On the Margins — 2026-03-02
On the Margins
Your daily health economics & actuarial brief
Monday, March 02, 2026
What's happening today
| ■ | HHS OIG found $285M in Colorado Medicaid overpayments tied to autism ABA therapy billing and documentation issues. |
| ■ | Minnesota reported $1.34B in 2024 340B net revenue, concentrated at large hospital systems. |
| ■ | SEC filings indicate Trump MFN drug pricing deals run three-year terms, raising questions on enforcement and confidential reference prices. |
| ■ | Cigna's Evernorth acquired CarepathRx, expanding its hospital pharmacy footprint and pushing vertical integration deeper into provider dispensing. |
| ■ | Prior auth expirations collide with CMS 2026 clocks and new reporting requirements. |
Key Stories
OIG flags $285M Colorado Medicaid overpayments for autism ABA therapy
A federal HHS OIG Medicaid audit found $285.2M in improper or potentially improper payments for applied behavior analysis autism therapy in Colorado. The watchdog said the payments went to clinicians billing Medicaid for ABA services. Separately, CMS announced new initiatives to crack down on healthcare fraud, a three-prong effort led by Vice President J.D. Vance. Plans and states should pressure-test behavioral benefit controls, because post-payment reviews can shift costs across contractors, providers, and state budgets.
Minnesota clocks $1.34B 340B net in 2024, and big hospitals take most
Minnesota Department of Health's February 27, 2026 report estimated Minnesota 340B covered entities generated at least $1.34B in net 340B revenue in calendar 2024. The state's largest 340B hospitals reported over $1B of that total, more than 80% of statewide net revenue. MDH also pegged 340B program operating costs at about $165M, roughly $12 per $100 of gross 340B revenue. For payers, this is spread economics: acquisition discounts stay with providers while commercial, Medicare, and Medicaid reimbursement often prices to non-340B benchmarks.
SEC filings peg Trump MFN drug pricing deals at three-year terms
SEC filings reviewed by STAT show some drugmakers' "most-favored nation" pricing deals with President Trump run for three years, then end. STAT reported the time limit is already hitting some companies as the earliest agreements reached their three-year mark. In parallel, Trump is pressuring wealthy European countries to pay more for drugs so U.S. patients can pay less, adding cross-border uncertainty. For payers and finance teams, a three-year reset cadence means periodic shocks to list-to-net assumptions and rebate strategy, not a one-time repricing.
Cigna's Evernorth buys CarepathRx, tightening its grip on hospital pharmacy
Cigna's Evernorth acquired hospital pharmacy company CarepathRx, extending its reach into health-system dispensing and infusion. The deal surfaced Feb. 26-27, 2026; Evernorth said it completed the acquisition in 2025 after a 2023 minority stake. CarepathRx serves nearly 10% of U.S. hospitals and offers home and ambulatory infusion solutions, making it a meaningful specialty channel. Owning the platform lets Evernorth capture pharmacy and infusion margin and steer site-of-care, tightening employer and provider negotiations on unit cost.
Prior auth expirations collide with CMS 2026 clocks and new reporting
A KFF Health News case on Feb. 27, 2026 described a Massachusetts patient whose Zepbound prior authorization expired, triggering a two-week treatment gap. She spent nearly three weeks chasing her PBM, doctor, and insurer, and was told the renewed approval could take 7-10 business days. That timing lands as CMS' interoperability and prior authorization rule (which excludes drugs) started Jan. 1, 2026, with plans reporting PA metrics by March 31, 2026. For actuaries, expirations and re-PAs are not just noise; they shift admin expense and can redirect care to higher-cost sites, a pattern AMA surveys flag.
Significant Digit
CMS says 2026 Physician Fee Schedule changes will cut Part B skin substitute spending by 90%--a rare policy lever that moves both unit price and premium math.
In CMS's 2026 Part A and B premiums fact sheet, the agency notes that finalized 2026 Physician Fee Schedule policy changes are expected to reduce Medicare spending on skin substitutes by 90% without affecting patient care. That is a reimbursement shock to wound care economics: product choice, site of service, and supplier margins will reprice fast. It is also a reminder that when a category looks like an ATM, CMS eventually shows up with a baseball bat.
