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Tuesday, June 23 · 7 stories
- Industry
Abarca Health and LucyRx Merge to Create Independent PBM Serving 9 Million Members
Abarca Health and LucyRx announced plans to combine operations, creating a larger independent pharmacy benefit manager serving more than 9 million members. The merger consolidates two independent PBMs in a market dominated by vertically integrated PBM-insurer entities. The combined entity will compete for Medicaid managed care pharmacy contracts as states and health plans increasingly scrutinize PBM practices and pricing transparency. No timeline for completion or details on operational integration were provided in the initial announcement.
- Industry
CareChoice CEO Scales Back Services Due to Limited Hospital Referrals
Arsen Ustayev, founder and CEO of CareChoice, is adjusting his company's service offerings and geographic footprint based on hospital referral patterns and varying state Medicaid policies. The executive, who previously founded adult day care provider SarahCare in Pennsylvania, has reduced certain services where hospital system referrals have not materialized as expected. His strategy reflects the critical role that hospital discharge planning and referral networks play in home health and post-acute care success, particularly in Medicaid-focused markets where state policy differences create operational complexity.
Monday, June 22 · 2 stories
- Industry
FDA Panel Recommends Moderna mRNA Flu Vaccine for Adults 50 and Older
An FDA advisory panel recommended approval of Moderna's mFlusiva, the first mRNA-based influenza vaccine, for adults ages 50-64 and those 65 and older under specific conditions. In late-stage trials, the vaccine demonstrated 27% greater effectiveness compared to standard flu shots. The panel's recommendation followed a June 18 meeting where FDA officials reviewed the clinical data. Final FDA approval would mark the first mRNA flu vaccine on the market, potentially expanding vaccine options for Medicaid managed care plans covering adult populations.
- Industry
Meta-Analysis Compares Weight Loss Efficacy Across Tirzepatide, Semaglutide, and Liraglutide
A new meta-analysis compared weight loss outcomes for three GLP-1 receptor agonists: tirzepatide (Zepbound, Mounjaro), semaglutide (Wegovy, Ozempic), and liraglutide (Saxenda, Victoza). The study evaluated clinical efficacy data across the three drug classes to determine comparative effectiveness for weight management. The findings provide evidence that could inform prior authorization criteria, formulary placement, and medical policy for obesity treatment in Medicaid managed care plans. Many state Medicaid programs have restricted or excluded coverage of anti-obesity medications due to cost, making comparative effectiveness data particularly relevant for coverage and utilization management decisions.
Friday, June 19 · 2 stories
- Industry
Freedom Senior Services Names New CEO Following Gemspring Capital Acquisition
Freedom Senior Services has appointed Dr. Brian Holzer as CEO following the company's acquisition by private equity firm Gemspring Capital. Holzer, a home-based care veteran, stated he plans to pursue aggressive mergers and acquisitions while expanding the company's service lines and client demographics. The leadership change follows the ownership transition to Gemspring Capital. This move signals continued consolidation in the home health sector, which increasingly serves Medicaid managed long-term services and supports (LTSS) beneficiaries.
- Industry
Eli Lilly Denies 340B Discounts to Hospitals Without Claims Data
Eli Lilly has begun denying 340B drug discounts to hospitals that have not submitted claims-level data under its reporting requirements, according to the American Hospital Association. The AHA confirmed the action in a June 18 statement, calling it "extraordinary." The move affects hospitals participating in the 340B Drug Pricing Program, which provides discounted outpatient drugs to eligible safety-net providers. This follows ongoing disputes between drug manufacturers and covered entities over data-sharing requirements that manufacturers have imposed despite regulatory uncertainty.
Thursday, June 18 · 2 stories
- Industry
Immigration Enforcement Creates Pediatric Mental Health Surge for Medicaid Plans
Hundreds of thousands of children, many U.S. citizens enrolled in Medicaid, are experiencing acute mental health crises following parental arrests in immigration enforcement operations. Children are presenting with developmental regression, somatic complaints including stomachaches, sleep disturbances, and academic decline. Research indicates these separations produce long-term behavioral health consequences requiring sustained clinical intervention. Medicaid managed care organizations face increased utilization in pediatric behavioral health services, emergency department visits for mental health crises, and demand for trauma-informed care coordination.
- Industry
STATus Report Episode Examines GLP-1 Weight Loss Drug Pipeline
STAT News published a video episode examining the future trajectory of GLP-1 weight loss medications. The segment, hosted by Alex Hogan, explores upcoming developments in the GLP-1 drug class, which includes medications like Ozempic and Wegovy. The episode appears to focus on market trends and pharmaceutical industry developments related to these medications. No specific policy changes, regulatory actions, or Medicaid coverage decisions are reported.
Wednesday, June 17 · 1 story
- Industry · KS
Seven Rural Kansas Hospitals Form Clinically Integrated Network
Seven independent rural hospitals in Kansas have formed the Kansas High Value Network, a clinically integrated network serving approximately 190,000 patients. The founding member hospitals represent a combined net revenue of $545 million. The network aims to support value-based care delivery and reduce purchasing costs through collective contracting and operational coordination. The formation reflects broader consolidation trends among rural providers seeking scale to participate in value-based payment arrangements.
Tuesday, June 16 · 2 stories
- Industry
Centene Announces Voluntary Separation Program for Most Employees
Centene Corporation confirmed it is offering a voluntary separation program to most employees as part of a broader repositioning effort. The managed care giant stated the program aims to deliver a simpler experience for members and partners while adapting to current healthcare market conditions. The announcement affects Centene's workforce across its health plan operations, though specific numbers of affected employees and program details were not disclosed. The timing follows industrywide pressure on managed care margins and administrative cost reduction initiatives.
