Top News
Roundtable Perspective on Employer Group Waiver Plans Highlighted at BMA Policy Summit
The Public Sector Health Care Roundtable was represented at the Better Medicare Alliance Health Executive Policy Summit on March 3 during the panel discussion “The Medicare Advantage Ecosystem: Policy, Innovation, and Real-World Impact.” Speaking on behalf of the Roundtable, Tom Bednar, Senior Vice President and Counsel at Healthsperien, highlighted the role public sector purchasers and Employer Group Waiver Plans (EGWPs) play within the Medicare Advantage (MA) program and the importance of ensuring these stakeholders are included in ongoing policy discussions.
During the discussion, Bednar emphasized that Medicare Advantage includes a diverse set of plan structures and beneficiary populations, including employer-sponsored coverage for public sector retirees through EGWPs. He noted that a significant share of MA enrollment is tied to public sector coverage and that these plans often operate under long-term contractual relationships between purchasers and MA plans, with benefits financed through a combination of taxpayer funding and employee contributions.
As policymakers consider updates to Medicare Advantage payment policies and risk adjustment through the annual Advance Notice and other regulatory actions, Bednar underscored the importance of transparency, predictability, and accuracy in program changes. He also highlighted the need for policymakers to recognize differences across MA plan types and to ensure that stakeholders representing employer-sponsored coverage are included in broader discussions about the future of the program.
Administrative Action
Details of Proposed MFN Drug Pricing Agreements Remain Unsettled
Recent disclosures from Pfizer and Eli Lilly show that their proposed “most favored nation” (MFN) drug-pricing agreements with the Trump administration are still not finalized, despite months of public discussion. According to filings with the U.S. Securities and Exchange Commission, both companies said they are still negotiating the final, binding terms of the arrangements. The preliminary deals would allow the companies to offer certain drugs at lower prices tied to international benchmarks while receiving policy concessions, including a temporary exemption from potential tariffs tied to a Section 232 investigation into pharmaceutical imports. Pfizer noted that its arrangement includes a three-year grace period from potential tariffs if the company expands U.S. manufacturing investment.
The evolving agreements have sparked debate across the pharmaceutical industry and among policymakers. Critics argue that the lack of transparency around the MFN deals, reportedly signed with multiple drugmakers including Merck & Co. and Sanofi, raises questions about pricing, market impact, and whether Congress should codify the approach. Dr. Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services (CMS), has suggested that formalizing the policy could prevent more aggressive drug-pricing measures in the future. At the same time, some say the initiative may expand drugmakers’ direct-to-patient sales opportunities rather than significantly lowering costs for insured patients. As negotiations continue, the final structure of these agreements, and whether lawmakers move to embed them in statute, remains uncertain.
MedPAC Examines Clinician Participation and Midyear Changes in Medicare Advantage Networks
The Medicare Payment Advisory Commission (MedPAC) on March 2 reviewed preliminary findings from a new analysis examining clinician participation in Medicare Advantage (MA) networks and the frequency of midyear provider changes. The analysis found that most primary care physicians and many specialists participate in at least one MA network, with overall participation rates of about 82% for both primary care providers (PCPs) and specialists. Participation varies by specialty and geography, however, with cardiologists participating in MA networks 94% of the time while emergency medicine specialists participate about 58% of the time. Most clinicians are also affiliated with multiple plans, with roughly three-quarters of PCPs and specialists participating in three or more MA networks.
MedPAC staff also evaluated how MA plan networks change during the year. Using data from February to June 2023, the analysis found that the median MA plan network grew modestly, with a 3% increase in participating PCPs and a 1% increase in specialists. However, networks also experienced provider exits during the same period, with the median plan losing about 6% of PCPs and 4% of specialists midyear due to factors such as retirement, relocation, or contract renegotiations. While the data suggest overall network stability, commissioners noted that provider departures can still be disruptive for beneficiaries, particularly those unable to switch plans outside of limited special enrollment periods.
The analysis represents the first phase of a broader MedPAC workplan launched in late 2024 to examine clinician and facility participation in MA networks, how beneficiaries use those networks, and how CMS network adequacy standards affect access to care. Commissioners encouraged staff to further explore how midyear network changes affect beneficiaries and whether policy changes may be needed to address potential imbalances between the ability of beneficiaries to change plans and the ability of plans to adjust networks during the year. For public sector purchasers that rely on Medicare Advantage plans, including Employer Group Waiver Plans (EGWPs), the findings highlight ongoing questions about network stability and how midyear provider changes may affect beneficiary access to care.
Congressional Action
Senior Democrats Seek Details on Administration Drug Pricing Models
Senior congressional Democrats are pressing the Trump administration for additional details on several proposed Medicare and Medicaid drug pricing models, raising concerns that the initiatives could be undermined by separate pricing agreements the White House has negotiated with pharmaceutical manufacturers. In a March 5 letter to HHS Secretary Robert F. Kennedy Jr., Senate Finance Committee Ranking Member Ron Wyden (D-OR), House Energy & Commerce Committee Ranking Member Frank Pallone (D-NJ), and House Ways & Means Committee Ranking Member Richard Neal (D-MA) said the administration has provided limited information on how the models would operate or whether they would deliver meaningful savings for beneficiaries.
The lawmakers specifically questioned two CMS Innovation Center proposals announced December 19: the Global Benchmark for Efficient Drug Pricing (GLOBE) Model and the Guarding U.S. Medicare Against Rising Drug Costs (GUARD) Model. GLOBE would require manufacturers to pay rebates if prices for certain Medicare Part B drugs exceed international benchmarks and would apply to the 50 highest-spend drugs with more than $100 million in annual fee-for-service spending. The GUARD model would apply a similar framework to selected Medicare Part D drugs with more than $69 million in gross drug costs.
Democrats also raised concerns that the models’ scope could be significantly limited if manufacturers that have negotiated “most favored nation” pricing agreements with the administration are exempt from participation. The White House has announced such agreements with 16 pharmaceutical companies, and lawmakers noted that several firms have suggested these deals shield them from the proposed models. The letter also questions whether participation in the CMS Innovation Center’s Generating Cost Reductions for U.S. Medicaid (GENEROUS) Model could allow companies to bypass the Medicare initiatives. The lawmakers requested that HHS provide additional analysis, release unredacted copies of the pricing agreements, and clarify how the models will be implemented by March 19.
