AMP is WAC -- 2/6/26

Ain't No Sunshine When You're Gone

No, I do not think that a groundhog is a meteorologist. But, one year I am determined to make it to see Punxsutawney Phil. I expect it to be silly and cold and over quickly. I will likely have to go solo because my family thinks getting a bus from a Wal-mart parking lot in the middle of the night to see a rodent predict anything is dumb. But the heart wants what the heart wants.

Prior Auth is a PITA. On Monday, KFF published polling showing prior authorization is the single biggest burden people cite in getting health care beyond cost. One-third of insured adults (34%) picked prior authorization over scheduling, billing confusion, or finding in-network providers. Among insured adults with chronic conditions requiring ongoing treatment, it was even higher (39%).

Prior authorization is the operational expression of payer skepticism. The system uses it to control utilization and manage spend. That creates predictable friction for neurology, rare disease, and any therapy where timing matters or clinical nuance does not fit into a template.

For manufacturers, this isn’t a communications problem -- it’s an incentive problem. Plans use prior authorization because it works as a gate, and because alternatives are increasingly easy to present, including in the provider office as the script is being written. That makes policy momentum around “fixing prior auth” both real and complicated: reforms tend to target speed, standardization, and transparency, not the underlying rationing logic.

The business implication is that evidence generation, coverage criteria engagement, and patient support infrastructure become inseparable. Patient groups also get a cleaner hook here, because the public is telling policymakers the burden is visible and personal.

Well Yeah. On Saturday, the New England Journal of Medicine published a Perspective on what happens when health insurance becomes fully corporatized and financially engineered. The policy debate has been trapped in a false binary: insurers as necessary administrators versus insurers as villains. This piece argues the more useful frame is incentives—specifically, what happens when corporate structure rewards margin management and financial performance above coverage.

The mechanism is straightforward: administrative complexity becomes a profit center. Prior authorization doesn’t just control utilization; it generates delay that shows up as medical cost savings. Specialty pharmacy steering captures dispensing margins. Accumulator programs protect plan revenue while shifting costs to patients. None of this requires denying coverage outright. It just makes access slow, expensive, or exhausting enough that utilization drops.

If policymakers decide corporatization is the problem, they could tackle it through stricter medical loss ratios or scrutiny of vertically integrated business practices.

For manufacturers launching complex therapies, this pushes toward earlier and more explicit evidence strategy, not just for efficacy, but for coverage criteria and outcomes guarantees. The default will increasingly be utilization controls that protect enterprise economics. Patient groups also get a cleaner story: access barriers aren’t just paperwork, they’re margin protection.

More than the Sum of Its Parts. On Monday, FAIR Health published a white paper using commercial claims to map prevalence and cost patterns across 44 chronic conditions in 2024. The top-line finding is straightforward: the majority of commercially insured patients had at least one chronic condition (57.5%), and multi-morbidity is common.

But what caught my eye -- average allowed amounts rose with each additional condition, from $1,590 for patients with none to $21,730 for patients with ten or more. The report also puts specificity on what “common” looks like, with hyperlipidemia the most prevalent (21.2%).

For pharma teams, this is why utilization management will not ease up in commercial. When employers and plans look at claims, they see compounding chronic burden, not individual illnesses. That makes “cost offsets” harder to prove inside one drug class.

Jump to Conclusions (Mat.) On Tuesday, The New England Journal of Medicine ran a Perspective making the case that Medicare drug-price negotiation is already a win. The argument is basically: big discounts, smart targeting, no chaos.

Hahahahahaha.

First, the early “success” is partly a function of which drugs were picked. These are older, high-spend products with long utilization histories and fewer surprises left in the market.

Second, the piece talks about savings like they drop straight into patients’ laps. But this is Medicare Part D. Everything runs through plans. The first cycle not producing visible access drama doesn’t mean the machinery is neutral. We are 30 days in. Talk to pharmacies on how they are doing. And where are all the stories on how much patients are saving? Right.

The real story here is not the discount number. It’s that negotiation is starting to look normal. Once something feels normal, it potentially expands. It gets tweaked. The guardrails get tested. The exception list gets shorter. Policymakers stop asking whether the program should exist and start asking how much more it can do. And I’m not sure we’re there yet.

