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Twice-Weekly Briefing
Tuesday, August 18, 2026
Issue 260818-55
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The MOC Brief
Health policy, priced and translated for self-funded plan sponsors
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In This Edition
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Business Group on Health finds 28 percent of employers covering GLP-1s for weight management will not commit to continuing in 2027. | | 2. |
Prescription drug prices fall 3.1 percent over twelve months while medical care services rise 2.7 percent. | | 3. |
CMS proposes requiring every off campus hospital outpatient department to obtain and bill under its own National Provider Identifier. | | 4. |
Federal auditors find three New York Medicaid plans denying behavioral health prior authorizations above the state's own threshold. | | 5. |
A money laundering guilty plea exposes a $1.42 billion equipment scheme that billed private insurers alongside Medicare. |
Five developments from the past week, each one attached to a number your plan can pull this month.
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01
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PHARMACY COVERAGE
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August 17, 2026
More Than a Quarter of Employers Covering GLP-1s Will Not Commit to 2027
Business Group on Health released its 2026 GLP-1 survey on August 17, covering 105 large employer members and fielded in February and March. Nearly eight in ten report that GLP-1 drugs are pushing their health care costs higher. Sixty-seven percent currently cover the drugs for weight management. Within that group, 72 percent say they are likely to continue coverage in 2027 and 10 percent say they likely will not, which leaves 28 percent unwilling to say yes. Cost sharing has barely moved. Eighty-three percent apply the same standard cost share they use for other drugs rather than a special design or a zero dollar arrangement. Looking ahead, 87 percent expect an oral GLP-1 to increase demand and only 9 percent expect prices to fall.
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MOC Perspective
Read the 83 percent first. Standard cost sharing on a chronic weight management drug means the decision to start, stay on, or quit gets made by the member at the pharmacy counter, on price, with no clinical judgment attached to it. That is a plan design choice, and it produces exactly the result most employers then complain about. High spend, high abandonment, and no measurable change in the conditions the drug was supposed to prevent. The 28 percent who will not commit to 2027 are not undecided about the pharmacology. They are undecided because they cannot prove anything either way from their own data. You can. Pull your GLP-1 population and follow it. Fill persistence at six and twelve months, who stopped and in what month, and what happened afterward in the medical file to A1c, blood pressure, bariatric referrals, and orthopedic volume. Run pharmacy and medical together, because the drug sits on one file and every effect you are paying for sits on the other. If persistence collapses at month four, the problem was never the unit price. It is that nobody reached the member before the refill did.
What To Do Now
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Measure GLP-1 fill persistence at six and twelve months for your own members, split by cost share tier. | | ▪ |
Match your GLP-1 population against your medical claims for A1c, blood pressure, bariatric surgery, and orthopedic utilization before and after initiation. | | ▪ |
Require your PBM to report net cost per member per month for the GLP-1 class, after rebates, with the calculation shown. | | ▪ |
Decide your 2027 coverage position from your own claims file rather than from a peer benchmark, and record the reasoning in your committee minutes. |
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Source: Business Group on Health
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02
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DRUG PRICE TREND
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August 12, 2026
Prescription Drug Prices Post Their Steepest Annual Drop Since 1963
The Bureau of Labor Statistics published its July Consumer Price Index on August 12. Prescription drug prices fell 3.1 percent over the twelve months ending in July, the steepest annual decline since 1963. Prices dropped 0.8 percent in July alone on a seasonally adjusted basis, and they have not risen in a single month this year. The rest of the medical basket ran the other way. Medical care services rose 2.7 percent over the same twelve months and the overall medical care index rose 1.7 percent, held down entirely by commodities, which fell 2.7 percent. Inside the month of July, hospital services rose 0.5 percent and physicians' services rose 0.2 percent while the drug index fell. Economists credit some combination of Medicare price negotiation, patent expirations, and competition in the weight loss market, and none of them can yet say how much belongs to which.
