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Friday, October 2 · 15 stories
- Industry
Hospital Revenue Cycle Leaders Flag 10 AI-Driven Payer Risks
In a Becker's Hospital Review roundup, revenue cycle executives from health systems including UC Davis Health, Harvard Medical Faculty Physicians, Rush University Medical Center, Carle Health, Lurie Children's Hospital, and Centerstone identify 10 top threats facing hospital billing operations. Leading concerns include payers using AI to review and deny claims faster than providers can respond, automation scaling existing workflow errors, governance gaps in AI-assisted coding creating compliance liability, silent "downcoding" that erodes revenue without appearing in denial reports, expanding prior authorization burdens, and organizational fragmentation that leaves no one accountable for end-to-end financial impact. The piece also highlights unmeasured "care abandonment" by patients unable to navigate administrative hurdles. No new regulation or enforcement action is reported; this is an industry survey of operational risks.
- Industry
AARP Foundation: Senior Poverty Rate Climbs for Fifth Year
An AARP Foundation analysis of 2025 Census Bureau data found poverty among adults 65 and older has risen for five consecutive years, reaching 15.4% in 2025, up from 9.4% in 2020. The analysis uses the Supplemental Poverty Measure, which factors in government benefits, taxes, and cost of living. Among adults 50 and older, 17.2 million lived in poverty in 2025; those 50-64 had the lowest rate at 12.1%, while women over 65 faced higher poverty (16.8%) than men (13.7%). The report highlights a broader trend of rising poverty across age groups since a 2020 low point.
- Industry
Insurers Trim 2027 Medicare Advantage Plans, Shift Toward Special Needs Plans
Becker's Hospital Review reports that Medicare Advantage insurers are cutting plan offerings in 28 states for 2027, with total plan counts dipping from 5,553 to about 5,532, even as national enrollment projections hold roughly flat at 34 million. Twelve insurers that sold MA plans in 2026, including several health system-owned plans and some Blue Cross Blue Shield affiliates, will exit the market entirely, while large national carriers like Centene, UnitedHealthcare, and Aetna are each leaving over 100 counties. Growth is concentrated in special needs plans, which will grow 9.4%, with some insurers limiting new dual-eligible enrollment to members already in the insurer's affiliated Medicaid plan. CMS raised 2027 MA payments by 2.48% (4.98% counting risk score trends), which insurers say is insufficient to offset rising medical costs, setting up a second consecutive year of enrollment upheaval ahead of the Oct. 15–Dec. 7 annual enrollment period.
- Industry
Rural Surgeon Shortages Drive Worse Patient Outcomes, Data Show
Becker's Hospital Review compiles data showing rural surgical workforce shortages are worsening patient outcomes. Nationally there are 59.2 surgeons per 100,000 people, with a projected shortage of nearly 28,000 surgeons by 2038, and 30% of counties have no identified surgeon. Rural Medicare beneficiaries face higher 30-day mortality, complications and readmissions after common surgeries, and death rates from emergency conditions like appendicitis and hernias are now 86% higher in rural areas than urban ones. Responses include federal rural health transformation funding, state-funded workforce grants such as UNC System's rural surgery partnership, and new accreditation pathways from the American College of Surgeons for rural cancer programs.
- Industry · RI
Brown University Health Cuts Jobs Citing Medicaid-Driven Cost Pressures
Brown University Health, Rhode Island's largest hospital system, announced buyouts for up to 200 non-clinical supervisors and layoffs of an unspecified number of executives, effective the start of its new fiscal year. CEO John Fernandez cited rising pharmaceutical, labor and supply costs alongside growing uncompensated care, insurer denials and bad debt. The system attributes much of the pressure to federal policy changes restricting Medicaid eligibility and ending exchange subsidies, projecting $346 million in charity care, denials and debt costs for fiscal 2027, $71 million more than the prior year, and a $64 million deficit. Despite the cuts, the system plans $210 million in capital facility upgrades and a January merit increase, and will end employee health plan coverage of GLP-1 drugs for weight loss starting Jan. 1.
