November 13, 2025 | 19 min read
Newsletter
November 13, 2025
Table of Contents
Maverick's Highlights💡
Dear Readers,
The government shutdown is over and the reckoning about what comes next begins.
We will be watching closely how the debate twists and turns on ACA health insurance premium subsidies before the December vote takes place. The Maverick team is also looking forward to how HHS shakes off its backlog of meetings and determines how it will move forward on its plans in a few key areas, including: prior authorization, new payment reforms to incentivize the use of technology in the health care system, and provider directories.
Don’t worry, we will keep you updated on what we learn. Best wishes for a great weekend.
–Julie
HIGHLIGHTS
General Federal News
- Yesterday, HHS hosted the MAHA Summit, and today, CMS is hosting a Connectathon.
- Provider groups are expanding their lawsuit over changes to vaccine recommendations.
Artificial Intelligence (AI)
- Next week, Congress will discuss the potential harms of AI chatbots, while OpenAI faces seven new lawsuits.
- MAI announced a new team focused on “Humanist Superintelligence.”
- Open Evidence will integrate guidelines from the National Comprehensive Cancer Network (NCCN) into its clinician search engine.
Digital Health
- Brown University researchers estimated the initial impact of telehealth flexibilities expiring.
- UnitedHealthcare is limiting its coverage for remote patient monitoring.
- ATA’s CEO, Ann Mond Johnson, will retire next month.
- DiMe is creating a framework for seniors to age in place with tech-enabled health care.
Interoperability and Health IT
- Senate HELP Committee Chair Bill Cassidy introduced a bill that would expand data privacy protections to health data not covered under HIPAA.
- Leavitt Partners proposed several policy recommendations to improve information blocking enforcement.
- Epic formally responded to Particle Health’s antitrust and information blocking lawsuit.
Investments
- Biotech Iambic raised $100 million to advance AI-powered drug discovery.
- myTomorrow, an AI-powered clinical trial recruitment platform, secured $29 million in Series A funding.
Payers and Providers
- CMMI announced a new drug pricing model using Most Favored Nations pricing in Medicaid, and President Trump announced negotiated prices with Eli Lilly and Novo Nordisk for GLP-1s.
- CMS announced the six tech vendors that will participate in the CMMI WISeR model. Congressional Democrats are trying to stop the implementation of the model through a new bill.
- Johns Hopkins is convening multistakeholder work groups to improve quality and utilization management.
General Federal News
FEDERAL SHUTDOWN NEWS
- President Trump signed a short-term government funding package passed by Congress at the White House last night (Wednesday, November 12, 2025), ending the longest government shutdown in U.S. history.
- The bill extends Medicare telehealth coverage through January 30, 2026, and retroactively pays for virtual care services that were delivered during the government shutdown.
- The bill provides backpay for federal employees, including severance pay for laid-off workers, and addresses future layoffs.
- The central issue that stymied negotiations for so long—extensions on enhanced Affordable Care Act subsidies that expire at the end of the year—is not addressed in the bill. Instead, as part of the deal reached with a bipartisan contingent of senators, Democrats will draft a legislative proposal to extend the subsidies and there will be a guaranteed opportunity for Congress to vote on it in mid-December.
- Flight disruptions and lapses in SNAP funding are expected to continue for several days.
- Although the shutdown ended without extensions to enhanced ACA premium subsidies, there are alternative reforms being considered:
- President Trump proposed giving cash directly to Americans, though it’s unclear exactly how this would be operationalized. More here.
- Four House Representatives introduced the bipartisan Fix It Act, which would extend the enhanced premium subsidies for two years. The bill proposes to offset these costs by creating an income cap, limiting Medicare Advantage (MA) “upcoding” practices, and targeting fraudulent behavior by ACA plan brokers.
GENERAL FEDERAL NEWS
- On Wednesday, November 12, 2025, HHS hosted the invite-only Make America Health Again (MAHA) Summit. While the agenda was closed to the public, discussion topics reportedly included psychedelic medicine, longevity, food as medicine, and GLP-1 medications.