- Industry
Elevance Health Focuses AI Strategy on Member, Provider, and Employee Experience
Elevance Health has outlined three strategic priorities for artificial intelligence deployment: simplifying member interactions, improving provider workflows, and enabling employees to access timely information. The health plan is integrating AI tools across its operations to enhance user experience and operational efficiency. These initiatives reflect broader industry investment in technology to manage administrative burden and member engagement. The timeline and specific implementation details were not disclosed.
Monday, June 15 · 4 stories
- Industry
KFF Health News Journalists Discuss ICE Detention Medical Care, RFK Jr. Comments
KFF Health News journalists appeared on national and local media outlets to discuss recent stories on medical neglect in ICE detention facilities and comments by Robert F. Kennedy Jr. regarding antidepressants. The media appearances covered investigative reporting on healthcare conditions in immigration detention and public health policy commentary. These discussions occurred as part of KFF Health News's ongoing coverage of healthcare access and policy issues. The appearances reflect broader public interest in healthcare delivery in detention settings and federal health policy discourse.
- Industry
Drug Shortage Confusion Leads to Preventable Congenital Syphilis Case in Arizona
A newborn in Arizona was diagnosed with congenital syphilis after the mother could not access penicillin through Pfizer's emergency allocation program during a national drug shortage. The case illustrates how supply chain disruptions and access barriers to penicillin — the only FDA-approved treatment for syphilis in pregnancy — are contributing to rising congenital syphilis rates. The CDC reported over 3,700 congenital syphilis cases in 2022, up from 335 in 2012. Medicaid covers approximately 42% of all births nationally and a disproportionate share of pregnancies affected by syphilis, making prenatal screening and treatment access critical managed care quality measures.
- Industry
Bipartisan Policy Center Finds Health AI Tools Largely Unregulated
A Bipartisan Policy Center report finds that most health AI tools currently deployed in healthcare settings operate outside existing regulatory frameworks. The report maps oversight gaps across federal agencies and identifies clinical AI scribes and prior authorization tools as examples of widely used applications with unclear regulatory authority. The analysis highlights inconsistencies in how different types of AI tools are classified and overseen by FDA, ONC, OCR, and other agencies. For Medicaid managed care organizations, the findings underscore the need for internal governance frameworks for AI utilization review, clinical documentation, and administrative automation tools until federal oversight clarifies.
- Industry
UnitedHealth Reaches Proposed Settlement with FTC Over Insulin Pricing Allegations
UnitedHealth has reached a tentative settlement with the Federal Trade Commission in a lawsuit alleging the company's pharmacy benefit manager inflated insulin costs. The proposed deal follows a similar settlement CVS Health reached with the FTC several months earlier in the same case. The FTC's lawsuit targeted major PBMs for practices allegedly driving up patient costs for insulin products. Specific terms of the UnitedHealth settlement have not been disclosed and remain subject to approval.
Friday, June 12 · 3 stories
- Industry
AMA Issues Policy Urging Exemptions in Upcoming Medicaid Work Requirements
The American Medical Association has issued policy guidance calling for exemptions in Medicaid work requirements expected to be implemented in multiple states. The AMA's position addresses work requirement policies that states may pursue following federal regulatory changes. The timing aligns with several states preparing to implement or expand work requirement programs. This matters for Medicaid managed care organizations because MCOs are typically responsible for verifying member compliance with work requirements and managing eligibility transitions, which adds administrative burden and affects member retention.
- Industry
Digital Behavioral Health Providers Shift AI Strategy from Copilots to Clinical Decision Support
Digital behavioral health companies are moving beyond AI copilot tools toward integrated clinical decision-making systems where AI, clinicians, and supervisors collaborate. This represents a strategic shift in how AI is deployed in behavioral health care delivery, moving from administrative assistance to clinical judgment support. The change reflects growing confidence in AI capabilities and evolving regulatory frameworks around AI in healthcare. For Medicaid managed care organizations contracting with digital behavioral health vendors, this transition will affect care quality metrics, clinical oversight requirements, and potentially liability and compliance frameworks.
- Industry
Health Plans Report AI Documentation Tools Driving Commercial Cost Increases
Nearly 70% of health plans surveyed by PwC identified providers' use of AI documentation and coding tools as a top three trend inflating commercial healthcare costs in the coming year. The report highlights concerns that AI-enabled coding may generate more comprehensive documentation and higher-acuity billing, potentially increasing claim volumes and costs. The findings reflect commercial market trends, as these AI tools are increasingly adopted across healthcare settings. Health plans are responding by evaluating claims review processes and utilization management protocols.
Wednesday, June 10 · 3 stories
- Industry
Average Drug Shortage Duration Reaches 5.3 Years in 2025
A new analysis shows the average drug shortage in 2025 has lasted 5.3 years, up from 4.3 years in 2024. The extended duration reflects chronic supply chain instability affecting generic medications, many of which are used extensively in Medicaid populations. The analysis highlights growing challenges in maintaining formulary stability and managing therapeutic alternatives. For Medicaid managed care plans, prolonged shortages complicate prior authorization processes, increase member access issues, and drive utilization of more expensive therapeutic substitutes.
- Industry
Health Systems Expand In-House Specialty Pharmacy Operations Amid 340B Restrictions
Health systems are increasingly establishing their own specialty pharmacy operations in response to tightening reimbursement and manufacturer restrictions on 340B contract pharmacy arrangements. Hospitals and health systems now represent the fastest-growing segment of direct participants in the specialty pharmacy market. The shift is driven by both revenue generation goals and manufacturers' evolving 340B policies that limit contract pharmacy access. This infrastructure buildout allows health systems to capture specialty drug dispensing margins and maintain access to 340B savings despite manufacturer restrictions.