- Industry
Mintz Quarterly Update Surveys PBM Policy Developments Through June 2026
In its Fall 2026 PBM Policy and Legislative Update, Mintz's Managed Care, PBMs & Pharmacies practice compiles federal and state developments affecting pharmacy benefit managers and the drug supply chain from mid-February through June 2026. The quarterly digest covers legislative and regulatory activity relevant to PBMs, health plans, and pharmacies operating across commercial and government-sponsored programs, including Medicaid. It serves as a reference roundup rather than a report on a single event, consolidating multiple developments tracked over the period. No specific effective dates apply since the piece is a periodic summary rather than a new rule or action.
- Industry · AZ
Aetna to Acquire Mercy Care Stakes From Ascension, CommonSpirit
CommonSpirit's Dignity Health and Ascension have each agreed to transfer their combined ownership stakes in Arizona's Mercy Care health plan to CVS Health subsidiary Aetna. CommonSpirit held a 49.75% stake in the plan as of mid-2026, and Ascension co-owns the remainder with Dignity Health. Aetna has run Mercy Care's daily operations and administrative services for more than 20 years, and the companies describe the ownership transfer as a natural evolution of that existing partnership. Mercy Care serves Medicaid and dual-eligible members through Arizona's Medicaid program and Medicare Special Needs Plans; the deal is expected to close in fiscal year 2027 pending regulatory review.
- Industry · VT
Brattleboro Memorial Hospital Names Interim CEO Amid Budget Crisis
Brattleboro Memorial Hospital's board named David Sanville, a healthcare finance consultant and former Mt. Ascutney Hospital CFO, as interim CEO effective at the start of fiscal year 2027. He replaces co-CEOs Tony Blofson and Elizabeth McLarney, who led the hospital for a year following the unexplained departures of the prior president and CFO in late 2025. The hospital faces a forecast $7.1 million deficit for fiscal 2027, following an estimated $9.5 million shortfall in fiscal 2026, and Vermont's Green Mountain Care Board recently level-funded the facility's budget pending clarification of inconsistencies in its proposal. The hospital does not expect to break even until fiscal 2028 at the earliest.
- Industry · WA
MultiCare Health System Launches New Medicare Advantage Plan
MultiCare Health System, a 13-hospital nonprofit system based in Tacoma, Wash., announced on Oct. 1 the launch of MultiCare Health Plan, a wholly owned subsidiary. Its first product will be a Medicare Advantage HMO with drug benefits, available for the 2027 plan year in three Washington counties, supported by independent physician association Physicians of Southwest Washington. Karen Decaran-Voigt, a longtime payer and provider executive with prior roles at Molina, UnitedHealth, CommonSpirit and Elevance, will lead the new plan. The move comes as MultiCare pursues an affiliation with Samaritan Health Services, whose own health plan continues to offer Medicaid and D-SNP products, and runs counter to a broader trend of health systems shutting down their own insurance plans amid rising costs.
- Industry
Home Care Providers Expand Dementia, Behavioral Health Offerings
In an HHCN+ members-only analysis, Home Health Care News reports that dementia care and behavioral healthcare are shifting from niche differentiators to baseline expectations for home-based care providers serving older adults. The piece cites examples including HomeWell Care Services exploring expanded dementia support, VNS Health's Dementia Care at Home program launched in 2023, Empath Health's new dementia education program in Florida, and specialist firms like Author Health building businesses around older adults' behavioral health needs. The author argues providers don't need to own these service lines outright but must have a credible plan, internal training, partnerships, or specialized programs, to address cognitive and behavioral health needs as more patients aim to age in place. No regulatory action or new policy is announced; the piece reflects industry strategy trends.
