Insights: Healthcare

Medicare Physician Fee Schedule (PFS) Reimbursement

CMS has issued the CY26 Physician Fee Schedule (PFS) final rule. Under the rule, CMS will implement two separate conversion factors (CFs). For Alternative Payment Model (APM) participants, the aggregate CF is set at $33.57, a 3.77% increase ($1.27) from the CY25 CF of $32.35. For non-qualifying participants (non-QPs), the aggregate proposed CF...

Drug Pricing (Medicaid/MFN)

CMS’s Center for Medicare & Medicaid Innovation (CMMI) has announced a new voluntary drug pricing model called GENEROUS (GENErating cost Reductions fOr U.S. Medicaid). Under the model, manufacturers will provide supplemental prescription drug rebates to participating states to align Medicaid net prices with what certain other countries pay (i.e.,...

Drug Pricing/Coverage (GLP-1s)

The White House has secured drug pricing commitments from Eli Lilly and Novo Nordisk. Like the commitments from other drugmakers (i.e., Pfizer, Merck), Lilly and Novo have agreed to guarantee most-favored nation (MFN) prices on all new medicines and provide state Medicaid programs access to MFN drug prices. However, the two companies have made...

Pharmacy Benefit Managers (PBMs, Cigna)

Cigna announced that its PBM, Express Scripts (under the Evernorth division), will shift to a rebate-free model in the commercial/employer-sponsored market. Under this model, discounts on drugs will be passed through upfront to beneficiaries at the pharmacy counter instead of relying on post-purchase rebates. This change will begin with fully...

Healthcare Extenders/Reforms (ACA eAPTCs, PBMs, HSAs, Extenders, MA, Site Neutral)

The government shutdown continues without a clear off-ramp, and we will soon reach a key inflection point regarding the ACA enhanced subsidies (the start of open enrollment on 11/1, the date by which consumers will start seeing increased prices for their existing or new policies). Republicans remain firm that the expiring eAPTCs should only be...

Healthcare, Macro

Government Shutdown, ACA, HSAs

There have been virtually no indications in the last couple of days that either side is feeling pressure to shift positions on the government shutdown and there are no major inflection points this week that would create an incentive for it to end. However, there are a number next week that create a notable incentive to re-open the government,...