Marco's Morning Report — Monday, August 24, 2026

Morning, Marco. Nights are behind you — here's the short version before you sleep. Today's biggest item is a deadline that lands today and quietly reshapes how your pharmacy buys Part B drugs. Cyclospora finally got a real update. And the Mets lost another one in the ninth, which is becoming a genre.

A · Top Stories

Deadline today · Aug 24

340B rebate plans are due to HRSA today — and approval makes participation mandatory for your hospital

Under HRSA's revised 340B Rebate Model Pilot, drug manufacturers who want in must submit their rebate plans to HRSA by today, August 24. HRSA says approvals go out by September 24, effective January 1, 2027. The pilot covers drugs selected under Medicare Drug Price Negotiation for 2026 and 2027 price-applicability years.

The part that matters: participation is voluntary for manufacturers but mandatory for covered entities. If a manufacturer's plan is approved, your hospital stops buying that drug at the discounted 340B price up front and instead pays full freight, then claims a rebate after submitting claims data. That's a working-capital change and a data-reporting burden landing on pharmacy, not on you — but it shows up as formulary friction on drugs you order. The AHA objected; an earlier version of this pilot was halted in court in 2025 after the hospital industry sued.

Worth doing: one message to inpatient pharmacy — which MFP-selected drugs do we stock, and are we hearing that any manufacturer filed a plan today? You'll know by September 24 either way.

Update · CDC posted Aug 20

Cyclospora: the lettuce outbreak grew again — 10,930 cases, 454 hospitalizations, onsets still running into mid-August

CDC's August 20 investigation update moved the Taylor Farms de Mexico iceberg lettuce outbreak from 9,481 to 10,930 confirmed cases across 17 states, with at least 454 hospitalizations and the same two Michigan deaths. Illness onsets now extend through August 11 — a month after the July 17 recall. Nationally, the surveillance page (Aug 18) shows 15,716 lab-confirmed domestic cases since May 1, 828 hospitalizations, 2 deaths, 47 states plus DC and Puerto Rico — against 1,180 cases in the same window last year.

Two things changed since you last saw this. First, the national count (15,716) is now running well ahead of the named outbreak (10,930) — most cases this summer are not attributable to the recall, and CDC says six more clusters are under investigation with no source identified. Second, those late onsets mean a patient admitted this week with three weeks of watery diarrhea, anorexia and weight loss is still in the plausible window. Cyclospora doesn't grow on stool culture and isn't on every multiplex GI panel — it needs a specific request. Treatment is TMP-SMX; elderly patients are the ones who land on your service for dehydration and AKI.

Worth doing: ask the lab whether your GI multiplex panel actually includes Cyclospora cayetanensis — several common panels don't. If not, it's a separate order and worth knowing before 3 a.m.

Aug 23 · Medscape

Same four HFrEF drugs, same trials, three different sets of marching orders

A deep dive published August 23 lays out an uncomfortable fact: no randomized trial has ever compared simultaneous versus sequential initiation of the four pillars of HFrEF therapy. Everyone agrees on the destination — ARNI/ACEi-ARB, beta-blocker, MRA, SGLT2 inhibitor, uptitrated to maximally tolerated doses. They diverge on the on-ramp. NICE puts all four up as first-line together; AHA/ACC/HFSA and ESC sequence it, with an ACE inhibitor preferred first and a switch to ARNI if symptoms persist.

No new data here — but it's the exact gap you live in. The newly diagnosed HFrEF patient on your service leaves with either one drug or four depending on who's covering, and the discharge summary is where that gets decided by default. Guideline ambiguity becomes practice variation at exactly your handoff point.

Talking point: worth ten minutes at the next group meeting — does your service have a written expectation for how many pillars get started before discharge, and who owns uptitration afterward? Absent a house standard, this is pure attending-to-attending variance.

B · The Debate

Should Medicare cut what it pays 340B hospitals for Part B drugs by 37%?

CMS's CY2027 outpatient proposed rule would drop reimbursement for 340B drugs from ASP+6% to ASP−33.4%, citing a hospital acquisition-cost survey CMS ran in early 2026. Comments close August 31 — a week from today — and today's HRSA rebate-plan deadline is the same fight in a different venue.