- On November 11, 2025, the FDA appointed Dr. Richard Pazdur, founding director of the FDA Oncology Center of Excellence, as the Center for Drug Evaluation and Research (CDER)’s new director, succeeding George Tidmarsh after his resignation. This appointment was unexpected, as Dr. Pazdur had declined the role a week earlier, according to a STAT News article. More here.
- The FDA will update “black box” warnings for hormone replacement therapy menopause treatments to expand treatment options and align labeling with current science. The FDA will remove references for risk of cardiovascular disease, breast cancer, and probable dementia but will not reconsider the warning of endometrial cancer risk for using systemic estrogen-alone products. Along with the announcement, FDA Commissioner Makary published op-eds in JAMA and The Wall Street Journal.
- The American Academy of Pediatrics (AAP), American College of Physicians, and several other provider organizations amended their legal complaint, originally filed on July 7, 2025, that argued that the removal of COVID vaccine recommendations for pregnant women and healthy children was “arbitrary and capricious.” The groups filed an updated complaint requesting the U.S. District Court void the Advisory Committee on Immunization Practices’ (ACIP) votes after HHS Secretary Kennedy replaced all of ACIP’s original members.
Artificial Intelligence
GENERAL NEWS
- On Tuesday, November 18, 2025, the U.S. House Energy & Commerce Subcommittee on Oversight and Investigations will hold a hearing to examine user safety concerns, potential safeguards, and broader implications of AI chatbot use.
- CMS selected the six vendors that will pilot the WISeR model in six respective states, using AI and other health tech to process provider prior authorization requests: Cohere Health (TX), Genzeon Corporation (NJ), Humata Health (OK), Innovaccer (OH), Virtix Health (WA), and Zyter (AZ).
- Microsoft AI CEO Mustafa Suleyman announced a new team devoted to building “Humanist Superintelligence,” or advanced AI designed to tackle practical problems while ensuring technology’s purpose remains to serve human interests. The team will focus on high-impact applications, including medical superintelligence, personalized education, and renewable energy.
- New York Governor Kathy Hochul reminded companies that operate AI companions about meeting safety requirements under the state’s new AI companion law, such as implementing crisis intervention protocols and regular reminders informing users they are interacting with a chatbot, not a human.
- Nvidia shares fell after SoftBank, a Japanese investment firm and Stargate Project founding partner, announced it sold its $5.8 billion stake in the chipmaking company to fund other AI investments, including with Open AI. More here, here.
- OpenAI and CEO Sam Altman are facing seven new lawsuits filed in California state courts, with allegations related to assisted suicide, negligence, wrongful death, and involuntary manslaughter. Plaintiffs claim ChatGPT’s design exacerbated mental health struggles and that OpenAI rushed GPT-4 to market without adequate safety testing.
- Separately, OpenAI is reportedly considering building consumer health products, including aggregated personal health records and generative AI health assistants, according to Business Insider. More here.
- Winning the global AI race could hinge on access to proprietary data, with intellectual property becoming a strategic advantage, according to a Fierce Healthcare op-ed by Wolters Kluwer Health’s Chief Medical Officer. He argues that creators of high-value training data will not give away data that threatens businesses but will become partners when their work is compensated.
ADMINISTRATIVE APPLICATIONS
- Mayo Clinic and Redesign Health unveiled Corvus, a new digital health startup with AI agents to help care teams with surgical referral processes.
- Luma Health, an AI-enabled care coordination platform for health systems using Oracle’s EHR, acquired digital intake and e-consent software provider Tonic Health from R1.
- PocketHealth, a connected care company developing agentic AI tools for health systems, launched Conductor, a suite of AI-enabled agents to streamline administrative tasks. Agents can assist with scheduling appointments, sending patient reminders, and directing calls.
CLINICAL APPLICATIONS
- OpenEvidence, an AI-powered medical search engine for clinicians, announced a licensing agreement with the National Comprehensive Cancer Network (NCCN) to provide NCCN’s oncology guidelines and Journal of the National Comprehensive Cancer Network material in the OpenEvidence platform
- Get Well and RhythmX AI merged to create a unified precision care platform that combines clinical, financial, social, and payer data into health systems’ EHR data, offering real-time care insights.
