Gary Culp

This week marked a meaningful step forward in fixing what’s broken in our prescription drug system. Congress passed the Pharmacy Benefit Manager Reform Act, bringing long-overdue transparency and accountability to a system that has driven up costs for patients, employers, and families far too long. For more than a decade, Blue Shield of California has been pushing to eliminate hidden fees, rebates, and spread pricing that benefit middlemen instead of people. From launching CivicaScript to reimagining the Pharmacy Benefits Manager (PBM) model entirely, California has shown that reform is not only possible, but it works. It’s encouraging to see those lessons now reflected on the national stage. Prescription drugs save lives only if people can afford them. This legislation puts consumers first, and it’s an important step toward a more transparent, fair, and sustainable healthcare system. There’s more work ahead, but this is real progress, and proof that change happens when we’re willing to challenge the status quo. #pharmacy #healthcare #healthcarereform  https://lnkd.in/gPm6JmFF

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Recently, Dr. Mehmet Oz spoke at the Milken Institute’s 2025 Global Conference on a Flourishing Future. Dr. Oz discussed shifting the paradigm for healthcare towards quality and highlighted some of his key priorities. Presently, the CMS Star Rating System is the method for measuring quality in the Medicare Advantage (MA) industry. While the star rating system has faced criticism, it remains the standard for evaluating quality, which ultimately leads to industry-wide rewards, penalties, and compensation. The CMS Star Rating System promotes and rewards quality, ensures carrier accountability, and provides beneficiaries with a tool to help them choose high-quality plans. Star ratings also have additional weighting categories to help drive further improvement in patient experience and access. CMS charges carriers with oversight of agents and brokers in the MA industry (42 CFR § 422.2274(c)). Carriers outsource this responsibility through contracts with Broker Support Organizations (BSOs), also known as FMOs, MGAs, NMAs, etc. In value-based care, my research indicates that the combination of Community-Based Brokers and Broker Support Organizations currently impacts 17 of the 42-star rating measures, particularly in areas that impact beneficiary satisfaction. This makes sense because they engage with Medicare beneficiaries early, often being their first point of contact with the Medicare program. They empower clients to make well-informed choices, help ensure the system works as intended, and provide consumers with protection when it does not. Brokers and Broker Support Organizations must collaborate with carriers to better demonstrate how healthier and happier members contribute to shareholder value. It is a win-win scenario. We are an additional resource in a resource-constrained industry that helps make that happen. We look forward to working with Dr. Oz to bring his evolving strategy to life, ultimately enhancing the well-being of the American people. #AdvocateforAgents #AdvocateHealthAdvisors #AdvocateforVeterans #MedicareAdvantage #Medicare #Medicaid #DrOz #MehmetOz #MilkenInstitute

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California’s SB‑41 isn’t just another compliance milestone..... Combined with federal legislature, we are on the cusp of major change, RIGHT NOW. The balance of power in pharmacy benefits is shifting toward employers who demand true partnership (from the traditional models). Employers have an opportunity to rethink how transparency and alignment shape their RFPs for 2026-27. As biosimilars like #Starjemza, a newly launched and more affordable alternative to Stelara, enter the market, employers now have clearer sightlines into whether their PBM is prioritizing cost‑effective options or clinging to opaque practices that SB‑41 seeks to eliminate. Don't be fouled into thinking a PBM owned bio-similar is the same thing. It's NOT. What excites me most is the ripple effect: these reforms for accountability and value will usher in the partners that have always been here for employers. MedOne Pharmacy Benefit Solutions, Transparency-Rx, Mark Cuban Cost Plus Drug Company, PBC, Ron Harrison For additional Information: https://lnkd.in/g3xbWDvg

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Dr. Gauri Puri, Business and Strategy Officer, analyzes the latest trends shaping revenue cycle management in this insightful new white paper. She discusses innovations such as conversational AI, AI-enabled coding, automated claims scrubbing, and automated payment reconciliation as tools for enhancing accuracy and reducing manual tasks. By leveraging predictive analytics, NLP, and AI technologies, providers can streamline revenue cycle operations to increase productivity and accelerate cashflow significantly. https://lnkd.in/enviqttw #rcm #revenuecyclemanagement #healthcarenews #ai #automation

