Healthcare Brew covers pharmaceutical developments, health startups, the latest tech, and how it impacts hospitals and providers to keep administrators and providers informed.

Healthcare Brew

Will Peischel

Healthcare Brew delivers the latest news and trends in healthcare.

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Coffee cup paired with a clock striking midnight

How the two-midnight rule influences Medicare coverage

A whole lot goes into whether a physician admits a beneficiary.

Quinn Sental

The US government opens probe into Change cyberattack

Among its goals, the Department of Health aims to ascertain if “protected health information” was breached.

Shannon Young

Biden admin: Short-term health plans must be ‘truly short-term’

New federal rules will restrict short-term health insurance policies to months, not years.

Dollar bill icon denoting healthcare payers

Payers

illustrated headshot of caroline catherman, healthcare brew reporter

Caroline Catherman

In August, CVS Health’s insurance arm Aetna announced a new reimbursement approach for its 

Right now, when an emergency lands a patient in the hospital for one or more nights and a provider submits a claim for inpatient reimbursement, Aetna either denies or approves it based on whether it deems the stay medically necessary.

Starting Nov. 15, Aetna said in an announcement it will automatically approve claims and do “severity” reviews instead for many of its approximately 4.2 million MA members. Rather than denying a claim it feels is inappropriate, it will just pay less for inpatient stays of lower “severity.”

Health systems have long complained about excessive MA 

. This automatic approval would appear to, in theory, reduce them.

So why, then, has the professional and lobbyist group the American Hospital Association (AHA) put out a 

 saying it is “deeply concerned” by this shift?

Advocates told us this rule makes it harder for hospitals to fight unfairly low payments and may even break federal policy that guides inpatient-level reimbursement.

Under the current system, when Aetna denies an inpatient care claim, providers can choose to appeal or resubmit it at a lower rate.

This new rule would still allow providers to request a “review and discussion with Aetna,” dispute the decision, or appeal for the full inpatient rate, Aetna spokesperson Phillip Blando told us.

But it’s harder to identify and appeal underpayments than denials, Becky Greenfield, a partner at law firm Wolfe Pincavage, which represents hospitals and health systems, told us. 

“If you had a straight-up denial, it’s really easy to see when the claim has been denied. You’re going to have zero pay,” Greenfield said, adding that providers might need additional resources to spot underpayment cases, like built-in codes in electronic health records or staff dedicated to the task.

Faced with an underpayment rather than denial, hospitals will likely need to go through the dispute resolution process laid out in their contracts with insurers rather than the traditional appeals process, the AHA’s Sept. 15 letter read.

“In most cases, this will be arbitration, a more costly and burdensome endeavor than traditional appeals and the outcomes of which almost always go undisclosed,” the AHA wrote.

This policy may also violate the Centers for Medicare and Medicaid Services (CMS) 

, the Healthcare Association of New York State alleged in an Aug. 20 

CMS did not respond to a request for comment before publication.

CMS issued the two-midnight rule for traditional fee-for-service (FFS) Medicare in 2013. MA plans have been officially required to follow it since 2024. The rule generally requires insurers to approve claims at an inpatient payment rate if the admitting physician thinks the patient’s condition is severe enough to require more than two midnights of care.

Aetna’s policy could result in lower outpatient-like rates being applied to these patients, Greenfield said.

“This—in my mind and in the minds of many hospital executives and many people that represent hospitals—is Aetna’s way of skirting the two-midnight rule,” she said.

Greenfield said CMS hasn’t done much enforcement against plans violating this rule.

 found Medicare—traditional FFS, at least—isn’t great at enforcement against hospitals, either. The report found from 2017 to 2021, FFS Medicare paid $23.9 billion in “improper payments” to hospitals for inpatient stays, $7.8 billion of that for short inpatient stays.

Aetna’s new policy is set to take effect less than five months after a 

Aetna’s move also follows another policy 

 by Cigna to reduce reimbursement. Effective Oct. 1, the payer will downcode (i.e., reduce reimbursement) for providers that it has identified as having “a consistent pattern” of upcoding routine services such as treatment for an earache or sore throat.

Cigna estimates “almost 99% of all in-network providers will not be affected,” according to a Sept. 9 release.

Why are hospital leaders mad about Aetna’s plan to reduce MA denials? 

