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The Strategist in Brief: August 14, 2025 · The Strategy Catalyst Dispatch

• 0:01
  This is the strategist in brief for August 14th, 2025.
• 0:06
  This week's key market dive looks at three payer headwinds, quietly reshaping how patients enter the healthcare system, how care is reimbursed, and who holds sway over reimbursement first.
• 0:18
  Medicare advantage now accounts for more than half of all Medicare enrollment and financial challenges have pushed plans to be more aggressive with prior authorization and other utilization management techniques.
• 0:29
  CMS is now preparing to expand the use of AI powered prior authorization in traditional Medicare as well under a new model called Wiser that will initially operate in six states.
• 0:41
  Second, a growing number of employers are replacing traditional commercial group coverage with IRAs in arrangement that offers employees a fixed pre-tax contribution to put towards the purchase of an individual plan, typically on the Affordable Care Act exchanges.
• 0:56
  As some employers exit their role as gatekeepers to group health coverage, health systems can no longer rely on B2B relationships to secure commercially insured volume.
• 1:06
  Third, commercial navigator services like Sures and Gardner that steer patients to lower cost providers are seeing increased adoption and competitors like Pager Health and Capital RX are adding their own offerings to the market.
• 1:20
  And now our market scans.
• 1:23
  Beginning in January, the Health Resources and Services Administration will pilot a three 40 B rebate program letting drug makers swap upfront discounts for post-purchase rebates.
• 1:34
  On 10 Medicare price negotiated drugs with providers paying the full price initially and filing claims within 45 days.
• 1:41
  The pilot could significantly disrupt health system finances by adding administrative burdens and cash flow risks.
• 1:48
  It could also set a precedent for long-term changes to the program making the coming months critical for providers to influence its scope and design.
• 1:56
  In another piece of News, United Health Group's stock has declined by a further 20% following a disappointing earnings release and confirmation of a Department of Justice probe into its business practices.
• 2:08
  UnitedHealthcare is dropping 600,000 PPO lives in MA next year.
• 2:13
  While Optum is exiting VBC contracts covering 200,000 PPO lives, the company appears to be shifting from aggressive expansion to cost control and operational stability, slowing m and a activity, and tightening utilization management while navigating political scrutiny.
• 2:31
  For our final piece of news, CMS released, its proposed Medicare payment policies for hospital outpatient and a SC services next year.
• 2:39
  Which includes provisions on site neutrality, price transparency, and three 40 b payments.
• 2:45
  By shrinking the inpatient only list, CMS is opening the door for more complex procedures to migrate into outpatient settings, intensifying competition for surgical volume, and potentially surgical talent as well.
• 2:59
  That concludes this week's edition.
• 3:01
  Be sure to check out the full version on the web@hmacademy.com.
• 3:05
  Thanks for listening.