Weekly Spotlight
Medicare Advantage Is Having a Rough Week
The program that now covers more than half of all Medicare beneficiaries faced scrutiny from multiple directions this week—a bipartisan Senate report, a $118 million fraud settlement, and a dark money disclosure—all pointing at the same underlying question: who is actually paying for Medicare Advantage?
A bipartisan Senate Joint Economic Committee report found that overpayments to MA plans caused standard monthly Medicare Part B premiums to rise from $185 in 2025 to $203 in 2026—a cost borne by every Part B enrollee, including the roughly 40% who remain in traditional Medicare and receive none of MA’s supplemental benefits. In 2025, MA plans were paid an average of 120% of what traditional Medicare would have cost for the same beneficiaries, totaling $84 billion in excess payments. Industry groups AHIP and the Better Medicare Alliance pushed back, arguing the analysis relies on flawed MedPAC assumptions and that aligning MA payments with fee-for-service would harm seniors.
The same week, the Department of Justice announced that Aetna had agreed to pay nearly $118 million to settle allegations of up-coding—assigning more severe diagnostic codes than patient records support to inflate risk-adjusted payments from CMS. Upcoding is a documented driver of the overpayment gap; the settlement puts a concrete number on a problem that otherwise tends to live in actuarial tables. Aetna did not admit wrongdoing.
A KFF Health News analysis added another dimension, finding that approximately 82% of the 16,000-plus public comments on the 2027 MA proposed rate notice shared the language of a letter from Medicare Advantage Majority, a group with undisclosed funding sources. The coordination is legal, but the scale and opacity have drawn attention as CMS weighs the final rate.
There is also a quieter consumer issue. MA open enrollment runs through March 31, and beneficiaries switching back to traditional Medicare face a barrier that is rarely discussed: in most states, insurers can legally refuse Medigap supplemental coverage to applicants over 65. Without Medigap, traditional Medicare exposes beneficiaries to substantial out-of-pocket costs. The practical effect is that the exit from Medicare Advantage is harder to use than the entrance.
Tags: #ALL
Centers for Medicare and Medicaid Services (CMS)
Dr. Oz Says ACA Enrollment Is ‘Too High,’ Cites Fraud Concerns
CMS Administrator Mehmet Oz told NBC News that he believes current Affordable Care Act (ACA) enrollment of approximately 23 million is too high, predicting it will fall to around 19 million, and attributing the excess to fraud, duplicate enrollments, and eligibility errors. The administration previously claimed 4 to 5 million people were improperly enrolled in 2024 at a cost of up to $20 billion to taxpayers; independent experts from KFF and Brookings called those estimates likely overstated, noting that most anomalies reflect bookkeeping errors rather than intentional fraud. ACA enrollment fell by roughly 1.2 to 1.3 million this year after Congress allowed enhanced premium tax credits to expire, driving double-digit premium increases.
Source(s):
Dr. Oz says Obamacare enrollment may be ‘too high’
Oz: Millions may be falsely enrolled in ObamaCare
Tags: #PAYER #PATIENT #ALL
Aetna Settles Medicare Advantage Fraud Allegations for $118M
The U.S. Department of Justice announced that Aetna has agreed to pay nearly $118 million to settle allegations that the insurer upcoded patient diagnoses to inflate risk-adjusted payments from CMS. Aetna did not admit wrongdoing as part of the settlement.
Source(s): Aetna Settles Medicare Advantage Fraud Allegations for $118M
Tags: #PAYER #HOSPITAL
Medicaid Eligibility Under Pressure: Work Requirements and Six-Month Checks Take Shape
Two federal actions are reshaping Medicaid eligibility verification ahead of 2027. CMS has issued detailed guidance requiring Medicaid expansion states to conduct eligibility redeterminations every six months rather than annually for most expansion-population adults, as mandated under the One Big Beautiful Bill Act (OBBBA); the guidance also extends the requirement to Section 1115 demonstration populations. Separately, states face significant administrative challenges preparing for Medicaid work requirement provisions also set for 2027, with narrow timelines to build the necessary eligibility verification infrastructure.
Source(s):
CMS Details Implementation of Medicaid Six-Month Eligibility Checks Under OBBBA
Medicaid work requirements leave states scrambling for 2027
Tags: #ALL
Medicaid Prescription Drug Coverage and Insurer Outlook Under Federal Pressure
Three pieces this week examine Medicaid’s prescription drug landscape as federal cuts loom. KFF published two analyses: a data brief showing Medicaid prescription spending has grown due to high-cost drugs including GLP-1s and cell and gene therapies, and a companion fact sheet on five key facts about Medicaid drug coverage for the roughly one in five Americans enrolled in the program. Meanwhile, Medicaid managed care insurers are projecting cautious optimism to investors despite anticipating significant federal spending cuts, betting that work requirements and other structural changes will stabilize their business model.
