Blogs
When GLP-1 Spend Spikes: PBM Strategies for Step Therapy, Exceptions & Equity
Unlike many specialty therapies, GLP-1 utilization is coming through consumers who are actively seeking treatment informed by direct-to-consumer marketing, social media, and cultural momentum around weight loss and metabolic health. Learn how defensible, non-discriminatory utilization management anchored in thoughtful PBM strategies can help control GLP-1 and specialty drug spend.
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Checklists
FHIR Payer-to-Payer Compliance
Preparing for mandated data exchange introduces coordination challenges spanning technology, governance, privacy, and program oversight. From interpreting federal interoperability rules to configuring compliant API workflows, organizations must translate policy into repeatable execution to prevent risk exposure.
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Blogs
How ACA Updates Continue to Shape Payer Operations in 2026
Marketplace affordability pressures influence enrollment and risk profiles. Compliance expectations shape data governance and clinical workflows. Product design decisions determine how effectively plans manage cost and utilization. Nowhere are these dynamics more complex than in Medicaid, where state-level variation demands tailored execution. Together, these forces define the payer operating environment in 2026.
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Tip Sheets
Market Entry for Health Plans
Launching a new product or entering a new market introduces complexity across operations, clinical programs, and compliance. From understanding readiness gaps to building care and business frameworks that meet regulatory expectations, health plans must align strategy with execution to avoid costly missteps.
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Blogs
Assessing Uncertainty: The Impact of Policy on Medicaid & D-SNPs
Changes in federal and state leadership, regulatory priorities, and budgetary negotiations are reshaping the ground beneath payers’ feet. At the same time, health plans are navigating a market defined by margin pressure, demographic shifts, and integration mandates. Even modest regulatory adjustments like eligibility verifications, matching-rate recalculations, and D-SNP alignment rules can significantly alter enrollment dynamics and financial projections. Evaluate how today’s evolving political environment is redefining Medicaid and D-SNP markets and how health plans and MCOs can stay resilient amid uncertainty.
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Blogs
2026 Medicare Physician Fee Schedule: Key Impacts for HMO Contracting
The 2026 Medicare Physician Fee Schedule (MPFS) arrives at a complicated moment for health plans. Leaders are still managing the financial drag from the 2025 conversion factor cut, network pressures tied to staffing shortages, and quickly shifting behavioral health and digital care models. The new MPFS rule introduces changes that may look incremental on paper, but together they impact how health plans will need to approach pricing, contracting, and operational planning for the next several years.
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