Hospital advocates say Aetna’s new payment policy sounds OK…until you read the fine print.

Cassie McGrath

It was May 2011 when then-Vermont Gov. Peter Shumlin signed a “universal and unified health system” act into law and the state began developing plans for broad public health coverage.

—to accomplish what had previously been impossible: establish a single-payer health system in the US.

Single-payer systems are a type of universal healthcare that work by having one entity—in this case, the Vermont government—pay for residents’ healthcare through taxes and other public funding. These plans can eliminate the need for private health plans, with countries like Canada, England, Germany, Singapore, Sweden, and Taiwan already offering this kind of insurance.

The hope is if one big group is negotiating costs, then spending would generally come down, as that negotiator would have more power and it would require less administrative work for providers.

Now, Oregon is looking to become the first successful state to implement universal healthcare.

To understand what’s going on in the Beaver State, we must first go back to 2019 when it established a task force for universal healthcare.

In 2022, that task force released a report with early insights into how universal healthcare could work in the state, projecting it would cost an estimated $980 million less in 2026 than the existing healthcare system.

The next year, at the recommendation of the task force, the state legislature created a follow-up Universal Health Plan Governance Board (UHPGB) to make a “comprehensive plan to finance and administer” universal healthcare in the state.

The board has until September 2026 to present that plan.

 are already on a health plan of some kind, according to the Oregon Health Authority, but UHPGB Executive Director Miriam McDonell said many people are underinsured, meaning they have some coverage but don’t use their health plan because care is still too expensive.

This aligns with national trends, too: Nonprofit the 

 about 1 in 4 US adults have health insurance but are considered underinsured.

So while most people in Oregon have some kind of coverage, McDonell said it doesn’t accurately demonstrate “the affordability of healthcare” or “the stress that it’s putting on families.”

The goal is to establish “unified financing,” McDonell said, meaning pulling together state, county, and federal funding to remove the need for private health plans (with some exceptions, like for beneficiaries receiving insurance through the Department of Veterans Affairs).

McDonell said the hope is for the publicly funded plan to be “desirable and less expensive” so Oregon-based employers wouldn’t need to have their own offerings anymore.

UHPGB is looking to understand how much the plan would cost, working with consulting group Milliman to conduct a review of healthcare spending data from 2023, McDonell said. This differs from Vermont, where the payment plan was to be determined after the law passed.

 are also looking to establish universal health plans, and 

 to make sure they build out the best options, though an established system is not yet in place in either state.

Taking many years to build out the plan is intentional, McDonell said, as there are a lot of different moving pieces and UHPGB wants to make sure to get it right.

“We’re in it for the long term,” McDonnell said.

 Vermont’s plan was doomed from the start, as the law never spelled out exactly how the single-payer plan would be paid for. By 2014, the program was nixed before anyone got coverage.

These days, Vermont is still facing high insurance costs, ranking 

 for how much residents spend, according to a study from personal finance company WalletHub. Nearly 20% of a household’s median monthly income (roughly $1,275 on average for silver-level plan premiums) is spent on health insurance.

But current Vermont state Rep. Brian Cina told us he isn’t giving up on universal healthcare.

For now, he said the state is focused on trying to cut costs as much as possible, including through the independent Green Mountain Board, which was established back in 2011 alongside the single-payer care act to keep healthcare spending down.

Cina said now that there’s an effort to “control costs” for healthcare, he hopes it will put the state in a position to afford single-payer insurance and “provide more of a universal program” in the future.

The Oregon state board has until next September to present its official plan.

Nearly 15 years ago, Vermont failed to pass universal healthcare. Now Oregon is looking to do it successfully 

The Oregon state board has until next September to present its official plan. 

A Medicare value-based care payment pilot is set to end Dec. 31, 2026, and health organizations are trying to figure out what to do about it.

What’s now called the ACO Realizing Equity, Access, and Community Health (ACO REACH) model was launched in 2021 under a different name by the Centers for Medicare and Medicaid Service (CMS) Innovation Center.

 (ACO), a group of hospitals and healthcare professionals that work together to provide 

 to patients with traditional Medicare. These organizations receive monetary bonuses or penalties if they save Medicare money based on historical or expected expenses. They do this through approaches like ensuring patients get primary care and reducing unnecessary treatments and tests.

