Ahead of a January 1 deadline requiring payers to adopt new prior authorization application programming interfaces, Epic Vice President of Value-Based Care Ryan Bohochik discusses the industry's progress implementing the technology. The interview covers how payers, including those running Medicaid managed care plans, are approaching electronic prior authorization standards mandated under federal interoperability rules. It highlights gaps and momentum observed across the industry as the compliance date approaches, drawing on Epic's vantage point working with payers and providers on these integrations.
Why it mattersMedicaid managed care plans that miss the January 1 deadline for electronic prior authorization APIs face compliance exposure and operational disruption in utilization management workflows.
Managed Care
Democrats in competitive congressional districts are attacking Republican incumbents over their votes for the One Big Beautiful Bill law, which cuts Medicaid funding by nearly $1 trillion to help finance tax cuts. The attacks are showing up in campaign advertisements and debates ahead of the midterm elections, with Republicans reportedly struggling to craft a consistent defense of the law's Medicaid provisions. No new policy action is described; the article covers campaign messaging and political positioning around the existing law. The dynamic signals Medicaid funding cuts remain a potent, unresolved political liability heading into the midterms.
Why it mattersState agencies and health plans should watch whether sustained political pressure over the law's Medicaid cuts produces legislative efforts to delay, modify, or repeal provisions before they take full effect.
Finance · Managed Care
In a recap of its 2026 Annual Conference, NASHP reports that state leaders from Alaska, Virginia, and a rural Tennessee FQHC shared early lessons from implementing the Rural Health Transformation Program (RHTP), a federal funding stream aimed at strengthening rural health infrastructure. Sessions covered community trust-building, sustaining investments beyond the program's five-year window, and ensuring smaller rural providers aren't excluded from grant opportunities due to limited administrative capacity. Leaders also discussed how changes under the One Big Beautiful Bill Act are compounding financial pressures on rural health systems, including hospital closures and maternity care deserts. NASHP says it will continue supporting states in aligning RHTP funding with existing rural health priorities such as maternity care, primary care, and chronic disease management.
Why it mattersState Medicaid and rural health agencies face a narrow window to design RHTP-funded infrastructure investments that remain sustainable once the five-year program funding ends, even as broader Medicaid financing changes strain rural providers.
LTSS · Maternal · Finance
In an editorial cartoon, Mississippi cartoonist Marshall Ramsey depicts Gov. Tate Reeves offering a "Rural Hospital Fund" bandage and aspirin to a patient in a full-body cast, who instead holds a prescription for Medicaid expansion. The piece satirizes Reeves' continued opposition to expanding Medicaid in Mississippi, suggesting his rural hospital funding efforts are a minor fix compared to the scale of the state's health care needs. No new policy action is reported; the cartoon is commentary on the ongoing political debate over Mississippi's uninsured population and rural hospital finances.
Why it mattersThe cartoon underscores the continuing political stalemate over Medicaid expansion in Mississippi, a debate with direct implications for rural hospital solvency and coverage for low-income residents.
Finance
Virginia-based nonprofit Sentara has rolled out Regard, an AI system that integrates with electronic health records, across all 12 of its hospitals to assist with patient monitoring and discharge planning. The tool helps physicians and case managers quickly parse admission charts, monitoring notes and medical histories to flag new or worsening symptoms earlier and start discharge and follow-up planning at admission rather than at the time of medical clearance. Sentara estimates the tool could save roughly 90,000 staff hours, though executives say the figure is a forecast based on unconfirmed pilot data and that no case manager jobs will be cut. The rollout comes as some Virginia hospitals have trimmed staff and services amid funding pressures tied to recent federal reconciliation legislation affecting Medicaid coverage.
Why it mattersHealth plans and case managers should watch whether AI-driven discharge planning speeds coverage determinations and reduces length-of-stay costs without displacing the staff who coordinate Medicaid beneficiaries' post-acute and home-based services.
LTSS · Managed Care
In its Health Care Inc. newsletter, STAT reports on rising health insurance premiums and notes CMS is moving forward with a new fraud crackdown. The piece also touches on employers potentially shifting more health care costs to workers as premium increases strain small businesses in particular, and references a "sad Medicaid gathering" without further detail provided in this excerpt. The newsletter format combines several short items rather than a single in-depth report. Full details on the CMS fraud crackdown and the Medicaid gathering are referenced but not elaborated in the available excerpt.
