On the Margins — 2026-03-05
On the Margins
Your daily health economics & actuarial brief
Thursday, March 05, 2026
What's happening today
| ■ | West Virginia fined Express Scripts $1.5M and ordered pharmacy repayments after a state probe into PBM practices. |
| ■ | CMS leaders Oz and Sutton signaled expanded use of mandatory CMMI payment models, reversing years of voluntary-only bias. |
| ■ | A proposed Education Department student loan cap change drew pushback from providers warning it could shrink APRN and PA pipelines. |
| ■ | Network Health reported 37% Medicare Advantage growth to 126,000 members. |
| ■ | Mount Sinai and Anthem went fully out of network after a brief extension. |
Key Stories
West Virginia probe hits Express Scripts with $1.5M penalty, pharmacy repayments
Express Scripts agreed to repay pharmacies and pay a $1.5 million administrative penalty after a West Virginia insurance regulator investigation, Becker's reported. The West Virginia Offices of the Insurance Commissioner reviewed compliance from May 2024 through August 2025, including reimbursement practices, pharmacy audits, and consumer appeals. Beyond the check, the required corrective actions raise ongoing operating and compliance costs. For payers, it is another reminder that PBM savings assumptions can get repriced by state enforcement cadence.
Oz and Sutton double down on CMMI mandatory model strategy
CMS Innovation Center leaders said Tuesday in Washington, D.C., that CMMI will keep pushing mandatory payment models. Director Abe Sutton and CMS Administrator Dr. Mehmet Oz said the goal is to move more providers, especially poor performers, into value-based arrangements. Mandatory design curbs opt-in selection, where efficient systems join and high-cost providers stay out. For actuaries and P&L owners, forced participation can reset benchmarks and increase reconciliation volatility, shifting more margin risk onto providers.
Education Department loan-cap proposal alarms APRN and PA workforce pipeline
Provider groups urged the U.S. Education Department to change a proposed student-loan rule that tightens borrowing caps for some health jobs. The draft would exclude post-baccalaureate roles such as APRNs and physician associates from higher caps allowed for "professional" degrees like physicians. Providers warned the carve-out could hamstring the clinical workforce pipeline by making advanced training harder to finance. For payers and systems, fewer new clinicians can translate into higher recruiting spend and sustained wage inflation, especially in shortage specialties.
Network Health posts 37% MA growth to 126,000 members
Network Health reported 37% Medicare Advantage growth in the most recent annual enrollment period, reaching 126,000 total MA members. The Wisconsin insurer, owned by Froedtert ThedaCare Health and backed by a Cost Plus partnership, posted 98% member retention. The company said this marks its second straight year of record growth and makes it the No. 2 MA carrier in its 27-county service area. For provider-sponsored plans, that scale-up pushes more economics into capitation and amplifies execution risk on network capacity and risk score discipline.
Mount Sinai and Anthem go fully out of network after brief extension
Anthem and New York City-based Mount Sinai are now completely out of network as of March 4, after a brief contract extension for facilities ended. The deal expired Dec. 31, 2025, and 9,000 Mount Sinai physicians exited the Anthem network as negotiations dragged on since spring 2025. The immediate math is ugly: higher patient cost sharing and more denials on one side, and volume leakage plus bad debt risk on the other. Finance teams should stress test cash and utilization shifts during the disruption.
Significant Digit
If your Medicaid managed care unit-cost analytics are built on T-MSIS, OIG says the "allowed amount" field is often garbage-in, garbage-out.
HHS OIG found that 28 of 39 states with comprehensive, risk-based Medicaid managed care had incomplete or inaccurate "amount allowed" data in T-MSIS for their largest plan's January 2020 encounter claims. That is the key field for comparing negotiated rates, spotting potential overpayments (paid greater than allowed), and doing any credible cross-state benchmarking. Translation: a lot of Medicaid oversight, rate-setting narrative, and trend analytics are still being run on a dashboard with missing gauges.
Other Relevant Headlines
Policy & Regulation
| CMS readies Elevance MA enrollment freeze over risk-adjustment data compliance | Fierce Healthcare |
| FDA voucher accelerates Hernexeos first-line approval in HER2-positive lung cancer | MedCity News |
| State Medicaid budgets face $664B cut due to 'Big Beautiful Bill': study | Healthcare Dive |
| Minnesota sues feds over nearly $244M in frozen Medicaid funds | Becker's Payer |
| How will the loss of enhanced premium tax credits affect older adults? | KFF |
Pharmacy & Drug Pricing
| FDA ramps up crackdown on GLP-1 drug compounding with fresh batch of 30 warning letters | Fierce Healthcare |
| Hospitals decry drugmakers' expanded claims reporting policies for 340B | Fierce Healthcare |
| CMS extends deadline to April 30 for drug maker GENEROUS model apps | Inside Health Policy |
Payer Operations
| Longtime Cigna CEO David Cordani to retire, Brian Evanko tapped as successor | Fierce Healthcare |
| Blue Cross Michigan reduces losses under cost-cutting program | Modern Healthcare |
| Centene urges CMS to cut red tape for Medicaid fraud crackdowns | Modern Healthcare |
Provider Economics
| HCA Healthcare says all-time high inpatient occupancy, ACA exchange attrition won't spoil 2026 volume growth | Fierce Healthcare |
ICYMI (Recent Key Stories)
- Wakely: Medicaid MCO margins flip to losses as enrollment drops -- A Wakely analysis finds Medicaid managed care plans' profits turned into losses amid declining enrollment. (2026-03-04)
- Medicaid dental coverage in three dozen states meets $900B cut threat -- A proposal to cut Medicaid by $900B could jeopardize dental benefits across about three dozen states. (2026-03-03)
- OIG flags $285M Colorado Medicaid overpayments for autism ABA therapy -- The HHS OIG reports Colorado Medicaid overpaid about $285M for applied behavior analysis services for autism. (2026-03-02)
- KFF: Enhanced ACA subsidies expiring in 2025 hit older enrollees hardest -- KFF says ending enhanced ACA premium subsidies in 2025 would raise costs most for older marketplace enrollees. (2026-02-27)
- CMS CY 2026 Physician Fee Schedule rule targets skin substitute pricing -- CMS's proposed 2026 physician payment rule would change how skin substitute products are priced and reimbursed. (2026-02-26)