The 161,765 providers within 103 ACOs participating in ACO REACH will have to decide whether to transition to another ACO model or exit the program altogether if it ends. The National Association of ACOs is lobbying for an extension, but CMS has not said whether that will happen.

“There’s a big question mark right now,” Lauren Makhoul, a healthcare regulatory consultant, told us.

ACO REACH is significant because it focuses on 

, requiring participating ACOs to make and follow an equity plan to reduce care disparities for underserved communities.

It’s also the first CMS Innovation Center model to include a track dedicated to high-needs Medicare patients, meaning patients with one or more chronic conditions that impact mobility, Makhoul said.

This track, along with a different risk adjustment structure and other flexibilities for things like telehealth and home visits, made it easier for smaller high-needs-focused provider groups to join an ACO, Makhoul said. For instance, high-needs ACOs only need 1,000 traditional Medicare beneficiaries in 2025 to participate in ACO REACH. Organizations in CMS’s permanent and biggest ACO program, the Medicare Shared Savings Program (MSSP), must have 5,000+ Medicare fee-for-service beneficiaries.

“There are many smaller, very focused, more niche provider groups that serve a much higher-need population,” Makhoul said. “[ACO REACH] made it possible for these folks to participate when they otherwise would not have been able to.”

In 2023, ACO REACH organizations were accountable for 2+ million patients, about half of them new to the model, according to CMS.

The 14 high-needs ACOs, though only accountable for 21,600 of those patients, averaged a 13.3% net savings rate in 2023 compared to a 2.8% net savings rate for standard ACOs, preliminary CMS data shows.

 If ACO REACH ends as planned, participating ACOs could try switching to the MSSP, which in 2025 has 476 ACOs with 655,725 healthcare providers and organizations providing care to 11.2+ million.

Both ACO REACH and the MSSP come with the possibility of great risk and reward, though.

 $4.1 billion in bonus payments to 75% of ACOs in the MSSP in 2024. But 16 ACOs owed a total of $20.3 million to make up for costing Medicare more money compared to past years, per CMS.

ACO REACH data from 2023 shows $948.4 million in savings for participants, but 36 of them—27% of participating ACOs—saw net losses, per CMS.

Switching from ACO REACH to the MSSP would likely still be “destabilizing” to participating healthcare systems and physician practices, Bartley Bryt, chief medical officer of Privia Health, a physician support company that manages nine ACOs known collectively as the Privia Quality Network, told us.

The programs differ in structure, quality measures, and cost targets, he said.

“Business processes—both for physician practices as well as the administrative side of the business—you’ve got to change them,” he said. “That takes time, energy, and money.”

 coauthored by Makhoul for a former employer, healthcare consulting and advisory firm Avalere Health, suggests ACOs serving high-acuity patients can also perform well in the MSSP.

Though every ACO is different, those that saw the biggest savings per patient in the MSSP served similar populations to high-needs ACOs within REACH. They had a higher proportion of beneficiaries who were dual eligible for Medicare and Medicaid and aged 85+.

“Based on the entities that are in MSSP that look the most similar to the high-needs ACO, [success] is possible,” she said.

Two hands exchanging money and a love heart with a heartbeat line running through it

Potential end of ACO REACH brings ‘question mark’ to value-based care

Accountable care organizations are asking CMS for clarity.

Maia Anderson

Ever wonder what entices an executive to jump ship and join a new health system? For Amy Perry, Banner Health’s insurance arm caught her eye.

Perry joined the Arizona-based nonprofit health system as president and COO in November 2021 and took the reins as president and CEO in July 2024. Before joining Banner, she was SVP of integrated care delivery and CEO of New Jersey-based Atlantic Health’s hospital division for four years.

Banner is Arizona’s largest health system and consists of 33 hospitals that handle roughly 6.4 million clinic visits per year and have more than 55,000 employees. The system brought in $15.6 billion in revenue in 2024.

Perry told Healthcare Brew the fact that Banner has its own health plan with about 1.2 million members was a big part of the reason she took the job, as she sees provider-sponsored health plans, or PSHPs, as a “really important approach to healthcare.”

PSHPs are health insurance companies that are owned, either partially or fully, by a health system, hospital, or other provider group. The largest example is the Kaiser Foundation Health Plan, which has more than 12.6 million members and is run by Kaiser Permanente, a California-based health system.

