Medicare Advantage belt-tightening — what does it mean for physicians?

Private health insurance, traditional Medicare and Medicare Advantage (MA) can be difficult for patients and physicians to understand — but insurance agents don’t want it that way, said the leader of a business that assists agents in their work.

The Brokerage Inc. is a Texas-based, family-owned field marketing organization that started in 1976. Staff support business operations of independent insurance agents while monitoring trends in health insurance and other forms of insurance.

MA has become a major part of the health insurance landscape of the United States. The program has gained notoriety for prior authorization policies that physicians and patients argue are bad for health care. MA plans directly affect patient choices that in turn shape clinical and financial decisions that doctors make. In Washington, D.C., leaders in the White House, the Department of Health and Human Services, and Medicare all have said it’s past time for prior authorization reforms.

The Brokerage Inc. Chief Operating Officer Cristin Hopkin Bishop spoke with Medical Economics about issues around MA and what those might mean for the near future of American health care.

This transcript has been edited for length and clarity.

Medical Economics: Our physicians might think of insurance as being the go-between, between themselves and their patients, and frankly, sometimes a barrier. Can you talk about the function of health insurance? How do you see yourselves working with both physicians and patients?

Cristin Hopkin Bishop: We really try to go into the local markets and be that advocate, be that resource for both the patient but also for the provider. Our agents are known to go in and have a relationship with that provider, with the doctor, with hospital systems or provider groups. There are a lot of clinics that our agents sit in at the local level, and they ask questions. They are that resource that the doctor or the staff there can help guide the patient to work with them. They navigate different carriers. We do work with all carriers that allow us to be in a brokerage shop, and so it just gives options to the patient, and it gives them the option to be able to navigate whatever's going on with them personally that the doctor might know about, and that insurance provider might not help them with. With prior authorization, or if one way doesn't work, then we're able to pivot, and we're able to find, hey, you have this chronic condition going on, maybe this carrier has a good chronic plan that could help you out. So in just different ways like that, we're really at the local level, trying to help patients navigate the insurance world.

Medical Economics: Medicare Advantage has grown in recent years. What are some current trends? What are you seeing in Medicare Advantage utilization and costs? What should doctors be looking for here in 2026, and even looking out into 2027 and beyond?

Cristin Hopkin Bishop: From our perspective, the clearest trend with regard to Medicare Advantage is that it does continue to grow. But you're exactly right — the cost picture underneath, everything is getting tighter. There are well over 50% of the market of Medicare beneficiaries who are on a Medicare Advantage plan now, so it's becoming a dominant form of coverage for Medicare beneficiaries. But you're right that on the utilization side, you're seeing plans face pressure because of higher utilization with maybe outpatient care or inpatient services, or even the high cost of specialty drugs. When you're thinking about the market and what's happening, I think for so many years since Medicare Advantage came out, it was such an expansive phase, right? It was growing, it was taking off. And now I think we're coming into a time where carriers have to be a little bit more focused on a cost management phase. So they've got to be aware of what we're spending our money on, and I think that's what we're kind of seeing from a trends perspective. You know, utilization is up, cost is up, enrollment is still up as well, but the margin is down. And so I think plans are having to reassess, especially going into their 2027 bids this year. What do their benefits look like? What's their doctor network? What doctors and physicians are they going to be working with? And then paying attention to the utilization rise and cost increases that we're seeing, and what those look like.

Medical Economics: If there is a rollback, say, in some of the supplemental benefits, and perhaps an increase in utilization leads to that decrease in margins, do you think there's going to be a retraction in Medicare Advantage in the coming years?

Cristin Hopkin Bishop: I think that's the big question everybody's asking. Supplemental benefits — they are the biggest differentiator from a Medigap or med [supplement] plan or being on traditional Medicare. It would be hard for MA plans to just completely cut those benefits because they are what attract clients to MA.

I think there might be some cuts, I think there might be some changes in how plans look. We'll see. I think it just comes back to being more targeted in how they fund what they're funding, and trying to maintain long-term growth. Time will tell on how much they cut — if that's the right word, I don't like to use that word. I think that they're just going to reinvest in other places. And I think the health plans have a lot of levers they can pull to make sure that dental, vision, hearing, over-the-counter card benefits, fitness benefits, meal benefits — those are very important to these beneficiaries. And I really think that they're going to try to just find other levers to pull to make that happen.

Medical Economics: Can you talk about the current regulatory environment around Medicare Advantage?

Cristin Hopkin Bishop: It’s happening, it's very active. I think Congress is trying to dig into the details of what is happening. We work closely with CMS — I was actually just in Washington, D.C. — and we are really trying to play a critical role in shaping MA and what it's going to look like. And CMS, they are looking at annual payment notices, they're looking at star ratings and quality, how we enroll clients, and they're putting audit programs in place. Obviously, they're looking at prior authorization and putting work in on how we can access that. And then on the drug side, Part D through the Inflation Reduction Act, that's a big piece of what has happened over the last few years that has put pressure on health plans. So, from a regulatory side, they're very active and very involved. But I think that as long as we are making it known that we want to work together, and we want to try to find a place where our beneficiaries are rewarded from this, and we can all work in the same vertical, it’s a good thing.

Medical Economics: There is frustration among physicians and their patients dealing with prior authorizations. Can you talk about both the regulatory side and the technology side? How do you see that evolving? The administration has made it known that they want prior authorizations to be streamlined and smoothed out. What are you seeing so far?

Cristin Hopkin Bishop: I think they're listening. The carriers are working with provider groups to try to find ways to make it more streamlined, to make sure that they are understanding what needs to happen. And using AI and using tools that have come into focus recently is going to help them — looking at what we can connect through, like, an [application programming interface] connection, or how payers can really implement certain operational changes. And they are listening, whether it's through workflows, transparency, maybe just making faster decisions. From a regulatory point, they [the administration] said, hey, this has to happen, and carriers and payers are listening, and they are doing what they've got to do to make sure that the beneficiary is taken care of.