CENTER UPDATE | December 2025

In this Issue:

  • Save-the-Date! 2026 V-BID Summit
  • Low-Value Care Persists Despite Risk-Based Payment Models in MA
  • New CAP Act Aims to Cap Drug Cost-Sharing for Marketplace Enrollees
  • Removing Cost-Sharing Increases Follow-Up Colonoscopy Completion
  • High Patient Costs Drive Treatment Abandonment
  • Nearly Half in US Worry About 2026 Health Costs
  • Proposed Federal Actions to Improve Access to Obesity Medications
  • Medicare Drug Plan Access Shrinks and Premiums Rise Under IRA
  • New Medicare Rule Expands Focus on Chronic Disease Prevention
  • Low Early Enrollment in Medicare Prescription Payment Plan
  • Rising Health Care Costs Are a Major Barrier for Small Businesses

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March 11, 2026 | 12 - 4PM EST

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Low-Value Care Persists Despite Risk-Based Payment Models in Medicare Advantage

A new study shows that Medicare Advantage (MA) organizations that transition to risk-based payment contracts do not see consistent reductions in low-value services or overall utilization. While some declines were observed—such as in emergency department visits and cardiovascular stress testing—most did not remain significant after adjusting for trends. The findings suggest that voluntary risk models may not be sufficient to meaningfully curb low-value care in MA.

New CAP Act Aims to Cap Drug Cost-Sharing for Marketplace Enrollees

The newly introduced ACA Copay Cost and Affordability for Patients (CAP) Act would limit annual out-of-pocket costs for prescription drugs for individuals with coverage through ACA Marketplace plans. The bill is designed to reduce high medication costs and improve affordability for marketplace enrollees. If enacted, the CAP Act could offer financial relief and more predictable drug spending for millions of Americans.

Removing Cost-Sharing Increases Follow-Up Colonoscopy Completion

New research has found that eliminating out-of-pocket costs for follow-up colonoscopies after a positive stool-based test led to a 41.2% increase in completion rates nationwide. The analysis, based on more than 10.8 million procedures from January 2022 to November 2023, shows a clear shift in utilization after cost-sharing was removed. These findings demonstrate that financial barriers play a significant role in whether patients complete the full colorectal cancer screening process, which is essential for early detection and improved outcomes.

High Patient Costs Drive Treatment Abandonment and Support for Insurance Redesign

In a mixed-methods study of 146 insured U.S. adults across 15 chronic conditions, 72% reported satisfaction with their plan yet expressed major concerns over high deductibles, unpredictable out-of-pocket costs, and affordability of medications. Many noted that cost exposure led to treatment abandonment, debt, or worsened health despite having insurance. Participants overwhelmingly supported designs that capped cost exposure for high-value care, such as eliminating coinsurance for necessary medications and offering transparent cost estimates up front.

Nearly Half in U.S. Worry About 2026 Health Costs

A new West Health-Gallup survey shows 47% of U.S. adults worry they won’t be able to afford health care in 2026, the highest level since tracking began in 2021. The data shows that prescription drug cost concerns also rose from 30% in 2021 to 37% in 2025.

Proposed Federal Actions to Improve Access to Obesity Medications

A new Health Affairs Forefront outlines steps the current administration could take to increase access to and affordability of obesity medications, emphasizing the potential for these therapies to reduce chronic disease burden and future medical spending. The authors, including V-BID Center Director Mark Fendrick, MD, recommend expanding Medicare coverage pathways, addressing high out-of-pocket costs, and aligning payment with clinical value. The President’s renewed focus on obesity treatment access and ongoing drug pricing negotiations could make these changes actionable.

Medicare Drug Plan Access Shrinks and Premiums Rise Under IRA

A new analysis finds that 2026 Medicare drug plan options and premiums vary sharply by geography and plan type. Rural beneficiaries face fewer Part D choices and higher premiums, paying about $43 per month compared with $33 in urban areas, with rural premiums rising 11% since 2021 while urban premiums declined 2%. These changes are attributed to the Inflation Reduction Act (IRA), as its new pricing and benefit design requirements have led plans to consolidate offerings and adjust premiums in response to evolving financial and regulatory pressures.

New Fee Schedule Rule in Medicare Expands Focus on Chronic Disease Prevention

The 2026 Medicare physician fee schedule final rule aims to shift payment toward chronic disease prevention by strengthening primary care, expanding diabetes prevention efforts, and adding new prevention-focused quality measures. The rule improves valuation for primary care services, supports behavioral health integration, and allows virtual delivery of the Medicare Diabetes Prevention Program through 2030, though fewer than 1% of eligible beneficiaries participate. It also introduces new measures related to diabetes risk, falls, and Hepatitis C, while urging CMS to develop broader health status metrics tied to preventable chronic conditions.

Low Early Enrollment in Medicare Prescription Payment Plan

A new Milliman analysis showhows that fewer than 1% of Medicare beneficiaries were enrolled in the Medicare Prescription Payment Plan as of June, despite the program allowing seniors to spread their annual Part D drug costs into predictable monthly payments. Uptake was slightly higher among beneficiaries using specialty medications, yet 14 of 15 people filling a high-priced prescription still did not enroll. Annual out-of-pocket drug costs are capped at $2,000 in 2025 and $2,100 in 2026, offering significant financial protection for beneficiaries with high drug spending. Limited awareness and unclear enrollment processes remain major barriers to broader participation.

Rising Health Care Costs Are a Major Barrier for Small Businesses

Small businesses report that health care costs are increasingly limiting their ability to hire, invest, and offer benefits. Premiums are a top concern, with many owners saying they’ve had to cut or change benefit offerings due to escalating expenses. Survey datashow that these rising costs are squeezing profitability and growth. Owners are calling for more sustainable, value-focused health plan designs.

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