As of 2022, 197 health systems in the US (or 31%) have PSHPs, according to healthcare analytics firm Trilliant Health.

PSHPs help health systems move away from a 

Healthcare’s reliance on sick people to generate revenue is a primary reason costs keep rising, according to Perry.

“When we are able, as health systems, to get premium revenue, we can actually save money when people stay well. It’s almost a completely shifted paradigm,” she said.

About 74% of Banner’s revenue came from the fee-for-service side of the health system and about one-quarter (or about $4 billion) came from premiums in 2024, Perry said.

“I’m just a fervent believer that we’ve got to find a way to migrate, as health systems, toward more of this at-risk, premium-based care,” she said.

However, it’s not easy to be both insurer and provider, according to Katherine Hempstead, a senior policy officer at healthcare research organization Robert Wood Johnson Foundation.

That’s because providers are typically incentivized to do more higher-cost procedures while payers try to keep costs down.

“When you’re trying to do both jobs, it can create a conflict,” Hempstead said.

Some large hospitals, including Northwell Health, the largest health system in New York, have 

 to create PSHPs. Northwell blamed high risk adjustment payments for why it shuttered its PSHP, CareConnect Insurance Company, in 2017, Fierce Healthcare reported. 

Perry acknowledged how hard it is to run both a health system and an insurer, saying “it’s very difficult to live in both worlds.”

However, despite the challenges, there are also upsides, she added, such as premium revenue that allows the health system to invest in chronic disease management and other things “you wouldn’t even consider on the fee-for-service side because there’s simply not enough funding.”

But premium revenue hasn’t shielded Banner from broader industry headwinds like Medicaid funding cuts and 

President Trump’s One Big Beautiful Bill Act, which was signed into law on July 4, is set to 

 by about $1 trillion over the next 10 years. Perry said Banner is bracing for a reality in which some services may have to be cut.

“We have a significant commitment to Medicaid patients and the service lines, but at the same time, there’s only so much we can do if we are scaled back,” Perry said. “Access will be affected, not only in clinics but in emergency rooms.”

To prepare for the cuts, which will take effect 

 over the coming years, Banner is “battening down the hatches like most health systems and trying to reduce our expenses as much as possible,” she said.

Tariffs on products like aluminum and steel already cost Banner roughly $23 million as of September, according to Banner’s SVP of Finance Adrienne Moore, and the health system expects that figure to be less than $35 million by the end of 2025.

In addition to navigating Medicaid cuts and tariffs, one of Perry’s top goals as CEO involves a $1 billion investment in technology the health system plans to pay over the course of five years, she said.

As part of that initiative, Banner created its own ChatGPT-like program called BannerWise via a 

 with AI company Anthropic to analyze data from things like physician notes and pathology results, Modern Healthcare reported earlier this month. Perry told Healthcare Brew this will help providers use the health system’s data “in a more strategic and analytical way.”

Beyond investing in technology, Perry said she’s very focused on connecting with the communities the health system serves in the near term.

“If we’re able to do that and we do it successfully over the next five years, I’m going to be one happy CEO,” Perry said. 

A woman, Amy Perry, Banner Health CEO, cutout and contained in an abstract shape while breaking the frame.

Banner Health CEO Amy Perry on running a health system with an insurance business

From health insurance to Medicaid cuts, Perry dishes on her first year leading Banner Health.  

Banner Health CEO on running a health system with an insurance business

In the world of prior authorization reforms, an insurance “gold card” may sound like a golden ticket. But some providers say the shine wears off fast.

, offered by UnitedHealthcare and states like Arkansas and Texas, allows providers with a track record of approved prior authorizations to bypass some of the process’s hurdles. And there are a 

 of hurdles. Prior authorizations take up an average of 13 hours of a physician’s week, according to a 2024 American Medical Association (AMA) 

A Sept. 4 press release from United claims a 40% increase in the number of provider groups qualifying this year compared to the year before, though United didn’t provide Healthcare Brew with the actual number.

But despite the program’s growth, gold cards don’t seem to be making a huge impact. Only 3% of providers in Texas qualified for the state’s gold card in December 2024, according to the Texas Department of Insurance. And an AMA survey published in August 2024 found just 8% of 1,000 physicians contracted with health plans that offered programs like gold cards.

