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340B’s Next Chapter Will Be Won (or Lost) on Data. Most Organizations Aren’t Ready.

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By ADAM COHEN

The debate over the 340B Drug Pricing Program is complicated. However, beyond the arguments over rebates, contract pharmacies, and program intent sits a simpler reality that every stakeholder should plan around. Whatever form 340B takes next, the value an organization captures will depend on its ability to document and justify every discounted transaction with detailed, defensible data. Most organizations are not yet equipped to do that.

The stakes are rising, and so is the burden of proof

Covered entities purchased roughly $100 billion in outpatient drugs through 340B in 2025, according to the Health Resources and Services Administration (HRSA), nearly double the 2022 total. Hospitals and clinics use those savings to fund uncompensated care, rural access, and services for underserved patients. Manufacturers argue the program has outgrown its original intent and point to the duplicate discounts and diversion that HRSA audits have identified. Contract pharmacies are caught between manufacturer restrictions, state protections, and the litigation that followed.

HRSA’s revised rebate pilot, scheduled to begin in January 2027, establishes that instead of receiving the discount at the point of purchase, participating providers will pay more upfront, submit claims data, and receive the 340B price afterward. Providers are right to worry about cash flow and administrative load resulting from this shift. However, the more lasting change is where the burden now sits. Providers must prove eligibility, transaction by transaction, before they are made whole.

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Healthcare Is the Only Industry (Part 2)

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Andrew Tsang

By ANDREW TSANG

(Part 1 is here)

The Healthcare Economy’s Smoking Gun

That is the generous side of the accounting, where healthcare produces benefits other industries get to keep. The other side coming in shows that healthcare treats damage other industries get paid to cause. Due to size alone, tobacco use is the best example. A cigarette company books a sale and keeps the profit. The lung disease shows up years later, in a clinic, on an insurer’s claim, in a hospital bed, and the company never sees that bill. Cigarettes are a textbook example of a negative externality, a product whose harm lands on people who were never part of the sale. Smoking generated more than $240 billion in healthcare spending. The bill got big enough that states sued the tobacco companies to claw back the public money spent treating smokers, and a 1998 settlement with forty-six states still has them paying. It took a nationwide legal fight to send even part of smoking’s bill back out of healthcare.

Stacked bars show roughly 612 billion dollars in annual smoking costs in 2018 dollars and a separate 2014 medical-spending breakdown, with taxpayers paying 64.5 percent of the medical bill.
Figure 6. Taxpayers pay most of smoking’s medical bill. Philip Morris sells a pack of smokes, but the taxpayers buy most of the lungs.

Part of what we call healthcare’s cost problem is really the cost of everybody else’s products. The smoker’s cancer treatment still enters the accounts as healthcare spending, where it joins the evidence that healthcare costs too much. Yes – hospitals can overcharge, insurers can overburden, and drugs can be overprescribed. But this patient arrived with a disease a cigarette company was paid to cause! Fixing the billing department won’t undo what put them in the bed.

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Healthcare Is the Only Industry (Part 1)

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Andrew Tsang

By ANDREW TSANG

Healthcare only industry in the room for your first breath – and it bills you for it.

The only industry in the room for your last one – and its claim outlives you.

The only industry that hires more humans every year to take care of everybody else.

The only industry whose best work is the sickness you never knew was coming.

The only industry that’s left holding the smoker’s lungs, the drinker’s liver, and the soda kid’s blood sugar – long after everyone else has cashed out.

The only industry that still needs a person at the bedside when the machines do the rest.

The only industry that has nearly a fifth of everything we make, and is still growing.

Healthcare should keep growing. It is the only industry whose whole product is human capacity—more years, and more ability to use them. It is the only industry that takes in the damage every other industry leaves behind. I don’t care how big tech, retail, autos or manufacturing get. Past a point we stop wanting more of what they sell, and none of them gets handed the bill for anyone else’s harm. As their machines take over more of the work, healthcare is where our money, our people, and our ambition should go. It will grow into whatever we pay it to do.

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Science FTW

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By KIM BELLARD

Science won. At least, that’s one of the takeaways from last week’s midterm elections. If you were one of the 124 million Americans who voted, you probably already know that there was a Blue Wave, with resounding Democrat victories across the country, even in historically red areas.

Georgia not only reelected its Democrat Senator – no surprise — but also elected a Democrat Governor, who will be the first black woman governor in the country, no less. Iowa elected a Democrat Senator and Governor. South Carolina is sending a Democrat to the Senate, and Mississippi – Mississippi!!! – may as well. Even Kansas elected a Democrat Senator, the first such in almost 100 years. Ohio and Texas not only flipped their Senators and Governors but Democrats won all the statewide elections.

Truly strange times.