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2026 presents a new and precarious landscape for California health care. With federal cuts looming from #HR1 and other actions, millions of Californians face skyrocketing costs — or losing their insurance coverage. In a new interview, CHCF CEO and President Sandra R. Hernández, M.D. says we've seen this before in the days before the Affordable Care Act, and we'll have to draw on those strategies and learnings to get through this. Thankfully, she says, tools like AI and a new generation of leadership have enormous potential to ease the path ahead. Now is the time for California health leaders to think big. Read her full interview: https://lnkd.in/gj9Dzbjx

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The CalAIM initiative is changing the way managed care plans support their Medicaid members in California. CalAIM encourages payers to address the full spectrum of health and non-clinical needs for vulnerable members—through advanced care management and by connecting members with community resources across California. By partnering with HealthEdge GuidingCare®, payers can improve healthcare access, help ensure regulatory compliance, and improve member outcomes. Learn more about how your health plan can improve population health with whole-person care: https://ow.ly/KQq050WyK83

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We are happy to announce that CareMore Health now accepts Aetna Medicare Advantage plans in California. This partnership expands access to our coordinated care model for Medicare Advantage beneficiaries. Brokers can now offer CareMore Health as an in-network option for Aetna Medicare Advantage plans. Combining Aetna's Medicare network reach with CareMore Health's whole-person care approach will give beneficiaries more options during this enrollment period.

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J2 is observing provider network “Shrinkflation” from persistent reimbursement pressure in Medicare Advantage. Shrinkflation is the economics term for consumers get less for the same price (e.g., fewer cheetos in a bag). With J2’s payer directory data, we analyzed 1,361 Medicare Advantage plans across the five highest enrolling states and found that 83% of plans narrowed their provider networks from Plan Year 2025 to 2026. Chart below. Given reimbursement headwinds, continued network narrowing seems inevitable. J2 will be tracking the many open questions that follow on patient access, MA penetration rates, provider finances and product strategies.

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Only 62% of Medicare Advantage enrollees are in plans rated four stars or higher—a steep decline from 74% last year. As CMS ramps up audit scrutiny and tightens performance thresholds, health plans need better ways to ensure coding accuracy and maintain compliance—without adding more manual burden. AI can help—from flagging documentation gaps in real time to streamlining coding workflows and reducing audit risk, it gives teams the speed and precision they need to stay ahead. See how AI is shaping smarter risk strategies 👉 https://lnkd.in/dzb_6pAr #AI #HealthcareAI #RiskAdjustment #MedicareAdvantage #PayerStrategy #GenerativeAI #AIforHealthcare #Quantiphi #SolvingWhatMatters

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Patient Engagement: The Common Thread Driving Medicare Innovation in California I recently attended the California Association of Health Plans seminar on Medicare in California: Insights & Shifting Market Dynamics, where industry leaders discussed the significant changes reshaping care for seniors and dual eligibles in our state. Two major developments stand out: 1️⃣ CMMS just issued an RFI on Health Technology Ecosystem seeking input on digital health solutions for Medicare beneficiaries and data interoperability infrastructure. The goal? Leveraging technology to empower seniors in managing their health, preventing disease, and accessing more efficient care. 2️⃣ CalAIM's implementation of integrated care models - particularly with California MCPs launching Exclusively Aligned Enrollment Dual Special Needs Plans (EAE-DSNPs) in 2026 to better serve those eligible for both Medicare and Medi-Cal. The throughline connecting these initiatives? Patient engagement. Without effective engagement strategies, even the best-designed care models fall short. This is especially critical for dual eligible populations who face unique barriers to care access. I found this article from Wellth particularly insightful on positioning health plans for success in this evolving landscape: Act Now: Position Your Health Plan for CalAIM D-SNP Success (https://lnkd.in/g2vDqPbX) As the article highlights, "Communication is the make-or-break factor" for D-SNP members who often contend with low health literacy and distrust in the healthcare system. Traditional outreach methods simply aren't sufficient. For health plans preparing for 2026 EAE-DSNP implementation, now is the time to develop engagement strategies that build trust and create meaningful connections with dual eligible members. What engagement strategies is your organization implementing to prepare for these changes? I'd love to hear your thoughts! #HealthcareInnovation #CalAIM #PatientEngagement #Medicare #MediCal #DSNP #DigitalHealth

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