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Policy Shakeups, Governance Wakeups
December 2, 2025
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Welcome to TrustWorks On Call, here with your healthcare business and strategy 411 for the week. If you enjoy our work, please consider forwarding it along to a friend and encouraging them to subscribe!
To celebrate our return from Thanksgiving break, we’re featuring another tool in the TrustWorks Collective toolkit: our Annual Board Assessment Survey. You can learn more about how it works in our Dialing In section, where we interview its creator and TrustWorks Collective Senior Advisor, Laura Sebastyn. And our Beyond the Whiteboard section takes a look at the booming GLP-1 market. But first, the news: |
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Behind the Headlines
Unpacking the forces driving healthcare’s biggest stories.
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1. GOP struggling to unite around healthcare plan.
- Last week, President Trump was expected to announce a new policy framework that would have extended the Affordable Care Act (ACA) enhanced subsidies for two years with limitations, including new income caps and minimum premium payments, only to abandon the plan amid pushback from Congressional Republicans.
- The Senate is committed to voting next week on a healthcare proposal, but elected Republicans are reportedly divided between a centrist camp supporting a limited subsidy extension, which could resemble the President’s pulled framework, and a more conservative wing that prefers to continue rolling back the ACA while redirecting some funding to Health Savings Accounts (HSAs).
TrustWorks Take: Rep. Marjorie Taylor Greene’s surprise retirement announcement has become an unexpected canary in the coal mine for broader Republican dysfunction on healthcare. After criticizing her party for allowing the ACA subsidies to expire without an alternative plan, Rep. Greene announced she will be retiring on January 5, 2026. Reportedly, she’s one of many House Republicans who feel disrespected by the White House and party leadership. Healthcare policy is at the center of these disagreements, as the White House has failed to craft a unifying plan that satisfies both moderate Republicans, worried that premium spikes will hurt their reelection campaigns, and party hardliners, who view ACA subsidy extensions as a nonstarter.
Because extending the ACA subsidies is so popular, with even half of Republican voters in favor, elected Republicans have put themselves between a rock and a hard place. Attempting to thread the needle (and fulfill President Trump's call to send healthcare subsidies “directly to the people”), Senate Republicans are exploring ways to redirect funds toward HSA-style accounts, but HSAs can’t be used to pay for premiums, which have become the focal point for rising healthcare costs. Any measure that can clear both chambers at this point would likely be too little, too late to address voters’ sticker shock on healthcare premiums. With retirements shrinking the Republicans’ House majority, their room for error on crafting such a measure has never been smaller. |
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2. FDA connects COVID shots to child deaths ahead of vaccine meeting.
- A Food and Drug Administration (FDA) internal memo, written by the director of the FDA’s vaccine division Dr. Vinay Prasad, claimed without evidence that “at least 10 children have died after and because of receiving COVID-19 vaccination,” and outlined planned revisions to vaccine approval processes.
- Dr. Prasad wrote the memo, leaked last Friday, in advance of the Advisory Committee on Immunization Practices (ACIP) meeting this week, in which the recently reconstituted committee will be discussing and potentially amending the childhood vaccine schedule.
TrustWorks Take: The FDA has yet to produce any supporting evidence for its claim that the COVID vaccine directly caused the deaths of at least ten children. The agency has only stated that these deaths were recorded in the Vaccine Adverse Event Reporting System (VAERS) and ignored or covered up by the Biden administration. A chorus of experts have expressed skepticism over these causal claims, which are difficult to prove from self-reported VAERS cases and need to face peer review by a medical journal. However, for an administration that wants to promote vaccine skepticism, this memo could provide sufficient cover for any upcoming changes to the childhood vaccine schedule.
Under Health Secretary Robert F. Kennedy Jr.’s leadership, the Trump administration keeps finding new ways to undermine vaccine confidence. Once-trusted regulatory bodies like ACIP have become politicized, and official government sources are now promoting debunked theories around vaccines and autism. Dissenters, such as former Centers for Disease Control and Prevention (CDC) Director Dr. Susan Monarez, are pushed out and replaced by vaccine critics, like the CDC's new deputy director. These moves, which are damaging in their own right, have also laid the groundwork for ACIP to upend the childhood vaccine schedule in its meeting later this week. This would trigger a cascade of changes to state and local vaccine policies impacting requirements for schools, childcare centers, and pediatric practice standards. |
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3. OPPS final rule eliminates Inpatient-Only List.
- Last month, the Centers for Medicare and Medicaid Services (CMS) published its 2026 Hospital Outpatient Prospective Services Payment System (OPPS) and Ambulatory Surgery Center (ASC) final rule, headlined by a 2.6 percent Medicare pay bump, up slightly from the proposed rule.
- The final rule confirmed that Medicare will be phasing out over three years the Inpatient-Only (IPO) List, which currently bars 1,731 billing codes from being performed in outpatient settings.
- In another push toward site neutrality, hospital-owned outpatient facilities will be paid to administer medications at the same rate as physician offices, which CMS projects will save $290M next year.
TrustWorks Take: In the final year of the first Trump administration, CMS promulgated a rule to phase out the Medicare IPO List, only for the Biden administration to undo those changes and restore the IPO List in 2022. So, it’s no surprise that the second Trump administration picked up where it left off by reissuing this policy. Trump's CMS has made it clear that it does not recognize a patient-safety distinction between the inpatient and outpatient procedures, and it will be far more permissive toward procedures performed at ASCs. This has huge implications for hospitals because, as evidenced by knee and hip replacements, procedures tend to migrate quickly to their lowest-cost allowable settings. And once Medicare covers something on an outpatient basis, commercial payers are quick to follow.