I’m allowing myself to hope that we’ll finally have a Congress that will fulfill its constitutional duties of acting as a counterbalance to the power of the Presidency, but one thing I’m particularly excited about is the prospect these results will be less about being a Blue wave than what The Washington Post called a “STEM wave.” Among the newcomers to Congress are a record number of physicians and scientists. They’re going to have their hands full.

Much has been written (including by me) about the Trump Administration’s attacks on science. Just last week The New York Times reported on How Trump Is Dismantling America’s Scientific Research Machine. Amid cuts in research grants, resignations and firings of top scientists, departures of leading scientists to other countries, and reductions in Ph.D. students, the Defense Department warned that its “innovation engine is at risk of stalling.” Even people who aren’t defense hawks should realize that spells big trouble for American science in general, and for all of us.

A year ago I wrote about how organizations like 314 Action and Stand Up for Science were leading the resistance to the attacks on science. 314 Action, for example, spent some $23 million on pro-science candidates, doubling its 2024 donations. Shaughnessy Naughton, president of 314 Action, told Alexander Nazaryan of The New York Times that the election results, especially the incoming scientist lawmakers, represent “a real repudiation of what has been two terrible years for science and public health.”

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Amy Bucher, Lirio Health

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Lirio Health is an interesting under-the-radar company, which works with plans, providers and others to try to influence the behavior of their members and patients. Of course, everybody wants to change the behavior of human beings, and it’s been proven over the years to be very hard. Lirio probably has more PhDs per square foot than any other company in this sector. I spoke with one of them, the Chief Behavior Officer, Amy Bucher, and she showed me a wide variety of case studies in which they are using a wording approach and psychographics to nudge people to better behaviors. A great discussion on how and whether we can use psychology to improve health.–Matthew Holt

The transcript (made by Youtube and Claude so blame AI for any mistakes!)

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Stop Testing AI Against Doctors. Test Doctors With AI.

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Manuel Pinilla

By MANUEL PINILLA

Every few months a new study reports that an AI model has outperformed doctors on a set of diagnostic cases. The latest one I’ve read came out in Science in October: Microsoft’s MAI-DxO, tested on 304 complex cases from the New England Journal of Medicine and run as step-by-step simulations, reached the correct diagnosis in about 83% of them. Primary care doctors and general internists, working on their own with reference materials, got 36%. Microsoft says the next step is a study with real patients.

I build clinical AI, so these results matter to my work, but they answer a different question from mine. In the setting we work on, emergency departments and primary care, a doctor will be in the room, and that doctor signs the diagnosis and answers for it. While that is the case, a score of AI against doctors tells me little about whether a tool helps. What I need to know is whether the doctor, with the AI, gets the diagnosis right more often, and what happens when the AI is wrong.

There is a second gap. A published case arrives already written up: the history is complete, the relevant findings are there and the question is clear. A real patient tells the story out of order, leaves out what they don’t think matters and sometimes can’t put into words what they feel. Getting from that to a good differential is a large part of a doctor’s job, and a benchmark mostly skips it. How a tool behaves in a specific setting, with the information that setting really provides, matters as much as what the model knows.

Where the AI shows up in the consultation

I’m an engineer, not a physician, and when I think about these tools my first concern is the interaction more than the model. To use a chatbot during a consultation, a doctor has to stop, summarize the case, write a question, read the answer and judge how far to trust it before turning back to the patient. In a ten-minute primary care visit or a crowded emergency department there is rarely time for that, so in practice the tool tends to be consulted afterwards, to check a diagnosis that is already more or less settled. By then the patient has left, and with them the chance to ask a different question or examine something that was missed.

That is the problem we set out to work on at Medsys AI, a startup in Madrid. Our assistant listens to the consultation and, as it goes on, suggests diagnostic hypotheses, questions worth asking and things to check in the physical examination. The suggestions are updated as new information comes up, and the doctor doesn’t have to type anything. What to do with them is the doctor’s call. The picture I had in mind was an attending standing behind a resident who is unsure, available to doctors at any stage of their career.

A couple of design decisions follow from that. The assistant shows several hypotheses with the reasoning behind each, drawn from more than a thousand clinical guidelines and checked by more than one model before they reach the screen. And the system is built so that we can change the underlying model and rerun our evaluations when a better one appears.

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Doctors As Legislators: Is that a good idea?

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By MIKE MAGEE

As we entered the 2026 Mid-terms, twenty physicians held seats in Congress, four in the Senate and 16 in the House, a record for physicians in the highest offices of the land. (I provide a list below.)

In the wake of Tuesday’s remarkable display of democracy, many have shined a light on several new elected physicians, including Sen. Abdul El-Sayed (D-Mich.), Sen. Annie Andrews (D-S.C.), and notably the election of a woman physician as governor of Ohio, Gov. Amy Acton (D-Ohio).

They will join, come January, two standing physician senators – John Barrasso (R-WY) and Rand Paul (R-KY), and leave behind two other Republican Senators, Bill Cassidy (R-LA) and Roger Marshall (R-KS), both mired in controversy.

