Top News
Roundtable Sends Letter to Senate Finance Committee Minority Staff on Prescription Drug Affordability
Last week, the Roundtable sent a memo to the Senate Finance Committee minority staff urging the committee to reduce prescription drug costs while preserving incentives for pharmaceutical innovation. Earlier this year, Senate Finance Committee Ranking Member Ron Wyden (D-OR), Senator Catherine Cortez Masto (D-NV), Senator Peter Welch (D-MA), and Senator Ruben Gallego (D-AZ) penned a Dear Colleague Letter claiming President Trump’s drug pricing policies are “mostly a farce” and outlining a Democratic-led effort to lower the prices manufacturers charge for drugs, reduce out-of-pocket costs, and bolster American innovation. In response, the Roundtable sent a memo outlining the challenges public sector purchasers are facing due to rising drug prices, sharing 2025 Specialty Drug Survey results, and expressing support for legislation that would improve prescription drug affordability for public sector purchasers and their beneficiaries. The Roundtable will continue partnering with Senate Finance Committee leadership to advance prescription drug affordability and sustainability for public sector purchasers and the millions of employees, retirees, and dependents they serve. The memo can be viewed here.
Hospital Lobby Responds to Conservative Think Tank Report on Hospital Prices and Consolidation
Last week, the Paragon Health Institute, a conservative Think Tank with significant influence on the Trump Administration, released a paper on The Hospital Cost Crisis: How Government Policies Drive Consolidation, Undermine Competition, and Fuel Soaring Prices. The paper argues that governmental policies including certificate-of-need laws, payment differentials between care settings, restrictions on physician-owned hospitals, Medicaid financing, and broad subsidies reward hospital consolidation of physician practices and distort the market with high and unpredictable prices. Although hospitals claim financial strain, the Paragon Health paper notes that many hospitals maintain solid margins, investment income, and reserves while spending heavily on administrative and other non-patient-care costs. To address these issues, the paper recommended policies to ensure Medicare payments are the same regardless of the site-of-care, improve price transparency and subsidy oversight, repeal anti-competitive rules, establish targeted charity-care standards, and restructure hospital support programs.
The American Hospital Association (AHA) responded by arguing Paragon relied “…on a long list of distorted and debunked arguments…” that would lead to reduced or closed hospital services, diminished access to care, and poorer health outcomes. The AHA blog post claims Paragon failed to account for the challenges hospitals face when caring for complex, high-acuity patients, accepting Medicare and Medicaid payments that are below the cost of care, and the reality of operating a hospital in a rural community. While the AHA did not pose specific policy proposals, they reinforced their commitment to ensure high-quality care is affordable and accessible by working with all industry stakeholders.
The Paragon Health Institute will be holding an event on Tuesday, April 28th, on Health Care Waste, Fraud, and Abuse, where issues raised in the paper may be discussed. Event speakers include Centers for Medicare and Medicaid Services Administrator Dr. Mehmet Oz, Senate Homeland Security Subcommittee on Investigations Chairman Senator Ron Johnson (R-WI), and House Energy Subcommittee on Oversight and Investigations Chairman Representative John Joyce (R-PA-13).
Administrative Action
CMS Innovation Center Delays Medicare Coverage of GLP-1s Pilot Program
In an exclusive interview with Reuters, the Centers for Medicare and Medicaid Services (CMS) Innovation Center said it was delaying the start date of the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model due to push back from major insurers. Announced late last year, the BALANCE Model was designed to couple healthy living solutions with glucagon-like peptide-1 medications (GLP-1s) to promote weight loss and manage obesity among beneficiaries enrolled in Medicare and Medicaid. Under the original plan, CMS would provide GLP-1s to Medicare beneficiaries through a Medicare GLP-1 Bridge from July 1, 2026, through December 31, 2026, while insurers prepared for rollout on January 1, 2026.
However, insurers, including CVS Health and UnitedHealth, expressed concern about the currently planned model structure and ultimately decided to opt out of participating in the model. Specifically, CMS Innovation Center Director Abe Sutton reported that health insurers asked for additional time and data on the Medicare population’s use of GLP-1s to appropriately underwrite their products. As a result, CMS will continue to operate the Medicare GLP-1 Bridge program for an additional year, through 2027, to allow insurers additional time to prepare for the change in coverage.
CMS and FDA Unveil Streamlined Coverage Pathway for Breakthrough Devices
The Centers for Medicare and Medicaid Services (CMS) and the Food and Drug Administration (FDA) announced Friday the Regulatory Alignment for Predictable and Immediate Device (RAPID) coverage pathway, a new process designed to accelerate Medicare coverage for certain FDA-designated Class II and Class III Breakthrough Devices. The pathway brings the two agencies into earlier alignment with device manufacturers during the development lifecycle, so that clinical evidence generated for FDA review can simultaneously inform Medicare coverage decisions. To be eligible, devices must address unmet needs among Medicare beneficiaries, meet specific FDA program criteria, and include an Investigational Device Exemption study that enrolls Medicare beneficiaries and measures clinical outcomes agreed upon by both agencies.
Under RAPID, CMS will issue a proposed National Coverage Determination (NCD) on the same day an eligible device receives FDA market authorization, initiating a 30-day public comment period. This timeline could enable Medicare coverage as soon as two months after market authorization, compared to a year or more under the current process. As part of this shift, CMS has announced it will pause the Transitional Coverage for Emerging Technologies (TCET) pathway for new candidates while it focuses on implementing RAPID.
A proposed procedural notice will be published in the Federal Register for a 60-day public comment period before the pathway takes effect.
Trump Administration Issues Executive Order Aiming to Bolster Treatment for Mental Illness
President Trump recently signed an executive order that seeks to support and expand access to innovative treatments for serious mental illness – with a particular focus on psychedelic drugs. The order framed rising rates of suicide and serious mental illness as a persistent national crisis that has not been adequately addressed by existing treatments. The
Judicial Action
Opioid Settlement Funds Set to Flow as Purdue Pharma Nears Final Legal Resolution
After more than two decades of litigation, the criminal case against OxyContin maker Purdue Pharma will reach a significant milestone next week. Yesterday, a federal judge postponed the planned criminal sentencing by one week so that victims of the opioid crisis can attend the proceeding in person. When sentencing does occur, the judge is expected to order Purdue to forfeit $225 million to the Justice Department (DOJ), clearing the path for the company to finalize a settlement of thousands of lawsuits stemming from its role in the opioid crisis, a settlement that could take effect as soon as May 1. Purdue previously admitted to aggressively marketing its products to doctors who were prescribing the drugs for illegal use and paying kickbacks to boost opioid sales.
The Sackler family, who owned the company, is required to contribute up to $7 billion over 15 years to state, local, and Native American tribal governments, with most of the funds directed toward fighting the opioid crisis. This is in addition to other opioid settlement fund dollars, more than $50 billion, being distributed to U.S. state, local, and tribal governments over an 18-year period stemming from lawsuits against major pharmaceutical manufacturers, distributors, and pharmacies, including Johnson & Johnson, CVS, Walgreens, and Walmart.
The federal government waived its right to repayment in the Purdue Pharma case for all but the $225 million to allow Purdue to direct its remaining assets toward repaying state and local governments that realized much of the cost and consequences of the epidemic. Purdue will be replaced by a new entity, Knoa Pharma, which will operate for the public benefit with a board appointed by the states, a corporate reorganization considered one of the most complex ever undertaken.
