With the recent passage of a major government funding bill, the conversation in Washington has shifted from the brink of a shutdown to the substance of the legislation itself. Buried within the appropriations are significant healthcare reforms that promise to reshape key parts of the industry. To unpack these changes, we’re joined by James Maitland, a leading expert on U.S. healthcare policy and the integration of technology in medicine. We’ll explore the seismic shifts facing pharmacy benefit managers (PBMs) and discuss how long-term extensions for telehealth and hospital-at-home programs will redefine patient care delivery for years to come.
The new law requires more transparency from PBMs and delinks their pay from drug list prices in Medicare Part D. How will this practically change their business models, and what tangible effects might patients and independent pharmacies see in the coming months?
This is a fundamental rewiring of the PBM incentive structure within Medicare, and it’s something many have been fighting for. For years, the business model has been a bit of a black box, with profits often tied to negotiating large rebates off of high list prices—a system that perversely encourages higher initial drug costs. By delinking their compensation from list prices, the law forces them to find value elsewhere, perhaps through flat, transparent administrative fees. For patients, the immediate change might not be dramatic, but over time, it’s designed to stop the bizarre phenomenon where their copay is sometimes higher than the cash price of a drug. For independent pharmacies, this is a breath of fresh air; they’ve long felt crushed by PBMs that steer patients toward their own mail-order or retail chains. Greater transparency means we can finally see the flow of money and challenge these potentially anti-competitive practices more effectively.
A prominent PBM lobby suggested that with these reforms, the focus should now shift entirely to drug manufacturers. To what extent do you agree with this assessment, and what other PBM practices, if any, still warrant regulatory scrutiny?
I heard that statement from Brendan Buck at PCMA, calling PBM reform a “boogeyman” that’s been “exorcised.” It’s a masterful piece of political messaging, but it’s a vast oversimplification. While it’s true that manufacturers play a huge role in setting high list prices, declaring the PBM issue “done” is premature. This reform primarily targets Medicare Part D. We still need to scrutinize PBM practices in the commercial insurance market, where many of the same opaque rebate systems and formulary games exist. Furthermore, the practice of “patient steering”—where PBMs aggressively push patients toward their own affiliated pharmacies—remains a major concern. It limits patient choice and puts incredible pressure on independent pharmacies. So, no, this isn’t done. It’s a significant first step, but we shouldn’t take our foot off the gas.
With the Acute Hospital Care at Home program now extended through 2030, how might this long-term certainty change how providers plan and invest in their programs?
The difference between a short-term patch and this extension through 2030 is the difference between surviving and thriving. Previously, with short, one- or two-year extensions, health systems were hesitant to make major capital investments. You can’t build a robust program on a foundation of uncertainty. Now, with a clear runway to 2030, hospital leaders can confidently invest in the necessary infrastructure: the technology, the specialized staffing, the supply chain logistics. They can build dedicated care teams and create sophisticated remote monitoring platforms. In terms of metrics, they’ll be laser-focused on proving value. Key performance indicators will include lower readmission rates compared to traditional inpatient care, high patient satisfaction scores, and, of course, reduced cost per admission. They’ll also be tracking clinical outcomes for specific conditions to build a definitive body of evidence that, as Krista Drobac from Moving Health Home noted, will be crucial in convincing lawmakers to make the program permanent.
Medicare’s telehealth flexibilities are now preserved through 2027, offering more stability than previous short-term extensions. Beyond simply continuing services, how does this five-year window enable healthcare systems to innovate and integrate virtual care more deeply into their long-term patient management strategies?
This five-year extension is a game-changer. It moves telehealth from a pandemic-era emergency response to a core component of strategic planning. Instead of just using it for urgent care or simple follow-ups, health systems can now design and implement sophisticated, hybrid care models. Imagine managing a chronic condition like diabetes or heart failure not with episodic office visits, but with continuous virtual check-ins, remote monitoring of vital signs, and proactive telehealth consultations when data shows a potential problem. This stability allows for investment in better platforms, training for clinicians to become “webside” manner experts, and the deep integration of telehealth data into electronic health records. It’s about shifting from reactive to proactive care, and a five-year window is the minimum time needed to truly build, scale, and prove the efficacy of those new models.
What is your forecast for hospital-at-home programs?
My forecast is one of strategic, sustained growth. This extension through 2030 provides the critical stability needed for health systems to move beyond pilot projects and truly integrate hospital-at-home into their standard care offerings. We’re going to see an acceleration of investment in the technology and logistics required to deliver acute care safely in the home. I anticipate that as more data is collected, demonstrating improved patient outcomes, higher satisfaction, and lower costs, the model will become an indispensable part of our healthcare system. The biggest challenge will be navigating state-level licensure and scope-of-practice laws, but the federal momentum is now undeniable. By the end of this decade, receiving inpatient-level care in the comfort of one’s own home will no longer be a novelty but a mainstream option for eligible patients across the country.