Physician leaders. Is this a good thing for our nation, struggling with an inequitable and prohibitively expensive health care system, a frayed and collapsing public health infrastructure, and a reckless vaccine policy launched by a public official whose own family members describe him as, well, “crazy.”

My short answer is “On the whole with notable exceptions, yes.” In search of an answer why, I go back to a speech I gave, now two decades ago, on March 12, 2006 at the AMA President’s Forum in Washington, D.C.

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Midlife Women Are Being Handed GLP-1s. Who Is Asking About Their Bones?

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By HANA KAHLEOVA

Tuesday October 20th was World Osteoporosis Day, and one number deserves more attention than it gets: one in two women over 50 will break a bone because of osteoporosis. Bone loss speeds up as estrogen falls during menopause. Yet in the rush to treat midlife weight gain with the newest drugs, bones rarely come up.

I think of a patient who sat down and named the drug before she said anything else. She was in her early 50s, and she wanted a GLP-1, the weekly injection everyone seems to be on now. She had gained weight around her middle that nothing would touch, and she had not slept through the night in months. Two or three times a night she woke up soaked, kicked off the covers and lay awake. Two of her friends had started the drug that spring. She expected a prescription, not a conversation.

She is a composite of women I have treated, but her request is common. About one in five adults ages 50 to 64 have taken a GLP-1 drug, the highest share of any age group. Many are women looking for relief from the weight gain and broken sleep of the menopause transition.

They have good reason to want something that works. For generations, women’s menopause symptoms were minimized or left for them to endure. A drug that finally does something can feel like overdue respect. In a 15-minute visit, it is also the fastest thing a doctor can offer. That is not an unreasonable choice. The question is whether it should be the first one.

What changed my answer for this patient was a line already in her chart. A bone density scan the year before had shown osteopenia, the thinning that comes before osteoporosis. It had earned a note to keep an eye on it and then dropped out of the conversation, as these findings so often do.

Here is why it mattered. The weight people lose on GLP-1 drugs is not all fat. Across clinical trials of these medications, roughly a quarter of the weight lost was lean mass. In one retrospective study of patients taking semaglutide or tirzepatide, bone density at the hip fell by nearly 3% over about three years. For a woman already losing bone as estrogen declines, rapid weight loss lands on top of an existing deficit. And about half of patients stop semaglutide within a year, often regaining weight, so some pay that cost without keeping the benefit.

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The page says $249 a month. The math says $747.

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By JOHN SAMARAS

Noom Med prices a GLP-1 plan at $249 a month. The last two words on the line matter.

“$129 To get started. $249/mo after the first 4-week supply (billed quarterly).”

That’s Noom’s pricing page on November 3, 2026. If a quarterly charge covers three months at $249, it comes to $747.

In a Buzz Health survey of 256 pharmacists in July, 68 percent reported more cash-pay GLP-1 sales over the past 12 months. Pay cash and your health plan may never see the purchase.

The $149 price that adds up to $298

Hims’ weight-loss page, read the same day, lists the Wegovy pill “From $149/mo.” A small mark leads to a footnote. That price “includes medication only,” and the required membership is “$39 for the first month, auto-renews at $149/month thereafter.”

At the lowest printed price, drug plus membership comes to $298 a month after month one, billed separately.

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Putting the “AI” in “Legal” (and “Health Care”)

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By KIM BELLARD

I once again have to thank The New York Times for introducing me to a new concept. Sarah Kessler wrote about the rise of “legal engineering” – for which, it turns out, one doesn’t have to be either a lawyer or an engineer.

Their role is to help integrate A.I. into the practice of law, whether at law firms or companies. That sure sounds like a prudent, if possibly belated, idea – and one suspects we’re going to see such “engineers” in other fields. I certainly hope that healthcare is one of them, sooner rather than later.

Irene Liu, the executive director of the A.I. initiative at Stanford Law School, explained the job to Ms. Kessler thusly: “If you were to just put it into an equation, it’s law plus technology plus business process.” That Venn diagram gets pretty small very quickly.

Mary O’Carroll, the C.E.O. of LegalEng Consulting Group, also explained the role to Ms. Kessler: “You don’t necessarily need a giant pyramid of lawyers anymore. People who have this kind of skill set don’t have to have a J.D., and they don’t have to be software engineers, but there’s business process re-engineering, or this M.B.A. type skill, that I think is really necessary.”

Ms. Kessler notes that they are sometimes referred to as “knowledge and innovation counsels,” “innovation attorneys,” or “legal applications engineers,” which may illustrate that the role is both new and evolving.

If you’re considering why this role is important, note that the 2026 Legal Industry Report from 8am™ found that 69% of legal professionals report personally using Generative AI (GenAI) tools such as ChatGPT, Gemini, or Claude for work-related purposes, up from 31% a year earlier.

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