7.
- Here’s how California Gov. Gavin Newsom is fixing a multibillion-dollar budget gap in the state’s Medicaid program through June.
- Evernorth Health President and CEO Eric Palmer, who is leaving the company in April 2026, will receive a cash payment of more than $5 million, an 8-K filing reveals.
- The United Health Foundation is contributing $7 million in grant partnerships to improve maternal and infant health, including $1.2 million to Detroit, Michigan to create the city’s first freestanding birth center.
- HBO comedian John Oliver was sued by Brian Morley, M.D., former medical director at AmeriHealth Caritas, for allegedly quoting Morley out of context on his weekly show, "Last Week Tonight."
- The America First Policy Institute released a report on pharmaceutical drug prices, and Milliman released a report on Medicare Advantage D-SNP plans.
- UnitedHealth Group has removed blog posts mentioning diversity, equity and inclusion, reported TechCrunch.