🏥 MA Market Update

An overview of Medicare Advantage from Chartis, top PBMs by market share, hospital economic updates, and more healthcare news from the week

PARTNERED WITH Happy Wednesday, Hospitalogists!   Today's is your usual mid-week check-in to everything happening across healthcare. Enjoy! Was this email forwarded to you? Subscribe Here SPONSORED BY SMARTERDX What if you could stop drowning in data... and start discovering hidden revenue and quality opportunities? If there's one resource healthcare has, it's data: with 30,000+ data points per patient chart and 75,000+ ICD-10 and HCPCS codes to track, even the best and brightest CDI teams miss diagnoses. That's where SmarterPrebill from SmarterDx steps in. It goes beyond data overload, analyzing 100% of patient charts to uncover missed diagnoses and untapped revenue. The result? A 5:1 ROI and an average of $2M in yearly revenue for every 10K patients discharged. In an industry where margins are razor-thin, this is the breakthrough health systems have been looking for. How's that feel? Ready to stop sinking in data? Let SmarterPrebill put your numbers to work for you. Get started now. BIG HEALTHCARE STORIES The most important news from the week Chartis Medicare Advantage Overview is a Must-Read Resource of the week goes to Chartis' overview of MA enrollment in 2025 including trended analysis from prior years. Highlights from the report include: Decelerating growth and penetration of MA plans versus traditional Medicare (3.9% in 2024 vs. 7.0% in 2023). That being said, it's still a growing market, and there remain plenty of opportunities. SNP growth displayed a similar decelerating growth trend, but still grew over 10% in 2025. Still, notably, 50% of new MA enrollees selected SNPs, particularly Chronic Condition SNPs. UnitedHealth Group holds a 40% market share in the SNP segment. The average senior has access to over 5,000 plans!!! But that number shrank 1.6% in 2025. Notable market exits and reduction of benefits Enrollment changes among for-profit's, nonprofits, provider sponsored plans (and, side note, their continued struggle), and startup plans (with a keen eye on Zing Health, which raised $140M in September 2024 to focus on the CSNP segment specifically) The Weekly Executive Summary Key considerations for decision makers. Notable moves, policies, and strategies Top PBMs Ranked: Drug Channels has been putting out some wonderful content lately around the state of the market and PBMs. To that end, per Adam Fein's analysis, CVS Health's Caremark, Cigna's Express Scripts, and UnitedHealth Group's OptumRx remain the largest PBMs in the U.S. as of 2025. Look at that big loss in Caremark gobbled up by Express Scripts in 2025. PBM Formulary Changes: The Big Three PBMs—CVS Health's Caremark, Cigna's Express Scripts, and UnitedHealth Group's OptumRx—have announced formulary exclusions affecting over 400 medications for 2025. Notable News & Moves: Oracle Health Breach: Oracle Health experienced a data breach compromising patient data across several U.S. hospitals. OSI Neurosurgery Merger: Orthopedic & Spine Institute Medical Centers (OSI) has announced a merger creating a new neurosurgery division. Compassus-Providence JV: The joint venture between Compassus and Providence is gaining traction despite ongoing regulatory scrutiny. Wells Fargo ERISA Dismissal: A judge has dismissed a lawsuit alleging Wells Fargo breached ERISA obligations related to prescription drug costs. JPMorgan Benefits Lawsuit: JPMorgan Chase employees have filed a class-action lawsuit, alleging mismanagement of health benefits. Morgan Health ICHRA Investment: JPMorgan Chase's Morgan Health has invested in Venteur, a health technology platform focused on personalized health insurance benefits.   Hospital Economic Indicators: Hospital Margin Improvement: Fitch Ratings reports margin improvements for U.S. not-for-profit hospitals in early 2025, though financial pressures continue. Strategic Healthcare Finance: Kaufman Hall's Ken Swanson advises healthcare leaders to prioritize long-term financial strategies amid market pressures. Healthcare Volume Benchmarks: Strata Decision Technology has released monthly benchmarks showing healthcare service volume trends. Microhospital Expansion: CommonSpirit Health, ChristianaCare, and WellSpan Health are among health systems building microhospitals to deliver acute care in smaller community settings.   Policy: Mangione Update: DOJ seeks death penalty for Luigi Mangione DOJ Anticompetition Taskforce: The U.S. Justice Department has launched a task force targeting anticompetitive regulations, aiming to eliminate rules harming competition across industries. HHS Job Cuts: HHS Secretary Robert F. Kennedy Jr. announced significant job cuts and restructuring at the agency. In a fact sheet, HHS disclosed a cut of 10,000 FTEs across the FDA (3,500), CDC (2,400), NIH (1,200) and CMS (300). Furthermore, HHS will consolidate 28 divisions to 15, and 10 regional offices to 5 in a major centralizing move of governmental healthcare resources. Healthcare centralization seems to be a big theme so far with the new administration. NIH Funding Cuts: Academic medical centers warn that cuts to NIH funding jeopardize critical healthcare research. These 20 medical schools lead NIH funding. CDC COVID Grant Clawback: CDC is clawing back COVID-19 grant funds previously allocated to states. MedPAC Congressional Report: MedPAC's March 2025 report outlines recommendations for Medicare payment policy improvements. Recommendations, summarized: IPPS and OPPS: update by amount specified in current law, plus 1%; redistribute existing disproportionate share payments to better distribute funds to hospitals that need funds the most. MPFS: replace current updates (e.g., constant cuts) with a reimbursement method tied to the Medicare Economic Index (e.g., healthcare cost inflation), minus one percentage point Dialysis: maintain current payment updates as per current law SNFs: cut base reimbursement by 3% Home Health: cut base reimbursement by 7% (!!!) IRFs: cut base reimbursement by 7% (!!!) Hospice: no increase to base reimbursement recommended (i.e,. 