The case FOR the cut

Brian Blase & the Paragon Health Institute, 340B: End the Spread

The program has become a $100 billion purchasing operation whose defining feature is the spread between what hospitals pay for a drug and what they bill for it — a margin that grows with the price of the drug and has nothing to do with what a patient can afford. Paragon's argument is that this "buy low, bill high" structure rewards acquiring physician practices and opening child sites in better-insured neighborhoods, because each new site extends the discount to a richer payer mix. The money flows disproportionately to large, wealthy systems rather than the struggling hospitals the program was written for, and none of it is required to reach patients as lower prices. CMS isn't guessing at the number: ASP−33.4% comes from hospitals' own reported acquisition costs. Paying a hospital 40 points above what it actually paid isn't charity care — it's an untargeted subsidy the Medicare beneficiary co-pays 20% of.

The case AGAINST the cut

Ashley Thompson, AHA · analysis by Scott Hulver et al., KFF

Thompson calls the 33.4% reduction a shocking cut arriving at the worst possible moment, with hospitals absorbing more uncompensated care as coverage losses mount. The redistribution is the sharper objection. Because the rule is budget-neutral, CMS moves $4.85 billion out of 340B drugs and back through an 8.44% bump to all non-drug outpatient services — including to hospitals that never qualified for 340B. KFF's modeling of CMS's own estimates puts safety-net hospitals at −5.8% of outpatient revenue and major teaching hospitals at −4.3%, while for-profit hospitals — ineligible for 340B by definition — gain 7.4%. Whatever one thinks of the spread, a policy that moves money from the thinnest margins to the fattest is a strange way to fix targeting. CMS is also accelerating a clawback for a 2018 policy a unanimous Supreme Court found unlawful.

Where it might land: comments close August 31; a final rule typically lands in early November, with an effective date of January 1, 2027 — and litigation is close to certain either way.

C · On My Radar

Mets 1, White Sox 2 — walk-off, again. Second walk-off loss of the weekend Sunday at Rate Field; New York dropped two of three. The line worth saving: Nolan McLean threw six shutout innings, one hit, four walks, six strikeouts and got nothing for it. Chicago's Grant Taylor blew the save and was credited with the win. Box score

Iran: the Hormuz squeeze gets legislated. Iran's parliament advanced plans for service fees on Strait of Hormuz transits on Aug 23, while Tehran warned neighbors that joining the US "economic war" invites tit-for-tat treatment. Shipping through the strait is already sharply down. Al Jazeera, Aug 23

Coyote vs. Acme opens Friday at 94%. The Wile E. Coyote-sues-Acme movie Warner Bros. tried to shelve debuted at a perfect 100% on Rotten Tomatoes before settling at 94%; Looper called it the funniest film of the year so far. Wide release August 28. Forbes

Cape Coral tropics check: quiet. As of Aug 23 the NHC was watching a low ~400 miles southeast of Bermuda (50% formation odds, tracking well northeast of the island) and a wave coming off Africa. Season to date: two named storms, zero hurricanes. Nothing pointed at Florida. NHC

Golf tech: no new developments in 48 hours — day 23. The only movement was a retailer pricing refresh on Aug 22 (SkyTrak+, Uneekor Eye Mini, Bushnell Launch Pro, Garmin G82 repriced) — not a product launch. Still in the pipeline with no ship date: Shot Scope LM1, FlightScope Mevo Gen2, ProTee VX + Golf Core.

Cuba: no new mainstream reporting in 48 hours. Nothing from Reuters, AP, BBC, Al Jazeera, CNN or the major dailies since Saturday's sanctions story. Background unchanged: sixth nationwide blackout of the year in early August, rolling outages over 20 hours a day, Díaz-Canel putting available fuel at ~40% of need.

D · Trends to Watch

340B is being fought in three venues at once, on three different clocks. HRSA's rebate-plan deadline is today, CMS's payment-cut comment window closes Aug 31, and the courts have already vacated one version of the rebate pilot. None of these three tracks is bound by the others' outcome, which means a hospital can win one and lose two. Watch the dates, not the headlines.

