ACP Calls for Stronger Oversight of Medicare Advantage to Protect Patients, Payment Accuracy, and Quality

Introduction and Context

Medicare Advantage (MA) has become a central part of the U.S. Medicare program. More than half of Medicare beneficiaries are now enrolled in MA plans, and enrollment is expected to continue rising. In its new position paper, the American College of Physicians (ACP) argues that this growth has outpaced oversight and created ethical, clinical, and fiscal problems that must be addressed if MA is to remain a reliable option for older adults and people with disabilities.

The ACP’s central message is not that Medicare Advantage should disappear. Rather, the organization says the program should better fulfill its original purpose: to offer Medicare beneficiaries coordinated, affordable, high-quality coverage while complementing traditional Medicare. The problem, ACP argues, is that current payment rules, quality reporting systems, and utilization controls have drifted from that goal. Some features of the MA market may encourage overpayment, favorable risk selection, restricted access to care, and confusion for beneficiaries. These concerns are especially important for people with low income, multiple chronic conditions, or limited geographic access to clinicians and postacute services.

This position paper is important because it reflects a growing consensus among clinicians and policymakers that MA’s rapid expansion has not been matched by adequate safeguards. The paper emphasizes three broad priorities: accurate payment, meaningful quality measurement, and protection of patient access. It also calls for greater transparency in plan ownership and financial relationships, including links among insurers, provider entities, and investors.

Why ACP Issued This Position Paper

ACP issued the paper because several persistent weaknesses in MA have become more visible as enrollment has grown:

• Payment vulnerabilities: Risk adjustment methods are intended to pay plans fairly based on the expected health needs of enrollees. ACP notes that these systems can be manipulated through practices that make beneficiaries appear sicker than they are, contributing to overpayment.
• Complex and fragmented quality metrics: MA plans are evaluated using multiple measures, but the system is often too complicated, inconsistent, and difficult for beneficiaries and clinicians to use meaningfully.
• Access barriers: Prior authorization, narrow networks, and delays in postacute or specialty care can impede timely treatment.
• Marketing and choice challenges: Beneficiaries may have trouble comparing plans, understanding benefits, or avoiding misleading marketing practices.
• Transparency gaps: It is often difficult to understand who actually owns or controls a plan, or how financial incentives may shape care delivery.

ACP frames these issues as both a patient safety concern and a matter of stewardship of public funds. If MA is overpaid, or if care is restricted in ways that undermine outcomes, the program fails both beneficiaries and taxpayers.

New Guideline Highlights

The paper is a policy position rather than a clinical guideline, so it does not present diagnostic algorithms or treatment pathways. Instead, it offers expert recommendations for reforming MA oversight. The major themes are:

• Payment should reflect true patient risk: Reduce opportunities for upcoding and other practices that inflate risk scores without improving care.
• Quality measurement should be streamlined: Replace fragmented, burdensome metrics with a smaller set of meaningful, patient-centered indicators.
• Utilization management should not block necessary care: Prior authorization and other controls should be limited, transparent, and evidence-based.
• Beneficiaries need clearer information: Plan choice, marketing, and benefit design should be easier to understand and less prone to manipulation.
• Ownership and financial relationships should be transparent: Regulators and the public should be able to see how MA plans are structured and who profits from them.

For clinicians, the practical takeaway is that patient advocacy in MA increasingly requires attention not only to medical decisions but also to plan design, authorization barriers, and enrollment choices.

Updated Recommendations and Key Changes

ACP’s paper should be understood in the context of a fast-changing MA landscape. Compared with earlier discussions of MA oversight, the paper places stronger emphasis on financial incentives, ownership complexity, and the mismatch between reported quality and actual patient experience.