- Spanish INBRAIN Neuroelectronics, developer of an implantable graphene neural processor, finalized a partnership with Microsoft to use the company’s Azure platform, including time-series large language models (LLMs) and analytics, to enable its brain-computer interface to adapt to individual patient neural signals in real-time.
- As AI algorithms begin receiving established reimbursement rates, like coronary arterial plaque analysis, which will move to a Medicare Category I code in January, medical groups warn that costly AI reimbursement could reduce payment for other physician services, according to a STAT News article.
- A JAMA Network Open analysis of FDA-approved AI/ML-enabled medical devices found the majority of devices (97%) were approved under the 501(k) pathway, which does not require clinical validation studies. Among the 950 devices analyzed, 76% were radiology devices.
RESEARCH APPLICATIONS
- Eli Lilly expanded its agreement with generative AI-powered drug discovery company Insilico Medicine in a new $100 million research and licensing deal. The new deal allows Lily to use Insilico’s Pharma.AI platform in small-molecule drug design.
- Oracle Health and Life Sciences partnered with Cancer Center Informatics Society (Ci4CC), a nonprofit connecting cancer centers and research initiatives, to design an EHR optimized for cancer care. Future projects will focus on advancing other AI-driven oncology initiatives, including in personalized medicine solutions and clinical trial innovation. More here.
- Moving from broader efforts to prevent disease to AI applications in life sciences and biomedical research, Dr. Priscilla Chan and her husband, Meta CEO Mark Zuckerberg, are shifting philanthropic resources to Biohub, a science organization.
- SOPHiA Genetics expanded its partnership with genomic sequencing firm Complete Genomics, combining its AI-driven data analytics platform and cancer assays with Complete Genomics’ DNBSEQ-T1+ sequencing system.
- Hepta, a new chronic-disease focused biotech company founded by former Illumina, Grail, and Google AI executives, launched last week with $6.7 million in seed funding.
- American Heart Association (AHA) President Stacy Rosen, MD, called for the industry to rethink clinical trial design to improve women’s representation, suggesting telehealth and AI could help address blind spots, in a STAT News article. Rosen noted women comprise only 30 percent of cardiovascular research participants, despite a 1993 mandate, with gaps contributing to misdiagnosis and undertreatment of women’s heart health.
Digital Health
GENERAL NEWS
- The Digital Medicine Society launched an initiative to create a blueprint for integrated, at-home, and tech-enabled care for older seniors. Through its Connected Health Collaborative (CHcc), DiMe will work with partners like the Consumer Technology Association, the FDA, and UMass Chan Medical School’s Program in Digital Medicine to create a pathway for building reliable, affordable infrastructure that enables aging in place. CHcc’s inaugural project was a blueprint for hospital-at-home programs.
- Omada Health will begin prescribing GLP-1 medications nationwide in 2026, expanding its current capabilities and complementing its existing virtual behavioral weight management programs.
- Tandem Diabetes Care received FDA clearance for its Tandem Mobi app, which allows users to connect their smartphones with the company’s automated insulin delivery systems and directly manage their diabetes.
- The American Red Cross launched the Resuscitation Suite App, which uses protocol prompts, timers, and real-time documentation to support evidence-based training and real-time support for Basic, Advanced, Pediatric Advanced, and Neonatal Advanced Life Support.
- Press Ganey’s Healthcare Consumer Experience 2025 report named technology, transparency, and trust as defining parts of the modern consumer care journey. While the digital ecosystem is expanding, most surveyed consumers still rely on Google search to identify a provider as the first step in their care journey.
- Electronic patient-reported outcome (ePRO) systems that included a combination of automated self-management coaching, nurse practitioner follow-up, and clinical decision support tools demonstrated the highest cost-effectiveness for symptom control for cancer patients undergoing chemotherapy, when compared to four other systems that only used one or two of the interventions.
