by Kimberly Marselas

By Mario Aguilar

While Medicare Advantage offers many advantages, it also has drawbacks that should be considered

Hospitals are discouraging infection testing to avoid Medicare penalties, a practice clinicians say jeopardizes patient safety and skews public reporting. As Brown University’s Andrew Ryan put it, “Basically, the measures are just really, really bad … this is honestly the worst” pay-for-performance program, underscoring deep flaws in how infection penalties are designed and enforced.

UnitedHealth’s Medicare Advantage program has come under scrutiny for allegedly exploiting diagnostic “upcoding” practices that drive billions in excess federal payments. Brown University researchers have launched Medicoding.org, a public tool that tracks how diagnostic coding in Medicare Advantage inflates payments to insurers. Health economist David Meyers explains that while some coding reflects real patient needs, much of the increase stems from insurers “gaming the system,” making beneficiaries appear sicker than they are

Traditional Medicare plan holders have typically not had to wait for prior authorization before receiving medical treatment. CMS recently announced a new program to test prior authorization requirements for certain services in six states to root out fraud, waste and abuse. Jeffrey Marr highlights what’s needed to set up a well-functioning prior authorization system.

Another news article speaks on a study published in Health Affairs that reveals a sharp rise in urban hospitals reclassifying themselves as "rural" under Medicare rules, allowing them to access financial benefits intended for rural health providers. Researchers warn that this loophole could redirect billions in federal funds away from genuinely rural hospitals and urge policymakers to take corrective action.

Hundreds of large, urban hospitals have taken advantage of a 2016 policy change to classify themselves as both urban and rural, allowing them to access financial benefits meant for rural hospitals. Researchers warn that this loophole could divert billions in taxpayer funds away from actual rural communities and into already well-funded urban hospitals unless policymakers intervene.

This piece, authored by Hayden Rooke-Ley, argues that while the Trump administration’s One Big Beautiful Bill Act threatens to gut Medicaid funding by nearly $1 trillion over a decade, states still have powerful tools to protect coverage and even strengthen their healthcare systems. By capping inflated prices in the private insurance market and redirecting those savings to Medicaid—where every dollar is federally matched—states can blunt the impact of federal cuts, support vulnerable providers, and reduce systemic inequities.

This article talks about two commentaries by Hayden Rooke-Ley that argue that neoliberal, profit-driven models of U.S. healthcare—particularly privatized Medicare and value-based payment—have failed patients by prioritizing corporate interests over access and quality of care. He calls for a shift to a publicly governed, single-payer system that removes financial conflicts of interest and restores decision-making to non-commercial entities and caregivers.

A bipartisan group of lawmakers has introduced legislation to stop Medicare Advantage insurers from collecting billions in federal payments for veterans who primarily receive care through the VA. Sparked by a Wall Street Journal investigation—supported by data from Brown University researchers—the bill aims to close a loophole that enabled an estimated $44 billion in excess payments from 2018 to 2021.

The article discusses how home health care workers in Rhode Island are fighting for better wages and working conditions through unionization, but their efforts are at risk due to proposed federal Medicaid cuts. David J. Meyers, a health economist at Brown University, warns that such cuts could have a “massive, qualitative impact on people’s lives” and ultimately increase health care spending as unmet needs at home lead to more hospitalizations and emergency visits.

The article discusses the looming expiration of pandemic-era Medicare telehealth expansions and the ongoing policy debate over their extension, including new research by Ateev Mehrotra and Jared Perkins who suggest that lowering reimbursement rates for telehealth could make its permanent expansion more financially and politically viable.

Is Medicare Advantage improving healthcare efficiency or creating higher costs that favor insurers? Hayden Rooke-Ley explores its rapid expansion, questions about cost and care quality, and the challenges of implementing effective regulations.

An increasing number of Medicare Advantage patients, especially those in their final year of life, are switching to traditional Medicare, leading to a significant cost shift from private insurers to taxpayers.

This article explores a study led by Brown University researchers on the billions in potentially redundant payments Medicare Advantage plans receive for veterans primarily cared for by the VA, despite industry claims, like those from UnitedHealthcare, that these payments reflect actual costs.

This article examines lawsuits from Medicare Advantage insurers, who claim minor customer service issues threaten millions in bonuses, while experts like Brown University's David Meyers argue that these cases reveal deeper flaws in a rating system that overstates plan quality without accurately reflecting patient care.

A decade ago, CMS tried to rein in Medicare Advantage overbilling, only to withdraw amid industry pressure, now fueling a $2 billion fraud case against UnitedHealth. Newly released court documents expose the struggle to protect taxpayer dollars while navigating powerful industry pushback.

This article highlights a study published in JAMA Network Open that explores the impact of hospital-SNF (skilled nursing facility) integration on participation in alternative payment models (APMs), particularly focusing on the Bundled Payments for Care Improvement Advanced (BPCI-A) program. The findings reveal that while integration influences APM participation, the effects are complex, pointing to broader implications for healthcare systems.

The Medicare Physician Fee Schedule is a cornerstone of U.S. healthcare policy, directly influencing how services are priced and covered. This Health Affairs blog delves into a brief analysis of the CY25 Physician Fee Schedule Proposed Changes and what impact it could have moving forward.

Dr. Ashish K. Jha, dean of the Brown University School of Public Health, addressed the House Committee on Ways and Means on why the U.S. is seeing a decline in private medical practices and what we can do about it.

Under the CMS 2025 Medicare Advantage Advance Notice, CAHPR researchers emphasize the expected revenue increases and minor changes in risk adjustment practices; highlighting the impactful changes on the horizon and the critical reforms that still await attention.

Are fully integrated Medicare Advantage plans for dual-eligible individuals delivering on their promise of improved care coordination and patient experience? Find out by reading this article featuring Dr. David Meyers.

Dr. Ryan et al., talk about the reforming episode-based payment models to achieve savings and quality in Medicare

Researchers at Brown University School of Public Health in Providence found that many Medicare Advantage beneficiaries disenroll from their plans within five years of enrolling.

Andrew Ryan and David Meyers penned this op-ed article in the Boston Globe.

Professors Andy Ryan and David Meyers study the cost and value of Medicare plans across the country, including controversial and rapidly expanding Medicare Advantage (MA) plans. Learn the upsides, downsides and incentives that guide these MA plans, and how reforming them could save billions of dollars every year.

How do we value the care of vulnerable Americans?

David Meyers, a health services researcher at Brown University, and his colleagues have been tracking differences between original Medicare and Medicare Advantage for years, using data from millions of people.

Explore Medicare Advantage and how it compares to Traditional Medicare.

An Interview with Health Services, Policy and Practice Professor Andrew Ryan