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MOC Perspective
Do not carry that 3.1 percent into your renewal conversation. The Consumer Price Index measures what a pharmacy collects at the counter from patients and their insurers. It cannot see the rebate a manufacturer pays your PBM weeks later, and it cannot see what your PBM keeps on the way through. Your plan's real number is net cost per member per month after rebates and after every administrative and aggregator fee in the chain, and nothing in this release moves it. What the release does hand you is a comparison your consultant is unlikely to volunteer. Public drug prices fell while medical services kept climbing, so a renewal explained to you as drug trend now has arithmetic working against it. Ask for the trend split. Pharmacy net of rebates, medical facility, and medical professional, each as its own per member per month line with its own twelve month change. Then ask which of those lines your PBM's compensation moves with. A vendor paid on a percentage of drug spend has no reason to hand you deflation, and a class where posted prices are falling is precisely where retained value goes to hide.
What To Do Now
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Request net cost per member per month for pharmacy, after rebates and after all administrative and aggregator fees, for the last eight quarters. | | ▪ |
Split your reported trend into pharmacy, facility, and professional lines and compare each against its own twelve month change. | | ▪ |
Confirm in writing how your PBM is compensated and whether any component moves with drug price or drug spend. | | ▪ |
Make your consultant reconcile any drug trend claim in your renewal against the published index before you accept the renewal. |
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Source: U.S. Bureau of Labor Statistics
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03
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SITE OF CARE
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August 13, 2026
CMS Would Make Every Off Campus Hospital Outpatient Site Bill Under Its Own Identifier
CMS used its August 13 MLN Connects newsletter to remind stakeholders that comments close August 31 on a proposal that changes how hospital owned outpatient sites identify themselves. The provision implements section 6225 of the Consolidated Appropriations Act, 2026, and rides inside the calendar year 2027 Hospital Outpatient Prospective Payment System proposed rule at 91 Federal Register 43656. Beginning January 1, 2028, Medicare would not pay a claim from an off campus provider based department unless that department obtains and bills under its own National Provider Identifier. Each one would also file an initial attestation showing it met the provider based regulations during the two years before the date of service, followed by later attestations on a schedule the Secretary sets. The rule reaches departments that are not on the provider's campus and not within the distance the regulations specify from a remote hospital location.
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MOC Perspective
The Medicare payment consequence is not the part that should interest you. Identification is. Today a hospital owned clinic across town bills under the main hospital's identifier, so when the same office visit costs your plan roughly twice what it costs in an independent practice, your claims file cannot tell you which building it happened in. The Health Care Cost Institute measured that gap at $116 in a physician office against $217 in an outpatient setting for a primary care visit, with the facility fee alone accounting for $114 of the price. Separate identifiers make those sites countable for the first time. Once each off campus department carries its own NPI, you can measure how much of your outpatient spend runs through hospital owned real estate, name the specific addresses, and build steerage that points at locations rather than at a general preference for lower cost settings. Comment closes August 31. Your coalition can file, and a plan sponsor explaining in plain terms what the current identifier scheme costs a private employer is a comment this agency has heard far less often than it should have.
What To Do Now
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File a comment through regulations.gov before August 31 supporting separate identifiers for off campus provider based departments. | | ▪ |
Ask your administrator now which of your in network outpatient sites are hospital owned and which bill a facility fee. | | ▪ |
Price your ten highest volume outpatient services at hospital owned sites against independent sites in the same market. | | ▪ |
Add facility fee disclosure and site of service reporting to your 2027 administrative services agreement. |
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Source: Centers for Medicare and Medicaid Services
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04
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MENTAL HEALTH PARITY
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August 13, 2026
Three Medicaid Plans Denied Behavioral Health Requests Above the State's Own Threshold
The HHS Office of Inspector General issued report A-02-24-01011 on August 13, finding that New York did not ensure three of its Medicaid managed care organizations complied with mental health and substance use disorder parity requirements tied to prior authorization. All three denied behavioral health prior authorization requests at rates above the threshold the state itself had set, measured on calendar year 2023 data. The comparative analyses the plans produced to justify those rates were not supported by sufficient data, so the state could not demonstrate that behavioral health denials were comparable to medical and surgical denials. OIG notes the noncompliance persisted more than six years past the October 2017 parity compliance deadline. It made two recommendations to CMS, one to build formal written monitoring procedures with defined denial rate thresholds and one to keep applying corrective action and sanctions. Both remain open, with updates due February 12, 2027.