- Industry · OK
Oklahoma Critical Access Hospital Plans Staffing, Contract Cuts for 2027
In a Becker's Hospital Review report, Arbuckle Memorial Hospital CFO Denise Welch describes how the Sulphur, Oklahoma critical access hospital is preparing its 2027 budget amid financial pressure. The hospital plans to cut staffing redundancies and hold outside contract spending flat rather than reduce wages, which Welch says would hurt amid competitive labor markets. Welch said the hospital will continue investing in technology and informatics infrastructure to avoid care delays and reduce outside exposure, while updating fully depreciated building infrastructure to maintain its current reimbursement status. The comments illustrate budget tradeoffs facing small rural hospitals heading into 2027.
- Industry · TN
Vanderbilt Health's FY2026 Margin Jumps on TennCare Payments, Acquisition
Vanderbilt Health reported fiscal 2026 operating income of $452 million (4.7% margin), up from $255 million (3.0% margin) in fiscal 2025, per its Sept. 30 financial report. Operating revenue rose 12% to $9.5 billion, driven by higher surgical, procedural, ambulatory and pharmacy volumes, while expenses grew 9.9% on staffing and drug cost increases. The system recognized $230 million in fiscal 2026 from TennCare's Hospital Investment Program, a supplemental Medicaid payment program using an average commercial rate approach, up from $179 million the year prior. Vanderbilt also completed full acquisition of Tennova Healthcare-Clarksville in February, and net income rose to $775 million from $424 million.
- Industry · FL
Survey Finds Mothers Face Major Barriers to Mental Healthcare Access
Count on Mothers and Inseparable released "Pulse Check 2026: Mothers on Mental Health, Care, and the Systems Around Their Families," a survey of 2,818 U.S. mothers and primary female caregivers conducted May 7-27. The report finds 50% of mothers nationally (48% in Florida) struggled with their own mental health in the past month, and 39% had a child needing behavioral health support in the past year, with 47% of those receiving only partial care or none due to barriers. Among parents facing barriers, 56% reported at least one insurance-related problem. Notably, mothers with employer-sponsored insurance reported less confidence their plans would cover adequate mental health care than mothers covered by Medicaid or CHIP, with only 6% of Medicaid mothers reporting no confidence in coverage versus higher distrust among commercially insured respondents.
- Industry
BHB Commentary: Outside Investors Improve Autism Therapy Accountability
In a Behavioral Health Business commentary, the author argues that the autism therapy industry's reputational scandals stem not from private equity or outside capital involvement, but from a lack of external accountability among founder-owned, independently run providers. The piece cites ABA Centers of America, Piece By Piece Autism, The Perfect Child, and Stepping Stones Behavioral Solutions, all organizations facing billing fraud, Medicaid scrutiny, or federal investigation, as examples lacking outside board oversight or capital-partner governance. The author contends that private equity and family office investors, while not guarantors of ethical conduct, tend to impose governance controls, compliance infrastructure, and risk oversight that founder-led organizations often cannot afford on their own. The commentary frames bringing in outside capital as a maturation step for an industry historically short on standardized oversight.
- Industry
BRG Study Finds 340B Drug Margin Hit $142 Billion in 2025
In its "6 study notes" roundup, Becker's Hospital Review reports on an October Berkeley Research Group study estimating patients and payers spent $244.3 billion on 340B drugs in 2025, more than double 2021's $108.4 billion. BRG calculates a "340B drug margin", the gap between covered entities' discounted acquisition cost and what patients and payers are later charged, at $142.2 billion in 2025, over double the 2021 figure. Commercial insurers bore 63% of that margin, Medicare 25%, and Medicaid managed care 7%, while Medicaid fee-for-service generates no margin since it reimburses at acquisition cost. BRG attributes growth to hospital acquisition of off-site clinics, expanded hospital participation, and a surge in contract pharmacies from roughly 1,300 in 2010 to about 35,000 today.