Other Relevant Headlines
Policy & Regulation
| CMS defers $259.5M Minnesota Medicaid match, flags questionable claims | CMS |
| Kennedy adds two ACIP members as vaccine schedule fights spill into court | STAT |
| Insurance groups say proposed flat Medicare Advantage rates fail to meet the moment | Fierce Healthcare |
| Medicaid Managed Care Reporting and Transparency: Managed Care Program Annual Reports | KFF |
| Veradigm avoids enforcement action in SEC probe | Healthcare Dive |
Payer Operations
| Elevance shuffles C-suite as top Carelon exec departs | Healthcare Dive |
| Teladoc projects lower integrated care membership after ACA subsidy lapse | Healthcare Dive |
Provider Economics
| UHS eyes rising admissions targets this year despite headwinds | Healthcare Dive |
| Inside Advocate Health's 'hospital room of the future' | Fierce Healthcare |
Digital Health & AI
| How can HHS drive clinical AI adoption? The industry wish list is starting to take shape | STAT |
| Labcorp expands PathAI pact to roll out digital pathology platform in US | Healthcare Dive |
| Health Gorilla urges court to toss lawsuit filed by Epic, health systems | Fierce Healthcare |
Pharmacy & Drug Pricing
| Walgreens debuts virtual weight management clinic with access to GLP-1 meds | Fierce Healthcare |
| Hims & Hers bullish on growth prospects even as it faces increasing regulatory scrutiny | Fierce Healthcare |
Workforce & Labor
| Massive Kaiser Permanente strike ends, though contracts are still being finalized | Fierce Healthcare |
ICYMI (Recent Key Stories)
- KFF: Enhanced ACA subsidies expiring in 2025 hit older enrollees hardest -- KFF analysis finds the 2025 end of enhanced ACA subsidies would raise premiums most for older enrollees. (2026-02-27)
- CMS CY 2026 Physician Fee Schedule rule targets skin substitute pricing -- CMS's CY 2026 physician fee schedule proposal would change how skin substitute products are priced and paid. (2026-02-26)
- State lawmakers seek restraints on wage garnishment for medical debt -- States are considering limits on wage garnishment practices used to collect unpaid medical bills. (2026-02-25)
- Tri-agencies extend QPA enforcement discretion to Feb. 1, 2026 -- Federal agencies extended temporary enforcement discretion tied to the No Surprises Act QPA rules until Feb. 1, 2026. (2026-02-24)
- DOJ and Ohio AG sue OhioHealth over network lock-ins and price gag rules -- The DOJ and Ohio attorney general filed an antitrust suit alleging OhioHealth used contract terms to restrict competition and pricing. (2026-02-23)
- Forced MA disenrollments jump to 10% as insurers exit markets -- Medicare Advantage members are being involuntarily moved as insurers withdraw from certain markets, pushing forced disenrollments to 10%. (2026-02-27)
- CMS 2027 ACA payment notice: non-network QHPs, no standard plans, lower ECP bar -- CMS's 2027 ACA payment notice proposes changes affecting QHP networks, standard plan options, and ECP participation requirements. (2026-02-26)
- A rare disease drug was approvable, then it wasn't: Inside a surprise FDA rejection -- A report examines how a rare-disease drug's outlook shifted abruptly after an unexpected FDA rejection. (2026-02-25)
- CMS posts Medicaid MCPARs; June 2026 prior-authorization metrics hit plans -- CMS released Medicaid managed care program reports and set prior-authorization performance metrics to take effect in June 2026. (2026-02-24)
- JAMA flags 10% forced MA disenrollment as 2026 exits hit members -- A JAMA piece highlights rising forced Medicare Advantage disenrollment tied to insurer market exits in 2026. (2026-02-23)
- Verifiable launches CredAgent to automate the provider credentialing grind -- Verifiable introduced CredAgent, a tool aimed at automating parts of provider credentialing workflows. (2026-02-27)
- Capstone: Medicare ACCESS model rates squeeze digital health margins -- Capstone analysis says Medicare ACCESS model payment rates could pressure revenue and margins for digital health providers. (2026-02-26)