Source(s):
Recent Trends in Medicaid Outpatient Prescription Drugs and Spending
5 Key Facts About Medicaid Prescription Drugs
Why Medicaid insurers are optimistic even as massive cuts loom
Tags: #PAYER #PATIENT #DRUG
Medicare Drug Pricing Update: Round 3 Negotiations Launch and Affordability Concerns Rise
All manufacturers of drugs selected for the third round of Medicare price negotiations under the Inflation Reduction Act (IRA) Drug Price Negotiation Program have agreed to participate, CMS announced March 13, allowing the agency to move into gathering clinical and patient-centered data for the 15 selected Part B and Part D drugs. Separately, a March 13 KFF poll found that 59% of Americans are at least somewhat worried about affording prescription drugs—the highest level since 2018—with 22% reporting they are “very worried” and majorities across party lines expressing concern.
Source(s):
All Drug Makers On Board For Third Rx Price Negotiations; CMS To Gather More Data
CMS moves forward with 3rd round of Medicare drug negotiations
Drug affordability worries highest since 2018: KFF poll
Tags: #DRUG #PAYER #PATIENT
Biden-Era Law Linked to Improved Medication Adherence in Medicare
A study published in JAMA Internal Medicine found that IRA prescription drug provisions reduced cost-related medication nonadherence among Medicare Part D enrollees by an estimated 4.9 percentage points in 2024, the first year the provisions were in effect. The provisions—including a cap on out-of-pocket drug costs and expanded low-income subsidies—drove non-adherence rates from 8.2% to 5.7% among Part D enrollees, while rates rose among privately insured patients over the same period. The effect was more pronounced among enrollees with multiple chronic conditions, where nonadherence fell by 7.8 percentage points. The study found no statistically significant improvement in broader healthcare-related financial strain, suggesting drug cost relief alone does not address premiums, deductibles, or existing medical debt.
Source(s): Biden-Era Law Linked to Improved Medication Adherence in Medicare
Tags: #PATIENT #PAYER #DRUG
CMMI Seeks Applicants For MAHA Pay Model To Address Chronic Disease
The CMS Innovation Center (CMMI) has opened its MAHA ELEVATE pay model to applicants, targeting chronic disease prevention through whole-person, lifestyle-based interventions combining psychological, nutritional, and physical approaches. Applicants must justify their proposed functional or lifestyle medicine interventions with evidence-based research and demonstrate a track record of successful delivery. The model advances the administration’s Make America Healthy Again agenda by emphasizing prevention over reactive disease treatment.
Source(s): CMMI Seeks Applicants For MAHA Pay Model To Address Chronic Disease
Tags: #PROVIDER #PAYER #PATIENT
Patient Advocates Worry GUARD Model Will Impede HIV Drug Access
HIV patient advocates are raising concerns that CMS’s GUARD (Guarding U.S. Medicare Against Rising Drug Costs) model could harm HIV patients by eliminating manufacturer-supported patient assistance and public health programs that make medications accessible domestically and globally. The HIV+HEP Policy Institute submitted comments warning that policies reducing these resources risk unintended consequences for patients in the U.S. and abroad. The GUARD model ties manufacturer inflation rebates in Part D to lower overseas drug prices, a design advocates argue could create perverse incentives that reduce support for vulnerable HIV populations.
Source(s): Patient Advocates Worry GUARD Model Will Impede HIV Drug Access
Tags: #DRUG #PATIENT #PAYER
MedPAC Recommends Increasing Physician Payment Rates, Cutting Rates For SNF, Home Health, Inpatient Rehab
The Medicare Payment Advisory Commission (MedPAC) is recommending that Congress increase Medicare physician payment rates while reducing rates for skilled nursing facilities (SNFs), home health agencies, and inpatient rehabilitation facilities, and eliminate payment updates for outpatient dialysis and hospice. The recommendations reflect MedPAC’s assessment that physician payments have fallen behind inflation and practice costs, while post-acute care payments remain above levels needed to cover efficient providers. MedPAC recommendations are advisory; Congress is not required to act.