“It’s a simple, elegant concept,” Kavita Nair, professor of neurology and pharmacy at the University of Colorado Anschutz Medical Campus, told Healthcare Brew. “Lots of the appeal gets lost in the actual operationalization.”

UnitedHealthcare’s program requires provider groups to have been in network for the last two consecutive years and have done at least 10 eligible prior authorizations annually with an approval rate of 92% for both years to get gold card status for a medical code.

Those who qualify submit an advance notification for a procedure through the same online portal, phone system, or fax process they would otherwise use to submit a prior authorization request. Unlike prior authorization, it doesn’t require clinical information. They then receive notification that no additional information is needed, according to a United FAQ page.

United said in its press release that 94% of the “most active gold card users” it surveyed said they’re satisfied overall and the program has reduced administrative tasks. United did not provide the number surveyed.

But to Nair, it feels like a “bait and switch” that gold card providers still have to submit a request through a portal before doing a procedure. 

“You’re still making folks go through hoops. You’re just saying ‘We’re not asking for additional clinical documentation,’” Nair said. “I guess we’ll take any steps that we don’t have to do, but it’s not creating the kind of meaningful impact that it could create.”

It’s also hard for independent groups to measure the exact impact these prior authorization reforms have, Kaye Pestaina, director of patient and consumer protection for the nonpartisan health policy research organization KFF, told us.

“We always have a barrier in terms of getting access to prior authorization data for commercial insurance,” Pestaina said.

Caduceus, Healthcare medical symbol on gold card.

As health insurance gold card programs grow, criticism persists

It’s a golden ticket…with fine print.

As gold card programs grow, criticism persists

HCBR-SHIP-audio embed

 the Trump administration has made to the Department of Health and Human Services (HHS) since January—including laying off 10,000 employees and 

 federal funds—is the dismantling of the Administration for Community Living, or ACL.

ACL is an agency within HHS that funds services for older people, such as centers for independent living. In March, HHS announced ACL’s services would be moved under other agencies, including the Centers for Medicare and Medicaid Services, and that roughly half the staff (or about 100 people) would be laid off.

In addition to things like food delivery for older people via Meals on Wheels, ACL also runs a lesser-known service called the State Health Insurance Assistance Program, or SHIP. Through it, counselors help Medicare beneficiaries understand their health insurance options, enroll in a plan, and file an appeal or grievance with the payer.

Experts from the think tank Urban Institute wrote in April the restructuring and layoffs could “make it more difficult to effectively administer the programs ACL once oversaw,” such as SHIP.

SHIPs “serve a really important role” in the Medicare program “because there really is no other resource to help beneficiaries that way,” Gretchen Jacobson, VP of Medicare at healthcare research foundation the Commonwealth Fund, told Healthcare Brew.

The SHIP program was created under the Omnibus Budget Reconciliation Act of 1990 and consists of roughly 12,500 staff members at more than 2,200 sites across all 50 states (plus Puerto Rico, Guam, the US Virgin Islands, and Washington, DC) who give beneficiaries guidance on navigating Medicare either in person, virtually, or via phone.

SHIP programs are federally funded and typically operated by state and county agencies focusing on aging residents, according to Jack Hoadley, research professor emeritus at Georgetown University’s McCourt School of Public Policy.

Helping beneficiaries navigate Medicare is an important component of the program because it can be pretty complex, Jacobson said.

In a 2023 survey from Medicare seller MedicareAdvantage.com, 64.6% of beneficiaries said they found Medicare “hard to understand.” And a 2022 survey from healthcare marketing firm Sage Growth Partners found 58% of beneficiaries stay in the same plan every year instead of reviewing their options because they find it difficult to understand.

Beneficiaries have around 40 Medicare Advantage plans to choose from in addition to traditional Medicare and Medigap options, Jacobson noted.

“There’s a lot of different layers of complexity for people on Medicare that even go beyond the complexity that people with commercial insurance face,” she said.

Unlike traditional insurance brokers, SHIP counselors aren’t employed by insurance companies and receive no financial incentives to steer beneficiaries to certain plans, so their advice is unbiased, Jacobson added.

From April 2022 to March 2023, SHIP counselors provided individual assistance to 1.7+ million people eligible for Medicare and their caregivers, according to experts at Georgetown University’s Medicare Policy Initiative.

