Wakely Wire

March 13, 2025

New Insights

Newsworthy Findings

Bonus Article

Just for Fun

New Insights

Whitepapers, briefs, press releases and more

Providers Taking Medicare Advantage Risk: Financial Forecast Playbook

Wakely, an HMA Company, supports a range of providers who take risk in MA and other government and commercial insurance programs. We offer an array of supports for our provider clients, from fully outsourcing a data, actuarial, or financial function to very specialized expertise for a niche problem. We recently developed a Provider Playbook that ... Read more

By Michael Cohen

Week in Washington 03/13/25

CMS Congress

View More Wakely Insights

Newsworthy Findings

CMS Takes Aim to Reduce Improper Enrollments and Promote More Affordable Health Insurance Marketplaces for Millions of Consumers

CMS’ new proposed rule, 2025 Marketplace Integrity and Affordability Proposed Rule, aims to take decisive action to root out these improper enrollments from the ACA’s Health Insurance Marketplaces. It is estimated that, if fully implemented, these actions will reduce improper federal spending on advance payments of the premium tax credit by $11 billion to $14 billion in 2027.

Read full article

Editor's Note

The CMS announcement highlights new measures to prevent improper enrollments and enhance affordability in Health Insurance Marketplaces. The changes, including stricter verification processes and adjustments to special enrollment periods, seek to protect consumers while ensuring subsidies reach eligible individuals.

Consumers Can Buy Zepbound and Wegovy Direct from Drugmakers If They Pay Cash

Drugmaker Eli Lilly is expanding its business of selling prescription medicines directly to consumers. The company is offering more vials of its obesity drug Zepbound to patients at a discount but only if they skip their insurance.

Read full article

Editor's Note

Eli Lilly's expansion of its direct-to-consumer sales for Zepbound reflects a growing trend in bypassing insurance barriers for obesity drugs, but affordability remains a challenge for many Americans. As Novo Nordisk follows suit with Wegovy, the debate over insurance coverage for weight-loss treatments continues to intensify.

Lawmakers Move to Allow Medicare Pay Cut, Drawing Rebuke from Physicians

The continuing resolution left in place a physician pay cut from Jan. 1, despite lobbyists’ hopes lawmakers would reverse it.

Read full article

Editor's Note

Physicians are pushing back against a recent funding bill that includes a 2.8% cut to Medicare reimbursement rates, arguing that practice costs have risen an average of 3.5% over the past year. This reduction could have severe consequences, particularly for rural communities already facing provider shortages and limited access to care.

Medicaid Expansion Cuts Could Hit Provider Revenue, Spike Uncompensated Care: Report

If states end their expansion programs, spending on healthcare services would fall by nearly $80 billion and uncompensated care costs would rise by nearly $19 billion in 2026.

Read full article

Editor's Note

If all states that expanded Medicaid were to roll back their programs, nearly 11 million non-elderly adults could lose coverage, leading to a projected $21 billion drop in prescription drug spending. Experts warn that hospitals and healthcare providers would bear the brunt of these cuts, straining resources and triggering ripple effects that could impact local economies.

Unpaid Claims and Coverage Gaps: Changes to the Military's Health Care Program Are Causing Disruptions

Changes this year to Tricare, the military’s health care program, have brought cascading disruptions to millions of service members, their families and network providers nationwide. About 16,000 health care providers on the East Coast alone have not been paid for months, forcing many to drop Tricare patients, reduce their hours or consider closing their clinics. On the West Coast, federal officials said, beneficiaries are struggling with a host of issues, including long wait times at call centers and stalled referrals and authorizations.

Read full article

Editor's Note

This report highlights the ongoing disruptions within the Tricare system, detailing the impact on military families, healthcare providers, and the broader network of services. As the Defense Health Agency and its contractors work to resolve these issues, service members and their families continue to face challenges accessing critical medical and mental health care.

Bonus Article

Scientists Discover New Part of the Immune System

A new study out of Israel has demonstrated that even after 120 years of research, there was a whole new component of the immune system which is now being theorized as a “gold mine” of potential antibiotics. Inside each of our cells, the discovering team explains in their study, a tiny structure called a proteasome recycles damaged and dead proteins to make new ones, a vital and normal function of cellular repair and maintenance. However, the proteasome has another responsibility that immunologists have never identified: fighting off bacterial infections.

Read Full Article

Just for Fun

Math Joke:

Why did the teacher give the rectangle a detention?

Prior Week

Q: In honor of LeBron scoring his 50,000th point, what is the 50,000th digit of pi?

A: 1-because just like the GOAT, pi never stops going!

All Wakely Wires

our industry newsletter.