Why it mattersMedicaid agencies and plans should watch for details on the referenced CMS fraud crackdown, which could signal new program integrity enforcement affecting providers and managed care organizations.
Finance
In a KFF Health News analysis, reporters break down federal data showing U.S. healthcare spending reached $5.3 trillion in 2024, or $15,474 per person, representing 18% of GDP and projected to hit 20% by 2032. The piece attributes rising costs more to prices than to increased illness, noting Americans get half as many in-person doctor visits as peers in other countries. It highlights that federal policy changes, including the One Big Beautiful Bill Act, are shifting costs from government onto households rather than reducing overall spending, while hospital care remains the largest spending category even as prescription drug costs grow fastest. Harvard's Michael Chernew warns spending growth outpacing GDP is financially unsustainable.
Why it mattersState Medicaid agencies and health plans face mounting pressure as federal cost-shifting policies increase the share of healthcare costs borne by low-income households, straining affordability and coverage retention.
Finance · Pharmacy
Oklahoma City-based Integris Health signed a definitive agreement Oct. 21 to become the third member system of Kaiser Permanente's Risant Health, a nonprofit launched in 2023 to expand value-based care. The deal comes about seven weeks after founding CEO Jaewon Ryu stepped down, with former Presbyterian Healthcare Services CEO Dale Maxwell now serving as interim leader during a national search. Risant, which already includes Geisinger and Cone Health, posted $12.6 billion in 2025 operating revenue and has committed billions in capital to support member systems. Integris, Oklahoma's largest nonprofit health system with 20 hospitals, reported an operating loss in fiscal 2025 and narrowed losses through the first nine months of fiscal 2026.
Why it mattersThe expansion signals continued consolidation among large nonprofit health systems pursuing value-based care models, which can reshape provider network dynamics and capital investment patterns that Medicaid MCOs and state agencies negotiate with in affected markets.
Managed Care · Finance
In a roundup, Becker's Hospital Review traces how evidence on GLP-1 drugs and pregnancy evolved from 2023 social media speculation about an "Ozempic baby boom" to formal clinical guidance by late 2026. Key milestones include a 2024 study finding no increased malformation risk in diabetic women taking GLP-1s around conception, an August 2026 international panel review of 34 studies finding no increased congenital anomaly risk but only partial direct evidence across clinical questions, and an October 2026 ACOG advisory recommending against use during pregnancy and stopping the drugs one to two months before conception. ACOG also said patients may resume injectable GLP-1s while breastfeeding with infant monitoring but should avoid oral versions. The guidance affects prescribers, OB-GYNs, and patients using GLP-1s for diabetes, obesity, or off-label fertility-related reasons.
Why it mattersOB-GYNs, prescribers, and health plans covering GLP-1s need updated clinical protocols and counseling practices as formal societal guidance now exists where none did three years ago.
Pharmacy · Maternal
The White House and South Carolina officials launched Project Lifeline 250, a six-month pilot providing free cybersecurity resources and technology to rural hospitals, according to an Oct. 26 news release from Gov. Henry McMaster's office. The initiative, involving the White House Office of the National Cyber Director, state agencies, and private tech companies including Cisco, Microsoft, Trellix and Zscaler, will strengthen network defenses, deploy backup technology to maintain services during cyber incidents, and identify outdated devices for replacement. The pilot builds on a similar Texas initiative, Project Watershed 250, and officials say it is designed to be scalable nationally. Officials have not disclosed how many or which South Carolina hospitals will participate.
Why it mattersRural hospitals, many of which serve high shares of Medicaid patients and operate with thin IT budgets, stand to gain free cybersecurity upgrades that could reduce disruptions to patient care and billing systems during cyberattacks.
An Oct. 26 report from Cedar and the Health Management Academy finds patient responsibility for large, slow-to-resolve hospital balances jumped to 49.3% in early 2026, up from 37.5% a year earlier, while smaller bills saw little change. The analysis, based on Cedar billing data and interviews with CFOs and revenue cycle leaders at five health systems, estimates roughly $28 million shifted from insurers to patients on comparable care volume, driven largely by high-deductible plans and coinsurance. Insured "underinsured" patients who exceed charity-care income thresholds but still face thousands in out-of-pocket costs are identified as a growing coverage gap. Some systems responded by raising charity-care income thresholds and deploying flexible digital payment tools, reporting measurable gains in collections and reduced bad debt.