Source(s): MedPAC Recommends Increasing Physician Payment Rates, Cutting Rates For SNF, Home Health, Inpatient Rehab
Tags: #PROVIDER #HOSPITAL #PAYER
CMS’ Oz Envisions Agentic AI in the Hands of Every Medicare Beneficiary
CMS Administrator Mehmet Oz, MD, outlined an ambitious vision for deploying agentic artificial intelligence (AI) tools directly to Medicare beneficiaries within a year, in a recent interview at HIMSS. Dr. Oz described AI as central to CMS’s modernization agenda, with the goal of giving every Medicare beneficiary access to personalized AI assistance to navigate their care and benefits. The statement reflects the administration’s aggressive posture toward AI adoption across federal health programs.
Source(s): CMS’ Oz Envisions Agentic AI in the Hands of Every Medicare Beneficiary
Tags: #PATIENT #PAYER
Oz Didn’t Invent the Medicare Fraud Fight. Is He Changing It?
A MedPage Today investigation examines how CMS Administrator Mehmet Oz has rebranded the longstanding federal approach to Medicare and Medicaid fraud—historically a “pay and chase” model—with dramatic social media clips and a self-described “war room.” The piece questions whether the theatrical approach represents a substantive shift in anti-fraud strategy or a repackaging of existing enforcement activity, and notes that some traditional fraud-fighting tools and personnel have been reduced under the current administration.
Source(s): Oz Didn’t Invent the Medicare Fraud Fight. Is He Changing It?
Tags: #PAYER #HOSPITAL #PROVIDER
Food and Drug Administration (FDA)
FDA Launches Unified Adverse Event Monitoring System, Replacing Fragmented Legacy Databases
The FDA launched the Adverse Event Monitoring System (AEMS) on March 11, consolidating previously separate reporting databases—including FAERS for drugs and biologics—into a single real-time platform accessible to the public, researchers, and agency staff. Commissioner Marty Makary described the legacy systems as “outdated and fragmented” and framed AEMS as part of the agency’s radical transparency agenda; FDA estimates the platform will save millions of dollars annually by eliminating duplicative infrastructure. The launch comes as FDA is also increasing scrutiny of telehealth companies selling compounded GLP-1 drugs, with AEMS enabling faster cross-category safety signal detection.
Source(s):
Goodbye FAERS? FDA Launches New Combined Adverse Event Database
FDA Launches New Adverse Event Look-Up Tool
FDA’s New Adverse Event System Extends Real-Time Reporting To All Products
FDA to unify agency’s ‘fragmented’ safety surveillance system
Tags: #DRUG #DEVICE #PROVIDER
Department of Health and Human Services (HHS)
RFK Jr.’s Vaccine Advisers Drop Proposal to Revisit COVID-19 Shot
The CDC’s vaccine advisory panel has dropped a proposal to revisit its recommendations for the COVID-19 vaccine. Some panel members appointed under HHS Secretary Robert F. Kennedy Jr. had publicly questioned the safety and manufacturing of the shots, including promoting a debunked theory that DNA contaminants in the vaccines are harmful. The move signals at least a temporary pause on efforts to formally roll back COVID-19 vaccine guidance at the federal level.
Source(s): RFK Jr.’s Vaccine Advisers Drop Proposal to Revisit COVID-19 Shot
Tags: #ALL
ARPA-H Launches Delphi Program to Develop Multi-Signal Wearable Biosensors
The Advanced Research Projects Agency for Health (ARPA-H) launched the Delphi program to support development of modular “chiplet”-based biosensors capable of tracking multiple signals—including inflammation markers, hormones, and drug levels—within the body. The program runs 4.5 years with initial prototypes expected in the first two years, and aligns with HHS Secretary Kennedy’s push for widespread wearable health monitoring. ARPA-H did not disclose total funding amounts but said past projects have ranged from $30 million to $150 million; solution summaries are due April 8.
Source(s):
ARPA-H kicks off wearable biosensor development program
ARPA-H launches program to develop biosensors that can track multiple signals
Tags: #DEVICE #PATIENT #PROVIDER
NIH Funding in Contradiction: Strong Returns, Delayed Disbursements, and Disproportionate Impact on Red States
NIH funding generated $94.15 billion in economic activity and supported 390,863 jobs in 2025, delivering approximately a 250% return on a $36.6 billion investment, according to a United for Medical Research report—yet that funding is failing to reach researchers on the ground. Despite Congress passing a funding bill more than a month ago that rejected proposed NIH cuts, grant awards have not yet been processed, with a former NIH institute director’s analysis of NIH RePORTER data confirming ongoing delays. The report also found that red states bore a disproportionate share of reduced NIH award activity: 16 of the 20 states that saw declines of more than 10% in 2025 awards voted for Trump in 2024, undercutting the administration’s stated goal of redirecting funding away from coastal universities.
