Insurers Threaten to Ghost Seniors Over Flat Rates, Trump Admin Negotiates Botox Prices, and HHS Wonders If Direct-to-Patient Is Just a Kickback Scheme

Hey all,

Happy Thursday! As insurers theatrically weep over a flat pay raise and the administration moves forward with aggressive drug price negotiations, it seems the healthcare industry is finally realizing that the federal checkbook actually has limits. It is a spectacle of irony to watch multi-billion dollar payers threaten market exits while pharmaceutical giants scramble to defend their margins against new price caps on everything from Botox to cancer treatments. Apparently, the only thing rising faster than medical utilization is the collective blood pressure of corporate executives discovering that "profit" is not a guaranteed government benefit.

Enjoy the rundown!

Jacob Brody (Co-founder and CEO of ZorroRX)

(Fierce Healthcare) Insurers Warn Flat 2027 Medicare Advantage Rates Could Prompt Benefit Cuts and Market Exits

Health insurers are warning that the proposed flat Medicare Advantage rates for 2027 could necessitate significant benefit cuts and force some plans to exit the market entirely. Industry groups argue that the minimal 0.09% net payment increase fails to account for rising medical costs and utilization, putting affordable coverage for seniors at risk. We should all simply mourn for these struggling multi-billion dollar conglomerates that might have to figure out how to stay profitable without getting paid for medical diagnoses that aren't actually linked to a doctor's visit. Full Article

(STAT News) Medicare Selects 15 New Drugs for Third Round of Price Negotiations..

Under President Trump's directive, CMS has identified 15 high-cost medications for the latest round of Medicare price negotiations, targeting physician-administered treatments for the very first time. The list takes aim at blockbuster drugs like Botox and various cancer therapies, aiming to slash the exorbitant costs currently burdening the system by 2028. It serves as a rude awakening for Big Pharma executives who are finding out that the "Art of the Deal" doesn't include unlimited price gouging on everything from migraines to cancer, proving that the days of treating the federal treasury like a bottomless piggy bank are officially over. Full Article

(Cost Curve) HHS Asks for Input On the Legal Risks Around Direct-to-Patient Approaches

The Department of Health and Human Services (HHS) has requested information regarding the structure of direct-to-patient pharmaceutical programs, signaling potential legal concerns that initiatives like the delayed TrumpRx could violate federal anti-kickback statutes. In tandem with a special advisory bulletin warning against using these models to induce other billable services, the agency is seeking feedback on whether explicit "safe harbors" are necessary to protect manufacturers from liability. This dual approach indicates that while the government is encouraging "pharm-to-table" efforts, significant regulatory clarification is required to ensure these cash-pay models can operate without running afoul of existing healthcare laws. Full Article