But lack of awareness is a big problem. A 2024 study from the Commonwealth Fund found only 1 in 20 Medicare beneficiaries are aware SHIPs exist.

Before the ACL’s restructuring, SHIPs were already challenged by very tight budgets, Jacobson said.

The programs are allocated roughly $55 million per year in discretionary funds and about $15 million per year in mandatory funds from the federal government.

As of May 2025, there were roughly 69 million people enrolled in Medicare, so the $70 million total equates to about $1 per beneficiary, according to Melissa Garrido, a research professor in the Department of Health Law, Policy, and Management at the Boston University School of Public Health.

On top of the low funding, SHIP has also recently faced threats of budget cuts.

Experts at Georgetown University’s Medicare Policy Initiative reviewed a draft leaked from the HHS’s Office of Management and Budget in April that proposed cutting all $55 million of the program’s discretionary funding.

However, the House Appropriations Committee released its FY 2026 bill on Sept. 1, which includes the discretionary funding. The bill was approved by Republicans on Sept. 2 and sent to the full House committee for approval, 

Without many resources to pay staff, SHIPs rely on volunteer counselors, Hoadley said.

The volunteers are often people who’ve retired from “very technical professional jobs,” particularly those with a healthcare background, according to Garrido.

They go through “intensive” training on all aspects of Medicare, Garrido said. But regardless, knowledge gaps can be prevalent. An April 2025 study, which Garrido coauthored, found the mean percentage of “accurate and complete answers” SHIP counselors provided to beneficiaries was 40%. 

“Policymakers should consider providing SHIP with additional resources for training and capacity improvements,” the authors concluded.

US capital building through a ship porthole

How Medicare’s little-known SHIP program works to guide beneficiaries

Though not well known, the SHIP program has existed for decades to help beneficiaries navigate the complex Medicare landscape.

About 1.3 million people could lose health insurance in 2026 due to marketplace and Medicaid changes in the 

, the independent Congressional Budget Office estimated Aug. 11.

 ways of paying for healthcare will have 1.3+ million more potential customers amid a “perfect storm” of insurance coverage losses, Sabrina Corlette, founder and director of the Georgetown University Center on Health Insurance Reforms, told us.

 protections, allowing them to charge some customers less in exchange for covering less.

Though some analysts argue these plans offer a good alternative to people who might otherwise go uninsured, the American Hospital Association says their growth could increase the billions of dollars per year hospitals and health systems spend on uncompensated care if these plans stick patients with medical bills they can’t pay.

“We’re going to see a lot more people experiencing medical debt, and the [healthcare] system is not going to be able to absorb all of that,” Molly Smith, group VP of public policy at the American Hospital Association (AHA), told us.

If a patient’s non-ACA plan can’t cover their expenses and they can’t pay, it “erodes the relationship” between patients and hospitals, Ariel Levin, AHA’s director for coverage policy, told us.

(Patients’ trust in hospitals is already low, down to 40% in January 2024, according to a July 2024 JAMA Network Open 

Not to mention, hospitals sometimes waste time and resources going through the traditional billing process for these plans, which often fails, Levin said.

 in the journal Health Affairs Scholar, administrative expenses for 5,639 hospitals were $166 billion, or 17% of total expenses.

“This is obviously a huge problem for hospitals,” Levin added.

In theory, if a patient knows what they’re getting into with these plans and is able to foot the medical bill themselves in the case of an emergency expense, hospitals still get paid. But 8 out of 31 sales representatives for these plans engaged in “potentially deceptive” marketing, like claiming a preexisting condition was covered when it wasn’t, in a 2020 secret shopper 

 from independent watchdog the Government Accountability Office.

Deceptive marketing can lead members to think they have full insurance coverage, then get shocked by hefty bills for 

, both of which ACA-compliant plans are required to cover.

And that marketing seems to be ramping up again.

“Purveyors of these products and arrangements will take advantage of shifts in public policy or periods of consumer confusion to market their products, often deceptively, to try to drive people to buy more,” Corlette said.

Insurance alternatives like healthcare sharing ministries—arrangements defined as nonprofits, not insurance, where members with shared religious beliefs pay a fee each month to cover each others’ medical bills—are using policy changes as a marketing hook to make their case to customers.