Source(s):
Despite delays, NIH grants generated a 250% return on $36.6B investment in 2025: report
Red states hit hardest by reduced NIH funding
NIH Funds Still Not Getting to Researchers
Tags: #ALL
Heard on the Hill
Congress Closes In on FDA: Rare Disease Investigation and Bipartisan Makary Scrutiny
Congressional pressure on the FDA intensified this week from both parties. Sen. Ron Johnson (R-WI) announced a formal investigation into FDA rejections of rare disease drug applications, requesting all complete response letters sent to rare disease developers and citing cases including PTC Therapeutics’ ataluren for Duchenne muscular dystrophy and UniQure’s AMT-130 gene therapy for Huntington’s disease; Johnson told Commissioner Makary directly that he “better start” overruling career researchers. Separately, both Johnson and Rep. Jake Auchincloss (D-MA) are seeking Makary’s appearance before their respective committees over his handling of FDA operations and personnel decisions since taking office. The pressure follows Makary’s announcement that biologics chief Vinay Prasad would depart the agency at the end of April.
Source(s):
Senator to Investigate FDA Rejections of Rare Disease Drugs
GOP senator is investigating the FDA over rejections of rare disease drugs
Lawmakers From Both Sides Of The Aisle Want Answers From Makary
Tags: #ALL
Trump Administration to Launch Tariff Probe Into Foreign Drug Pricing Policies
A senior Trump administration official announced the U.S. Trade Representative plans to launch a Section 301 tariff investigation in the coming months targeting foreign drug pricing policies, which the administration argues force American consumers to subsidize global pharmaceutical innovation. Many drug pricing experts dispute that premise. The probe is part of a broader USTR effort to examine trade concerns raised by U.S. industries.
Source(s): Trump Administration to Launch Tariff Probe Into Foreign Drug Pricing Policies
Tags: #DRUG #PAYER #PATIENT
Notable Notes
Hospital Expenses Grew Twice as Fast as Prices in 2025, AHA Finds
The American Hospital Association’s (AHA) annual Costs of Caring report finds hospital expenses grew 7.5% in 2025—more than twice the rate of growth in hospital prices—driven by a 13.6% surge in drug costs, a 9.9% increase in medical supply spending, and a 5.6% rise in workforce costs. Hospitals spent an estimated $43 billion collecting payments in 2025, including nearly $18 billion overturning denied claims, while inpatient volumes rose 5.3% and outpatient visits climbed 9.8%. Medicare reimbursed hospitals just 83 cents on the dollar in 2024, resulting in more than $100 billion in underpayments.
Source(s): Hospital Expenses Grew Twice as Fast as Prices in 2025, AHA Finds
Tags: #HOSPITAL #PAYER #PROVIDER
Medtech Under Cyber Siege: Stryker Hit by Pro-Iran Group, Intuitive Surgical Discloses Phishing Breach
Two major medical device manufacturers disclosed significant cybersecurity incidents this week. Stryker confirmed a cyberattack beginning March 11 that disrupted its global Microsoft network environment; employee devices displayed the logo of Handala, a cybercrime group linked to Iran. The attack wiped data remotely across enterprise systems, disrupting order processing, manufacturing, and shipping, though Stryker said it found no evidence of ransomware or malware and identified 12 surgical technology platforms that remain unaffected. Separately, Intuitive Surgical disclosed a phishing incident in which an unauthorized third party accessed customer business and contact information, as well as employee and corporate data through a compromised employee account.
Source(s):
Stryker investigating cyberattack that caused widespread outage
Medical device manufacturer hit by cyberattack, possibly from Iranian-backed hackers
Medical Equipment Maker Stryker Says Cyberattack Disrupted Its Global Networks
UPDATED: Stryker hit by international cyberattack linked to pro-Iran group
Stryker’s manufacturing, shipping disrupted after cyberattack
Intuitive Surgical hit by cybersecurity phishing incident
Tags: #DEVICE #HOSPITAL #PROVIDER
EPA Proposes Rolling Back Biden-Era Limits on Ethylene Oxide Used in Medical Device Sterilization
The Environmental Protection Agency (EPA) has proposed rescinding key provisions of the Biden-era rule that tightened emissions limits for ethylene oxide (EtO), a chemical widely used to sterilize medical devices. The agency argues the stricter limits threaten the supply of sterile medical equipment, reversing a Biden administration cancer-risk determination that had justified the original rule. Critics note the rollback contradicts EPA’s prior finding of elevated cancer risk at commercial sterilizer facilities.