- Adding video storytelling and narrative messages to text-based blood pressure and hypertension self-management interventions for Black veterans did not provide additional clinical improvement, according to a study in JAMA Network Open.
TELEHEALTH
- Brown University’s Center for Advancing Health Policy Research estimated the initial impacts of Medicare telehealth flexibilities expiring: in the first 17 days of October, the proportion of office encounters via telehealth declined by 24 and 13 percent for Medicare FFS and Medicare Advantage (MA) beneficiaries, respectively. This decline was more pronounced in some states than others. Florida, Louisiana, Washington, Tennessee, Maryland, Oklahoma, and New York saw reductions of 40 percent or more.
- The American Telemedicine Association (ATA) announced its CEO, Ann Mond Johnson, will retire on December 10, 2025 and will be succeeded by Kyle Zebley, ATA’s current VP of Public Policy and Executive Director of its advocacy arm, ATA Action.
- LifeMD divested its majority stake in WorkSimpli, a productivity platform, for $22 million to focus on its virtual primary care platform, treating issues like weight management and women’s health, and expanding its capabilities to offer more longitudinal, cardiometabolic services in 2026.
- Optain Health, an AI-enabled retinal screening startup, acquired EyePACS, a company that combines web-based screenings for diabetic retinopathy with telehealth consults from ophthalmologists, to create a combined service that expands access to early screening services.
WEARABLES
- WHOOP launched Advanced Lab Uploads, a feature that will allow users to upload previous lab results to their profile for a better assessment of their health. This follows a previous announcement that allowed users to order lab tests from Quest Diagnostics directly through the app.
- Oura is partnering with Tidepool, a diabetes tech nonprofit, to advance diabetes research by creating a combined dataset with metrics from Oura’s smartrings and diabetes devices like continuous glucose monitors (CGMs) and insulin pumps.
- Samsung Health partnered with iFIT to integrate a diverse selection of workouts, including pilates, yoga, barre, and mindfulness exercises, into its health app that users can complete while tracking their health metrics in real-time through their Galaxy Watch.
REMOTE PATIENT MONITORING
- UnitedHealthcare will no longer cover remote patient monitoring (RPM) for most conditions, including Type 2 diabetes and hypertension, deeming RPM medically necessary only to treat chronic heart failure and hypertension during pregnancy.
Interoperability and Health IT
INDUSTRY NEWS
- In a new white paper, Leavitt Partners proposed several policy recommendations to improve information blocking enforcement, including Congressional action to simplify currently fragmented penalty structures and more funding for enforcement efforts.
- Epic denied all allegations that it engaged in anticompetitive behavior and defamation against Particle Health, in a formal response to the payer-focused API platform’s antitrust lawsuit. Rather, Epic claims it protected patients and providers from Particle’s inappropriate data-sharing methods.
- LongitudeRx, a specialty pharmacy created by the health system-led collaborative Longitude Health, will use Innovaccer’s Gravity Platform to unify pharmacy, EHR, and payer data to improve 340B compliance, automate reimbursement workflows, and support payer and manufacturer partnerships.
- Longitude Health announced Vishal Agrawal, formerly Chief Strategy and Corporate Development Officer at Humana, as its CEO in October.
- Epic recently expanded eligible data imports to include risk adjustment and supplemental data that are likely intended to target population health initiatives, according to Brendan Keeler’s LinkedIn post.
- Get Well and Rhym X AI merged to create a unified precision care platform that combines clinical, financial, social, and payer data into health systems’ EHR data, offering real-time care insights.
- Vatica Health, a health tech company offering risk adjustment and quality solutions for providers, merged with Cozeva, a value-based care enablement company that coordinates workflows between payers and providers.
- Combining the use of Quick Dementia Rating System (QDRS), the patient-reported outcome tool, and a Passive Digital Marker (PDM), a machine learning algorithm that analyzes data from the EHR is a scalable and cost-effective approach for early detection of Alzheimer’s, according to results from a randomized clinical trial.