Thursday, October 1 · 16 stories
- Industry
Aledade Promotes ACO Model to Boost Primary Care Coordination
In a sponsored Becker's Hospital Review piece, Aledade argues that strengthening primary care as a health system's coordinating hub improves outcomes and financial sustainability. The piece cites research showing Medicare patients with limited primary care access face higher rates of emergency surgery, postoperative complications, and 30-day readmissions. It contends health systems often struggle with fragmented EHRs and delayed claims data that undermine timely care coordination, and promotes Aledade's accountable care organization model as a way to give clinicians operational support without replacing existing infrastructure. The piece is industry marketing content rather than a report of new policy or regulatory action.
- Industry
Health Systems Build Digital-First Primary Care Teams Alongside Clinics
Becker's Hospital Review reports that Cleveland Clinic, Inova Health System and MCR Health are redesigning primary care delivery to treat digital engagement as a parallel "second clinic" alongside traditional in-person visits. Cleveland Clinic Florida is building dedicated teams of medical assistants, nurses, pharmacists and advanced practice providers to manage a 153% surge in patient portal messaging since 2020, separate from scheduled office visits. Inova is restructuring scheduling and access pathways around patient convenience rather than traditional clinic hours, while MCR Health, a federally qualified health center, is emphasizing mobile services, community partnerships and outreach to overcome transportation and trust barriers. The shift reflects a broader industry move toward team-based, longitudinal care that is not tied to a single clinician, location or visit type.
- Industry
Hospital Leaders Detail Tactics to Cut Observation-Status Denials
In a Becker's Healthcare webinar sponsored by CorroHealth, five hospital and health system leaders discussed strategies for reducing revenue loss tied to observation-versus-inpatient status decisions. Panelists from Bozeman Health, Premier Health, Jackson Memorial Hospital, Children's Hospital of Philadelphia, and CorroHealth described rising payer denial rates, some markets now exceeding 30%, up from under 17% in 2020, often tracing back to the initial status call at admission. Tactics discussed include embedding observation liaisons in emergency departments, daily case rounds within 24 hours of admission, cross-functional teams spanning the revenue cycle, and change management to drive clinician buy-in. The panel emphasized that technology alone cannot fix denial trends without organizational alignment and provider-driven, regulation-consistent status strategies.
- Industry
Analysis Shows MA Insurers Cutting Benefits Despite 2027 PR Claims
Major Medicare Advantage insurers issued press releases Thursday touting their 2027 plans as preserving core benefits, but a Leerink Partners analysis of CMS Medicare Plan Finder data found widespread cuts to dental allowances and Part B premium givebacks. UnitedHealthcare saw dental cuts affecting nearly 70% of members and increased cost-sharing; Humana cut Part B givebacks for 62% of members while modestly raising dental allowances; Centene, CVS/Aetna, Elevance and Clover Health also reduced benefits, with Clover's cuts described as the most pervasive, including a $1,144 increase to its maximum out-of-pocket limit. The cuts come amid a broader industry pullback driven by elevated senior care costs and insurer complaints about reimbursement, with insurers projecting MA enrollment will fall 6% to 34 million in 2027, a projection CMS disputes. Medicare open enrollment runs Oct. 15 to Dec. 7.
- Industry
Aspirion Pitches AI Tool to Find Patterns Behind Clinical Denials
In a Becker's Hospital Review piece, Aspirion executives argue that hospitals focused only on overturning individual clinical denials miss the recurring patterns driving them, and promote the company's AI-enabled "ClinIQ" platform as a solution. The piece cites Kodiak Solutions data showing revenue leakage across more than 2,300 hospitals rose about 25% in 2025 to $48.4 billion, driven partly by clinical denials tied to medical necessity, and a survey finding 76% of revenue cycle leaders expect denial rates to keep rising. Aspirion frames denials as falling into two categories, payer behavior versus provider documentation gaps, and says its tool helps health systems distinguish the two at scale and route insights to CDI, utilization management, and managed care teams. Aspirion reports its clients see appeals filed 2.2 times faster and a 64% resolution rate using this approach.