Foodborne surveillance is outrunning its own outbreak labels. Cyclospora's national count (15,716) now exceeds the named lettuce outbreak (10,930) by nearly 5,000 cases, with six unattributed clusters open. The recall closed a door; the season kept going. Expect the "is this outbreak over?" question to increasingly have no clean answer — and note CDC's own caveat that Cyclospora can't be whole-genome sequenced, only genotyped, so attribution will stay fuzzy.

A wave of cardiology practice change lands next weekend. ESC Congress 2026 runs Aug 28–31 in Munich with a record 59 trials across 12 Hot Line sessions. Three to watch from an inpatient seat: LIBREXIA ACS (factor XIa inhibition in 14,000+ post-MI patients — the anticoagulation-without-bleeding question), CARDIO-TTRansform (eplontersen in 1,400+ ATTR-CM patients, a direct challenge to tafamidis), and PRESC1SE-MI (the ESC 0/1-hour troponin algorithm versus standard pathways, which is really a rule-out and throughput question). ESC Hot Lines

E · Ideas & Opportunities

Two-line email to pharmacy today. "Which Medicare-negotiated (MFP) drugs do we stock, and did any manufacturer file a 340B rebate plan by today's HRSA deadline?" You'll have your answer well before the Sept 24 approval date, and it tells you which drugs may get formulary friction on Jan 1.

One question to add to the summer diarrhea H&P. Bagged or shredded lettuce in the past three weeks — and if the story fits (prolonged watery diarrhea, profound anorexia, weight loss, relapsing course), say Cyclospora out loud to the lab rather than assuming the GI panel caught it. Onsets are still being logged into mid-August.

Post-nights watch: Coyote vs. Acme, Friday, 94% and reportedly very funny. Low cognitive load, which is the point after a stretch of nights.

H · Background / Already Covered

Items older than 48 hours, or already reported without new developments

Measles — 2,777 confirmed as of Aug 20 (94% outbreak-associated, 47 jurisdictions, 16 cases among international visitors). Reported here Aug 23; no update since. CDC
COVID — Rt growing or likely growing in 47 states as of Aug 19, while overall acute respiratory illness activity stays "very low." Reported Aug 23. CDC Rt estimates
Puerto Rico water emergency — 48-hour rotating shutoffs since Aug 7 across San Juan and six nearby municipalities (180,000+ customers; 500,000+ people island-wide), driven by San Juan's driest month in 120+ years plus the June Superaqueduct rupture. FEMA water trailers deployed for an initial 30 days. Reported Aug 23; no new development.
Cuba sanctions — Treasury/State designation of nine state-owned mining, metals and construction firms plus ICAP leadership. Reported Aug 23.
Alfalfa sprouts outbreak (E. coli O26:H11 + Salmonella, Everything Sprouts LLC of Minneapolis) — 55 cases, 15 states, 4 hospitalizations per CDC's Aug 21 posting. Reported Aug 23.
Jalapeño Salmonella Javiana — holding at 431 cases / 57 hospitalizations / 32 states; peppers from Sinaloa via Coast Citrus Distributors. Exposure window closed in July.
Antibiotics and the gut microbiome, 8 years later — the Nature Medicine analysis of 14,979 Swedish adults (published March 2026) found a single course of clindamycin, fluoroquinolones, flucloxacillin, tetracyclines, TMP-SMX, cephalosporins or macrolides associated with reduced species diversity up to eight years out; penicillin V barely registered. Medscape resurfaced it Aug 21 — old study, good stewardship argument. Medscape
NYC Legionnaires' outbreaks — the Upper East Side cluster (Carnegie Hill/Yorkville, cooling towers, 7 deaths) was declared resolved by the city in late July; the separate Central Harlem cluster reached 99 cases and 4 deaths, traced to 12 cooling towers on 10 buildings. Both closed out before this window.
CY2027 OPPS comment deadline Aug 31; CY2027 PFS comment deadline Sept 14. Standing calendar items.