DATA PRIVACY AND SECURITY
- U.S. Senate Health, Education, Labor, and Pensions (HELP) Committee Chair Bill Cassidy (R-LA) introduced the Health Information Privacy Reform Act, a bill that proposes to expand privacy protections for health data not covered by HIPAA. The bill directs the HHS Secretary to work with the Federal Trade Commission to create appropriate privacy, security, and breach notification protections for data associated with health apps, smartwatches, and other wearable devices. More here.
Investments
AI INVESTMENTS
- Synchron raised $200 million in Series D funding to commercialize its Stentrode Brain Computer Interface Platform, a nonsurgical platform that translates brain activity into digital devices.
- Biotech Iambic raised $100 million to advance AI-powered drug discovery using the company’s multimodal transformer models that predict clinical endpoints and protein-ligand structures.
- myTomorrow, an AI-powered clinical trial recruitment platform, secured $29 million in Series A funding.
- Integrated outpatient mental health provider Amae Health secured $25 million in Series B funding with participation from Cedars-Sinai Ventures to open more clinics and advance its AI-driven care platform. The company’s precision medicine platform, built on Palantir’s Foundry system, integrates multimodal data to support the treatment and research of severe mental illness.
- Evidium, developer of clinical and cost forecasting tools, raised $22 million in Series A funding to expand the commercialization and modeling capabilities of its computational reasoning platform.
DIGITAL HEALTH INVESTMENTS
- Wearables company NextSense received an investment from Corundum Neurosciences as part of a Series A funding round, to advance NextSense’s brain health solutions and sleep tracking devices.
Payers and Providers
DRUG PRICING
- The Center for Medicare and Medicaid Innovation (CMMI) announced the GENErating cost Reductions for U.S. Medicaid (GENEROUS) model, designed to lower Medicaid prescription drug spending through negotiating most-favored nation (MFN) pricing with participating pharmaceutical companies. The model will run for five years, from 2026 to 2030. CMS released a Request for Applications (RFA) for drug manufacturers and is seeking letters of intent from state Medicaid agencies interested in participating. More here.
- Last week, the Trump administration announced deals with Eli Lilly and Novo Nordisk to lower prices for their GLP-1 drugs—including Ozempic, Wegovy, Mounjaro, and Zepbound—for federal health care programs and President Trump’s direct-to-consumer initiative, TrumpRx. Experts think the greatest impact to consumers will be negotiated prices for the Medicare program. The details:
- Medicare: Prices for Wegovy, Ozempic, Zepbound, and Mounjaro will be $245 per month, with co-pays limited to $50 per month. Medicare will seek to cover GLP-1s for patients with obesity and related comorbidities for the first time.
- Medicaid: States will have the option to cover the drugs at Medicare prices in Medicaid programs.
- TrumpRx (Direct to Consumer): Novo Nordisk’s Wegovy and Ozempic will be offered at $350 per month, and Eli Lilly’s Zebound will be offered at $346 per month. Should either manufacturer develop an oral version of the GLP-1s, the initial dose will be priced at $150 per month on TrumpRx. Both drug companies also announced discounted prices for other diabetes and insulin products through TrumpRx.
PAYERS
- The post-government shutdown debate about whether and how to extend ACA premium subsidies may be informed by President Trump’s push to send subsidies directly to consumers, which is being met with considerable pushback by experts who say that the idea would ruin the individual marketplace risk pool and cause insurers to leave the market altogether.
- A new report shows that health insurers are struggling to turn a profit on their federal health program lines of business.
- A new survey by Cornell Health Policy Center shows that bringing per-enrollee Medicare Advantage (MA) spending to levels comparable with traditional Medicare would substantially reduce the supplemental benefits offered by MA plans.
- Cigna announced several leadership updates: The Cigna Group appointed Amy Flaster as Chief Medical Officer (CMO) after she served as the CMO of Cigna’s insurance division. In its announcement, Cigna also noted other leadership changes, including the resignation of Dr. David Brailer, Executive Vice President and Chief Health Officer since 2022.