0%) IPF: structural changes to reimbursement (eliminating the 190 day lifetime limit on covered days in freestanding IPFs) Confirmations: Dr. Oz CMS Confirmation: Dr. Mehmet Oz has been confirmed by the Senate as administrator of the Centers for Medicare and Medicaid Services (CMS). NIH Confirmation (Bhattacharya): Dr. Jay Bhattacharya has been confirmed by the Senate as NIH director. FDA Confirmation (Makary): Dr. Marty Makary has been confirmed by the Senate as the new FDA commissioner.   Medicaid Cuts & Updates: Medicaid Provider Payments Debate: Provider taxes and state-directed payments are facing increased scrutiny amid Medicaid budget cut debates. Medicaid, SNAP Cuts Impact: Commonwealth Fund reports that proposed cuts to Medicaid and SNAP could trigger significant job losses and reductions in state revenue. Medicaid Advocacy: Health system CFOs are advocating on Capitol Hill against proposed Medicaid cuts. Duplicity: Payors receive duplicate payments from Medicaid in the billions per WSJ report. Quick GLP-1 / Weight Management Updates: GLP-1 Spending Surge: Evernorth reports spending on GLP-1 weight-loss medications is surging faster than other specialty pharmacy categories. Lilly Lawsuit: Eli Lilly has sued two pharmacies that compound drugs, alleging infringement related to unauthorized copies of its popular weight-loss medications, Mounjaro and Zepbound. Noom integrates with LillyDirect. Collective Health and Noom partner on weight management benefits. Omada and CVS Caremark roll out new weight program for payers. Quick Notables Collaborations and launches to keep a pulse on.  Providence partners with Collective Health to create the Providence Health Plan powered by Collective Health for self-funded employers. Providence also scales its virtual acute care across hospitals. Duke Health expands in North Carolina through $284M purchase of CHS owned Lake Norman. Summit Spine scales physician-centric model after recapping with Wellspring Capital Management. Summit is up to 17 ASCs and 44 clinics across 4 states. Novant wins approval for $320M hospital in South Carolina. Smaller ASCs see big revenue growth from ortho demand. The Doctors Company to acquire ProAssurance in $1.3B deal. Aledade and Humana expand value-based care to rural clinics and FQHCs. New laws in CT and ME target PE and REITs in healthcare. Powers Health and OSNI bring advanced joint care to Indiana. Mental health tops 2025 investment targets. CentralReach is acquired by Roper Technologies to scale ABA services. CentralReach has over 200k users and provides software for ABA and IDD. VMG Health published a nice analysis of Surgery Partners as a case study for PE in the ASC sector. Notable and CityMD launch multi-year AI partnership. TrampolineAI launches AI contact center which appears to be the next craze in the agentic AI race. Causaly unveils agentic AI for scientific discovery. 'With agentic AI in Causaly Discover, life sciences teams can access, analyze, and synthesize information across the Causaly Knowledge Graph and internal and external data sources.' Google releases new AI drug discovery models. Sentara and Inflo launch tech-powered follow-up to help with patient navigation. Apple is developing AI agents that would become a health coaching service. Lol. Lmao even. Amazon tests health shopping assistant using generative AI. Cohere Health launches smarter prior auth with Cohere Align. Oura appoints first CMO to expand clinical focus. Premier Health ends its medical transition services. Person Family Medical Center partners with Validic for heart health in NC. North Carolina launches virtual school mental health with Hazel Health. PayrHealth and SlicedHealth partner on RCM and contracting. Talkspace expands to AZ Medicare population. Stamford Health and Oula open midwifery clinics in Connecticut. SPONSORED BY NEUROFLOW Behavioral health is a massive blind spot for risk-bearing organizations, often hidden until patients appear in costly ED visits or inpatient stays. But NeuroFlow is changing that. Their AI-enabled platform unifies behavioral and physical health strategies, helping health plans and integrated systems proactively identify and support members exactly when needed. Organizations ignoring behavioral health risk falling behind as healthcare moves toward whole-person health. Read my latest Hospitalogy Deep Dive to see how NeuroFlow isn't just patching gaps but creating an enterprise-wide solution to drive real value for members and have greater leverage over your total cost of care strategy. Check it out HOSPITALOGY TOP READS My favorite reads & resources from the week Heavy ChatGPT users tend to be more lonely. Great Pear Healthcare Playbook interview from Oshi Health's Sam Holliday Stat's First Opinion on why Medicaid should be block grants. McKinsey's overview of generative AI in healthcare - current trends and their perspective on what's next. And finally, two from the Health Care Blog - Matthew Holt's Sword Health story, and Hone Health interview Hospitalogy Archive MISCELLANEOUS MADDENINGS Random personal anecdotes and musings from me That's all for this edition!   Stay tuned though - my next newsletter will be a breakdown of Baylor Scott & White after sitting down with Baylor's CEO, Pete McCanna who was very gracious to spend some time with me recently. Insights on leadership, culture, Baylor's strategy, and more coming your way. Thanks for the read! Let me know what you thought by replying back to this email.   — Blake   Share Hospitalogy, Earn Rewards Have friends who'd love Hospitalogy too? Click the link below to share Hospitalogy with your friends and earn awesome rewards! PS: You have referred 0 people so far Share Hospitalogy! Get your brand in front of 43,000 executives and healthcare decision-makers. 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