Many health systems are still holding onto inpatient procedural revenue as an important cross subsidy, but the march toward site neutrality feels inevitable. The transition can be slowed down or sped up, but it’s going in only one direction. The only remaining strategic question is how quickly systems can prepare for it. For this reason, we created our Site-Neutral Payment Calculator, which allows providers to quantify the financial implications of site-neutral reform across their own procedures and care settings. |
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Beyond the Whiteboard
Visualizing key trends from the healthcare industry
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Imagining a Ceiling for GLP-1 Spending
Starting with the FDA’s approval of Ozempic to treat Type 2 Diabetes in 2017, the hype around and demand for GLP-1 drugs has skyrocketed, driven by the breadth of conditions they can treat and the impressive results they return, especially for weight management. In addition to Type 2 Diabetes, GLP-1 drugs have now received FDA approval to treat obesity, cardiovascular disease, chronic kidney disease, serious liver disease, and sleep apnea, and they’ve shown promise with other conditions like substance use disorder and osteoarthritis. (There’s also been hope that GLP-1s could treat Alzheimer’s, but Novo Nordisk just announced unsuccessful early trial results on that front.) List-price sales of GLP-1s increased from $14B in 2018 to $72B in 2023, with sales growth accelerating over that period as obesity-indicated GLP-1s started hitting the market.
In light of such rapid growth, it’s worth exploring how much our healthcare system could spend on GLP-1s at their peak. As of May 2025, about 12 percent of US adults had ever taken a GLP-1 drug, and another 14 percent were interested in taking them. That works out to about one in four adults, or 66M people, who can be considered in the market for GLP-1s. Prices vary widely based on insurance, but if each of these 66M adults paid the TrumpRx cash-pay price of $350 per month for their supply, that would amount to a collective $277B spent on GLP-1s per year. For comparison, US net pharmaceutical spending reached $487B in 2024. Of course, a variety of practical limitations would prevent a single class of drugs from ever comprising over half of all drug spend. However, Eli Lilly’s Mounjaro and Zepbound have been found to be cost-effective at TrumpRx pricing (but not current prices), suggesting that, at a societal level, the averted cases of obesity, diabetes, and cardiovascular disease would generate significant returns on investment.
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Dialing In
Sharing insights from our work with clients
Three Questions with Laura Sebastyn, MSM
Principal and Senior Advisor, TrustWorks Collective
1. What inspired you to create our Annual Board Assessment Survey?
Anytime we take on work with a physician group or health system, I’m always paying close attention to their governance. Organizations often engage us to address visible challenges that, once you peel back the layers, stem from a governance structure that isn’t fully aligned with the group’s current needs. Governance gaps can show up in many ways: interpersonal tensions, limited engagement, process inefficiencies, or simply having too many voices involved in every decision. It’s helpful when we can see these patterns, but real progress requires the board to see them too. That’s what sparked the idea for the Board Assessment Survey. We designed a self-assessment tool that provides both quantitative and qualitative insight into how the board views its own performance. It’s become an incredibly effective tool for constructive dialogue and meaningful improvement.
2. What makes this Board Assessment Survey different from others?
Most board assessment tools fall into one of two traps: they are either overly complicated and buried in too much theory and jargon, or so generic that they fail to reveal anything meaningful let alone actionable. We built our survey very intentionally to avoid both pitfalls. It's streamlined, but not simplistic. Every question is designed to generate insights boards can act on, and the data it creates allows them to rank and tailor their focus as appropriate.
Once we determine who should participate—typically the full board of directors, but also often committees, advisory boards, and physician leadership—we gather emails and administer the survey electronically. The survey questions are grouped by theme, covering areas such as meeting effectiveness, clarity of roles, conflict resolution, and decision-making discipline. After we gather the responses, we analyze the results, which include input from individual confidential discussions, and present a synthesis back to the board, highlighting strengths, misalignments, and practical recommendations. Much of the survey’s impact comes from bringing issues to the surface in a structured, neutral way. Once the board has that shared understanding, finding the right solutions becomes a lot easier.
3. What kinds of lessons do boards learn from taking this survey?
The survey works by holding up a mirror to the board, so there’s as many lessons to learn as there are challenges in physician group and health system governance. One big theme, though, is recognizing when the governance structure hasn’t evolved alongside an organization’s growth. Many organizations create their governance structure early on and rarely revisit it, even as their size, strategic direction, and organizational complexity change. For example, I once worked with a multi-specialty group that guaranteed every specialty a seat on the board. That worked just fine in the beginning, but as new specialties were added, the board grew large enough that decision-making became cumbersome. The assessment revealed that most people on the board recognized the need to streamline its structure, and because this insight came from the members themselves, it served as a foundation for making that change. This is exactly why we advocate for annual assessments, to ensure governance remains adaptive, responsive, and aligned with where the organization is headed.
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Thank you for tuning into this week’s TrustWorks On Call. We’ll see you next Tuesday with another round of TrustWorks Takes. With your help in sharing TrustWorks On Call (subscribe here), we’re living up to the Collective in TrustWorks Collective. And if you ever need help thinking through a healthcare problem, don’t hesitate to reach out to us.
Best Regards,
Anthony D’Eredita and TrustWorks Collective
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