- Cigna Healthcare and Earvin “Magic” Johnson are partnering to release an album intended to improve mental wellbeing through music — the album uses evidence-based techniques to support stress relief and relaxation.
- Priority Health appointed Nick Gates as its next President, following 20 years at the health plan. He was most recently Senior Vice President of Finance and served as Interim President after Praveen Thadani stepped down in May 2025.
- Oscar Health reported a $137.5 million loss in Q3 but maintained its 2025 outlook; CEO Mark Bertolini highlighted the company’s efforts to protect access to ACA plans.
PROVIDERS
- Johns Hopkins is starting a new initiative called the Providers, Health Plans, Policymakers and Patients Aligned in Care Transformation (PACT). The health system will convene multistakeholder work groups to address three topics: 1) hospital quality and process-based metrics, 2) ambulatory value-based care performance metrics, and 3) utilization management.
- The work group focusing on utilization management will start by standardizing clinical guidelines for cardiovascular disease and musculoskeletal pain and finding opportunities to automate prior authorization.
- The Children’s Hospital Association rebranded to emphasize that children’s health is a bipartisan issue and will use its database that integrates encounter-level data from 50 children’s hospitals to advocate for key topics like children’s mental health and workforce capacity building.
- Kaiser Permanente reported a $218 million operating income in Q3 2025, reversing its $608 million operating loss in Q3 2024. Executives cited future headwinds of an aging population and coverage reductions associated with the One Big Beautiful Bill Act (OBBBA).
- Medicaid and ACA coverage losses associated with the OBBBA will likely challenge the financial sustainability of community-run clinics that provide care to all, regardless of factors like insurance and immigration status, or Community Health Centers (CHCs), according to a Health Affairs Forefront article.
PAYERS AND PROVIDERS (M&A)
- The Indiana Department of Health approved a Certificate of Public Advantage (COPA) allowing Union Hospital to acquire Terre Haute Regional Hospital, owned by HCA Healthcare, despite warnings from the Federal Trade Commission during both the Biden and Trump administrations that the merger will increase costs and reduce access for patients.
VALUE-BASED CARE
- Six House Democrats introduced the Seniors Deserve SMARTER Care Act, a bill that prohibits CMS from implementing the WISeR model or anything substantially similar. The lawmakers argue the pilot, which proposes to use technology to implement prior authorizations in Medicare fee for service starting January 2026, will cause delays in care and harm to patients.
- CMS selected the six vendors that will pilot the WISeR model in six respective states, using AI and other advanced technologies to process provider prior authorization requests: Cohere Health (TX), Genzeon Corporation (NJ), Humata Health (OK), Innovaccer (OH), Virtix Health (WA), and Zyter (AZ).
- Carrum Health, a value-based substance use disorder treatment program for employers, expanded to cover treatment for cannabis, sedative, and stimulant use, in addition to its existing alcohol and opioid-focused treatment models.
- Federally Qualified Health Centers (FQHCs) that participated in value-based payment programs between 2014 and 2023 performed better on seven of nine quality measures compared to FQHCs that did not, according to a recent study.
- Federal investments in primary care between 2011 and 2024 resulted in improvements in population health and practice experience, but delivered mixed results on patient engagement and costs according to a systematic review in JAMA Health Forum. Policymakers should focus future efforts on multipayer alignment and adequate data collection.
HEALTH EQUITY & SDOH
- Elevance Health beneficiaries enrolled in both MA and Medicaid who used grocery card benefits had increased rates of annual well visits, primary care, and other specialty appointments, suggesting that access to nonmedical supplemental benefits can increase outcomes, according to a study led by the Elevance Health Public Policy Institute.
- A recent HHS Office of Inspector General (OIG) opinion offering an FQHC enforcement discretion over concerns that distributing food boxes to the community—to both existing patients and nonpatients—may be seen as illegal kickbacks and illustrates the need for a clear safe harbor clause that enables health care organizations to furnish Food is Medicine-type programs without fear of violating federal fraud and abuse laws, according to a Health Affairs Forefront article.
Last Updated on November 21, 2025
Contact Us
Have any questions? We'd love to hear from you.