Source(s):
EPA Proposes To Scrap Biden-Era Limits On Device Sterilization Chemical
EPA Aims to Weaken Limits on Cancer-Linked Gas Used to Sterilize Medical Equipment
Tags: #DEVICE
Cardiologists Receive the Most Industry Payments for AI Medical Devices
A University of Pennsylvania study published in Health Affairs Scholar found that AI device companies paid nearly $60 million to more than 46,000 physicians between 2017 and 2023. Cardiologists received the most payments, followed by neurosurgeons and radiologists. The study used the Open Payments database linked to Medicare Provider Data, raising questions about conflicts of interest as AI-enabled devices proliferate across specialty care.
Source(s): Cardiologists Receive the Most Industry Payments for AI Medical Devices
Tags: #DEVICE #PROVIDER #PAYER
A Third of Americans Have Cut Spending or Borrowed Money for Health Care
A new survey finds that more than 80 million Americans—roughly one-third of the population—have cut spending or borrowed money to pay for health care. Reported sacrifices include skipping meals and reducing driving. The findings arrive as medical costs continue to climb and as Congress debates changes to coverage programs that could reduce access for millions of additional people.
Source(s): A Third of Americans Have Cut Spending or Borrowed Money for Health Care
Tags: #ALL
A ‘Disquieting Plateau’: Healthcare Costs Are Up, but Survival Among Heart Patients Stays the Same
The U.S. cardiovascular mortality rate declined dramatically from 2000 to 2011 but has remained largely unchanged since, even as healthcare costs have continued to rise. Researchers describe the stalled progress as a “disquieting plateau,” raising questions about whether additional spending on cardiovascular care is translating into meaningful patient outcomes gains.
Source(s): A ‘Disquieting Plateau’: Healthcare Costs Are Up, but Survival Among Heart Patients Stays the Same
Tags: #PROVIDER #PAYER #PATIENT
AATS Wants to Improve Research in the Field of Cardiothoracic Surgery
The American Association for Thoracic Surgery (AATS) has launched a formal collaboration with the National Heart, Lung, and Blood Institute-supported Cardiothoracic Surgical Trials Network (CTSN) to advance clinical research in cardiothoracic surgery. The partnership will leverage AATS membership to generate new trial concepts and address persistent challenges in patient recruitment and long-term outcomes data collection. A new AATS-CTSN Committee will guide study design from early-phase to large comparative effectiveness trials.
Source(s): AATS Wants to Improve Research in the Field of Cardiothoracic Surgery
Tags: #PROVIDER #HOSPITAL
Nearly Half of All Surgeons Have Considered Leaving the Profession Due to Burnout
A new report drawing on feedback from more than 1,500 surgeons—including many in cardiac surgery—finds that nearly half have considered leaving the profession due to burnout. The findings add to a growing body of evidence on healthcare workforce strain, particularly among surgical specialties.
Source(s): Nearly Half of All Surgeons Have Considered Leaving the Profession Due to Burnout
Tags: #PROVIDER #HOSPITAL
Panel: AI Can Improve Prior Authorization in Healthcare But Won’t Solve All the Issues
A healthcare finance panel concluded that artificial intelligence (AI) can improve the prior authorization (PA) process but will not eliminate the structural issues driving its complexity. Jeremy Friese, MD, founder of Humata Health, described PA as addressing genuine variation in care quality across the U.S. Panelists called for new approaches that increase transparency and reduce friction while preserving PA’s role in managing costs and supporting care quality.
Source(s): Panel: AI Can Improve Prior Authorization in Healthcare But Won’t Solve All the Issues
Tags: #PAYER #PROVIDER #HOSPITAL
The Trump Health Policy Both Parties Are Bullish On
Blue and red states are embracing a policy finalized during Trump’s first term that encourages Affordable Care Act (ACA) marketplace enrollment sign-ups. The bipartisan adoption reflects the policy’s ability to expand coverage in a way that aligns with both Republican market-based and Democratic coverage-expansion priorities.
Source(s): The Trump Health Policy Both Parties Are Bullish On
Tags: #PAYER #PATIENT
Opinion: Congress Must Pass Legislation to Ensure Medicare Covers Breakthrough Medical Technologies
A physician and inventor argues in STAT News that Congress must pass bipartisan legislation to close persistent coverage gaps for breakthrough medical technologies under Medicare. The piece references the 2016 legislative creation of a Medicare Coverage of Innovative Technology (MCIT) pathway and calls for renewed action to ensure safe and effective new technologies reach patients through the Medicare program.
Source(s): Opinion: Congress Must Pass Legislation to Ensure Medicare Covers Breakthrough Medical Technologies
Tags: #DEVICE #PAYER #PATIENT