Why it mattersHealth system finance and revenue cycle leaders face mounting bad debt risk from insured patients who fall outside traditional charity-care eligibility, making earlier affordability screening and payment flexibility a financial necessity rather than a patient-experience nicety.
Finance
Becker's Hospital Review published a ranking of 109 U.S. health systems by their most recent annual revenue, led by Kaiser Permanente at $127.7 billion, HCA Healthcare at $75.6 billion, and CommonSpirit Health at $40.1 billion. The list, compiled from self-reported financial results for periods ending in 2025, shows uneven growth across the sector: many large systems posted mid- to high-single-digit revenue gains driven by patient volumes, payment rate increases, and ambulatory and pharmacy expansion, while others grew through mergers and acquisitions or saw declines after divesting hospitals. The compilation is ongoing and not exhaustive, with Becker's inviting additional systems to submit data for inclusion.
Why it mattersHealth plans and state Medicaid agencies negotiating managed care network contracts and rate terms can use these revenue benchmarks to gauge hospital system leverage and consolidation trends affecting provider payment negotiations.
Finance · Managed Care
The FDA has approved Novo Nordisk's Awiqli (insulin icodec-abae) as the first once-weekly, long-acting basal insulin for children ages 10 and older with Type 2 diabetes, according to the company's October 23 announcement. The drug cuts basal insulin injection frequency from seven times weekly to once, and is approved as an adjunct to diet and exercise. Approval relied on adult Type 2 diabetes studies, a pediatric pharmacokinetic study, and the ONWARDS clinical trial program. Awiqli is now available at more than 70,000 U.S. pharmacies.
Why it mattersState Medicaid pharmacy programs and MCOs will need to evaluate formulary placement, utilization management, and prior authorization criteria for a new high-cost pediatric insulin option that could shift prescribing patterns and drug spend.
Pharmacy
PacificSource, Moda and Providence are withdrawing from the individual health insurance marketplace in Central Oregon, leaving only BridgeSpan Health and Regence BlueCross BlueShield, which are both owned by the same nonprofit parent. Both remaining carriers are raising premiums by roughly 20% for next year. PacificSource's Erik Wood attributes the exits to Congress's failure to renew enhanced premium tax credits, which shrank enrollment and pushed younger, healthier people out of the risk pool, leaving a smaller, costlier population and unsustainable volatility for carriers. Open enrollment begins November 1, and Oregon shoppers in the region will face far fewer options and steep rate hikes.
Why it mattersIndividual market consumers in Central Oregon face reduced plan choice and steep premium increases, while reduced ACA marketplace competition signals broader federal subsidy policy risk that could ripple into state Medicaid eligibility churn as people lose or forgo coverage.
Finance
DispatchHealth is rolling back its emergency room-alternative, payer-facing care model and laying off workers as it pivots to become a technology and staffing partner that helps health systems deliver complex care at home. The company ended relationships with six health systems as part of the restructuring. Alongside the pivot, DispatchHealth named President Erin Bartley as CEO effective November 1, succeeding Jennifer Webster, and hired Brian Ko as CFO. Bartley said the shift responds to a reimbursement environment where payers have scaled back investment and the industry has not fully proven savings from home-based complex care.
Why it mattersHealth plans and health systems relying on DispatchHealth for hospital-at-home or ER-diversion services will need to renegotiate arrangements as the company exits direct payer contracting in favor of a health-system enablement model.
LTSS
In a year-long reporting project, KFF Health News documents how more than 130 Americans across the country are struggling to afford premiums, copayments, prescriptions, and medical bills as healthcare spending outpaces the broader economy. The piece profiles patients going uninsured, rationing medications, selling homes, and putting medical bills on credit cards, including an uninsured travel nurse billed $93,000 after a stroke and an ACA enrollee with a $10,000 deductible. Overall U.S. health spending hit nearly $5.3 trillion in 2024, up from $3 trillion a decade earlier, and is projected to reach 20% of GDP by 2032. The reporting notes Congress's decision not to extend enhanced ACA subsidies and federal health program cuts, alongside a modest drop in prescription drug prices, as context for the affordability crisis ahead of the midterms.
Why it mattersRising consumer cost-sharing and the lapse of enhanced ACA subsidies will drive coverage churn and bad debt that strain providers, insurers, and state exchanges managing affordability and uncompensated care.
Finance · Pharmacy