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MOC Perspective
Swap Medicaid for your plan and the test does not change. The nonquantitative treatment limitation analysis that tripped these three organizations is the same comparative analysis your plan owes under federal parity law, and the number the auditors reached for first was the denial rate differential between behavioral health and medical surgical care. Most plan sponsors have never seen that number for their own members. Your utilization review vendor has it. Why it matters past compliance is simpler than the regulation makes it sound. A behavioral health denial does not end the episode, it relocates it. A member turned down for residential treatment or an extended course of therapy does not stop being sick, and the cost reappears in the emergency department, in disability, and in the medical claims of every condition the untreated illness drives. The National Safety Council puts the return on mental health treatment at four dollars for every dollar spent, which means a denial that saves your plan a thousand dollars was never a saving. Ask for the differential in writing, with the analysis behind it. If your vendor cannot produce the analysis, you do not have one.
What To Do Now
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Request your behavioral health and medical surgical prior authorization denial rates side by side for the last two plan years. | | ▪ |
Obtain the written nonquantitative treatment limitation comparative analysis your plan is required to maintain, and read it yourself. | | ▪ |
Identify members filling psychotropic prescriptions with no corresponding behavioral health claim and route them to care. | | ▪ |
Name the individual accountable for parity documentation and set a fixed date the analysis gets refreshed each year. |
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Source: HHS Office of Inspector General
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05
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CLAIMS INTEGRITY
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August 14, 2026
A $1.42 Billion Fraud Scheme Billed Private Insurers Alongside Medicare
The Justice Department announced on August 14 that Eldar Zarbavel, 45, of Pepper Pike, Ohio, pleaded guilty to laundering roughly $3.4 million in health care fraud proceeds through Northeast Ohio banks during June and July of 2024. He opened the accounts for Royce Medical Supply LLC, a Florida durable medical equipment company that a Russia based criminal organization used to submit $1.42 billion in false claims between July 2022 and July 2024. The department describes the underlying matter, Operation Gold Rush, as the largest health care fraud case it has ever prosecuted, and states that the organization set out to target, exploit, and steal from Medicare and private health insurance companies. Zarbavel faces up to 20 years and is scheduled for sentencing on December 16, 2026.
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MOC Perspective
Read the phrase private health insurance companies twice. Schemes at this scale do not sort their victims. A shell supplier with a real identifier, real member numbers, and a claim format that clears every edit gets paid by whoever is holding the file, and a self funded plan holds its own file. The reason $1.42 billion moved before anyone stopped it is that the detection question cannot be answered one claim at a time. Nothing about a single brace order looks wrong. The pattern looks wrong. A supplier that appeared recently, bills a narrow set of high margin codes, serves members scattered across states with no clinical relationship to the ordering physician, and posts a volume curve no legitimate business produces. Your administrator can run that query in an afternoon. Whether it runs, how often, and what happens to the output are contract questions rather than technical ones. Ask what supplier screening happens before payment instead of after, ask for the recovery totals from the last two years, and read the clause that decides whether recovered dollars come back to the plan or get shared with the vendor that found them.
What To Do Now
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Ask your administrator in writing what pre payment supplier screening it runs and how often it checks the federal exclusion list. | | ▪ |
Pull three years of durable medical equipment claims and rank suppliers by growth rate rather than by volume. | | ▪ |
Flag any supplier billing your members across multiple states with no ordering physician relationship in those markets. | | ▪ |
Read your recovery clause and confirm who keeps recovered dollars and what share the vendor takes. |
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Source: U.S. Department of Justice
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The Bottom Line
Five stories, and four of them turn on a number your own vendor is already holding. Fill persistence for your GLP-1 population. Net pharmacy cost per member per month after rebates. The behavioral health denial rate sitting next to the medical surgical one. The equipment suppliers whose volume grew faster than your enrollment. The fifth is the exception worth acting on this week, because the number does not exist yet. Separate identifiers for hospital owned outpatient sites would let every self funded plan in the country see where its outpatient dollars actually go, and the comment period closes August 31. None of this waits on new legislation. It waits on a plan sponsor willing to put the question in writing, attach a date to the answer, and treat that answer as a term of the contract rather than a courtesy. Renewal season is the only stretch of the year when the request carries real weight, and it is open right now.
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Thanks for reading.
Jude Odu
Founder and Principal, Model Optimal Care
Author, Model Optimal Care: End U.S. Healthcare Waste, One Health Plan at a Time
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