RISE National 2025 kicked off Wednesday with a dynamic panel that explored key changes and priorities under the new administration and potential long-term impacts on Medicare Advantage programs. Here’s what we learned.
The industry was optimistic in November after the election. Republicans appeared to like Medicare Advantage and plans felt relieved that their jobs were safe and secure.
But moderator Melissa Smith, founder of Newton Smith Group, said some have expressed concern in the last few weeks of policy changes, executive orders, cuts made by the new Department of Government Efficiency, the confirmation of Robert F. Kennedy Jr. as secretary of the Department of Health and Human Services, and Friday’s upcoming confirmation hearing of Dr. Mehmet Oz as administrator of the Centers for Medicare & Medicaid Services (CMS).
“We’ve had a hard time to catch our breath and figure out where we are,” Smith said, asking the panel for their thoughts on the state of Medicare Advantage policy amid all this change.
Medicare Advantage has undergone incredible policy, operational, and payment pressure over the last four years, said Andrew Schwab, founder & CEO, Platform Government Strategies.
Since the election, the pressure on Medicare Advantage has lessened but it’s not eliminated, he said. Health policy think tanks have discussed eliminating quality bonus payments as well as health risk assessments and chart reviews. There is also discussion about making Medicare Advantage the default option of Medicare. Republicans are interested in reforming Medicare Advantage and making it work better.
His recommendation to attendees: Keep an open mind and be fluid as possible.
“We are in a new space,” Schwab said. “It is what is dynamic and wonderful about the United States of America, with a government that turns over and new things happens. You move away from the traditional way of doing things. Companies able to navigate that will thrive.”
Sean Creighton, managing director, Avalere, who spent nearly 15 years at CMS, leading the policy development and implementation of major public programs, agreed. He said there is “a lot of noise” in the system but the big issues that have made headlines in recent years including consolidation, vertical integration, reform of the PBM market, prior authorization, and utilization management are still the important issues.
Part of the reason Medicare Advantage is under the microscope is because of the success of the industry. “As you get bigger, there will be more scrutiny. That isn’t going to change,” Creighton said.
Ana Handshuh, principal, CAT5 Strategies, who co-moderated the panel discussion with Smith, said that she’s noticed as a result of the scrutiny that some health plans feel revenue pressure and tighten up their utilization management and prior authorization practices and it can have an opposite effect because they reprocess claims and appeal and the end result is an increased cost of care because of the delay in care.
Schwab agreed and noted that it’s important to remember that Medicare Advantage is a public-private partnership. Elected officials will feel the pressure from constituents about denied claims and they are in the “what to do about it phase.” Schwab believes that Medicare Advantage reforms will be on the table during the second half of this year into 2026. “One thing I keep hearing is the desire of smaller regional Medicare Advantage to have some quality footing with the big girls and boys,” he said.
Although panelists couldn’t predict what exactly would be included in the 2026 Medicare Advantage Final Rule, Creighton believes that the Trump administration may only do what is absolutely necessary under the Biden administration’s proposed rule and focus on purely technical updates.
Schwab told attendees to expect the unexpected. Perhaps there will be technical changes or there could be major differences between the proposed and final rule. Companies must be able to pivot, he said.
To be fluid, Handshuh suggests organizations create a framework for fast decision-making, develop different scenarios and playbooks to handle each one, and identify who needs to be in the room to make quick decisions when there is no playbook developed for an actual scenario.
“One takeaway is to build an agile, forward-thinking organization,” she said. “Whatever that means in your organization, if you have been putting it off, now is the time.”