Charting Hearts, Adding Emojis. Last month, JAMA Network Open published a research letter on emoji use in the electronic health records.. The dataset was enormous: 218.1 million notes from 1.6 million patients at Michigan Medicine (2020 through September 2025). Emoji use was rare, but it rose sharply in 2025, and the dominant setting was clinician-to-patient communication, especially portal messages and telephone encounters.

Here’s the problem -- interpretation varies by age and context, and the study flags the obvious risk: miscommunication in clinical documentation and patient-directed instructions. And then there’s the quiet operational detail that is the tell: their Epic portal restricted patients from using emojis, so the emoji “voice” was mostly clinicians talking to patients, not a two-way cultural artifact.

Beyond just being a little huh, the story is a reminder that the patient experience is increasingly mediated through digital micro-interactions.

Whole in Three: PBM Updates

On Tuesday, Congress tucked pharmacy benefit manager (PBM) reforms into the must-pass appropriations package that was signed into law. (It only took a decade.) In the same week, the Federal Trade Commission (FTC) locked in a settlement with Express Scripts, and the Department of Labor proposed an Employee Retirement Income Security Act (ERISA) rule aimed at PBM compensation disclosure for employer plans. Three different levers, aimed at the same basic complaint: PBM economics are causing harm.

Quick reminder for those of you that don’t deal with this on the regular: PBMs negotiate rebates and discounts with manufacturers, decide which drugs get preferred formulary placement for health plans, and set pharmacy reimbursement. Over time, those functions became tightly bundled. Critics argue that when PBM revenue scales with drug price or rebate size, it can reward high list prices and rebate-heavy contracting, even if net prices fall. And because rebate contracts, affiliate relationships, and spread pricing are difficult for plan sponsors to audit, it has been hard to answer a basic question: who is getting paid, by whom, and for what value.

The new law is meaningful but limited. Mechanically, Congress does a few specific things in Medicare Part D. It bars PBMs and their affiliates from earning compensation tied to a drug’s price, pushing the model toward flat, bona fide service fees. It requires 100% pass-through of manufacturer rebates and related price concessions to the plan sponsor, with new enforcement authority for the Centers for Medicare and Medicaid Services (CMS). And it directs CMS to define and police “reasonable and relevant” pharmacy contract terms, including reimbursement and dispensing fees, while making PBMs financially accountable when violations trace back to delegated functions.

This narrows how much of the system can run on rebate opacity, but it does not make rebates disappear overnight, and it does not guarantee patients see savings at the pharmacy counter. Most of these standards do not fully apply until plan years beginning in 2028, which leaves plenty of room for the market to adapt and for old behaviors to resurface in cleaner packaging. Which most of you know, has already been happening.

The FTC settlement with Express Scripts is directionally important but narrow. It targets a specific set of behaviors where the agency believes the harm was clearest: preferring higher-cost drugs over identical lower-cost options, calculating patient cost sharing off list price rather than post-discount price, and reimbursing pharmacies in ways that obscure acquisition cost and fees. Right instinct. The open question is whether this scales across the market or a one-off compliance exercise.

And then there is regulation. The Department of Labor’s proposed ERISA rule pulls PBM compensation into the employer’s fiduciary line of sight. Framing PBM revenue as a reasonableness question under ERISA raises the stakes for plan sponsors and consultants. But disclosure alone does not resolve the harder issues. Timing, cash flow, and confidentiality still matter. So do benefit design choices that determine whether any of these changes show up at the point of sale or stay buried in back-end economics.

Read together, this is not disruption. It is constraint. Congress is setting boundaries around how PBMs can get paid in Medicare. The FTC is testing real-time behavioral enforcement. ERISA rules are nudging employers to look harder at what they are buying. PBMs are not going away. Formularies and utilization management are not going away. The incremental win here is that opacity is no longer the default. The next set of fights will be about whether savings move forward to patients, whether pharmacies are forced to finance the system through cash-flow risk, and whether employers actually change benefit design rather than renewing the same contracts with better disclosures.