Issue	Earlier Policy Focus	ACP’s Emphasis in This Paper
Payment	General concern about cost growth	Risk adjustment and overpayment vulnerabilities need tighter controls
Quality	Star ratings and reporting performance	Measures are too fragmented and should be streamlined and strengthened
Access	Network adequacy standards	Prior authorization and postacute access barriers deserve stronger limits
Transparency	Basic plan disclosure	Ownership structures and insurer-provider-investor relationships should be clearer
Equity	General nondiscrimination goals	Need specific protections for low-income, chronically ill, and rural beneficiaries

The biggest conceptual shift is that quality and value cannot be judged only by plan ratings or premiums. ACP argues that access, appropriateness, and accountability must be measured directly.

Topic-by-Topic Recommendations

1) Payment Accuracy and Risk Adjustment

The ACP recommends reforms that make MA payment more closely reflect the actual health status and expected needs of enrollees. Risk adjustment is necessary because plans that enroll sicker patients should receive higher payments. However, when coding intensity is manipulated, plans can be paid more without delivering better care.

ACP’s position is that policymakers should:

• Strengthen auditing and oversight of diagnosis coding practices.
• Reduce incentives for practices that inflate risk scores without clinical justification.
• Ensure that payment systems do not reward selection of healthier enrollees.
• Align plan incentives with genuine care coordination rather than financial gaming.

The clinical implication is important: if plans are rewarded primarily for documentation rather than outcomes, resources may be diverted away from actual care delivery.

2) Quality Measurement

ACP is critical of the current MA quality environment, which includes a large number of metrics that can be hard to interpret and may not reflect what matters most to patients and clinicians. The organization favors a more streamlined system that is easier to understand and more directly connected to outcomes.

ACP supports quality measures that are:

• Clinically meaningful and tied to patient outcomes
• Comparable across plans
• Simple enough for beneficiaries to use when choosing coverage
• Robust against manipulation
• Focused on access, continuity, and equity

The paper suggests that a smaller set of stronger measures may be better than a larger set of weak ones. This is a common theme in health policy: measurement only improves care when it is trusted, interpretable, and linked to action.

3) Prior Authorization and Utilization Management

Prior authorization is one of the most contentious features of MA. While it can prevent unnecessary services, ACP argues that it is often used in ways that delay or deny medically appropriate care. This can be particularly harmful for patients with complex conditions, those needing specialty care, and those requiring postacute services after hospitalization.

ACP’s recommendations emphasize that utilization management should:

• Be limited to services where there is clear evidence of overuse.
• Use transparent criteria that clinicians can understand.
• Offer rapid review and appeals processes.
• Avoid creating administrative burdens that discourage needed care.
• Not disproportionately affect patients with chronic illness or disability.

ACP is especially concerned that prior authorization can function less as a quality safeguard and more as a cost-containment tool. The paper argues that when delayed care leads to worsening illness, the system may increase downstream costs and harm patients.

4) Plan Choice, Marketing, and Beneficiary Protection

Many beneficiaries choose MA during confusing enrollment periods and may be exposed to advertising that does not clearly explain limitations such as network restrictions, out-of-pocket costs, or prior authorization rules. ACP says plan choice should be more transparent and less vulnerable to misleading marketing.

The paper calls for:

• Clearer information about premiums, cost sharing, network restrictions, and authorization requirements.
• Greater oversight of marketing practices and broker incentives.
• Better tools to help beneficiaries compare plans based on their actual health needs.
• Protection against confusion that can lead to inappropriate enrollment or plan switching.

For older adults with cognitive impairment, low health literacy, or limited support, these protections are especially important.

5) Access to Clinicians, Specialty Care, and Postacute Services

ACP emphasizes that MA should not create hidden barriers to care. Narrow networks and administrative hurdles can make it difficult for patients to see the right clinician at the right time. This is particularly concerning for people with complex conditions requiring ongoing care coordination.

ACP’s recommendations support policies that:

• Ensure adequate access to primary care and specialty clinicians.
• Facilitate timely postacute placement and rehabilitation when medically needed.
• Prevent network design from becoming a barrier to continuity of care.
• Address rural access gaps where provider shortages are already severe.

The paper highlights that access problems are not evenly distributed. People with low income, multiple chronic illnesses, and those in rural areas often bear the greatest burden.

6) Transparency, Ownership, and Accountability

A distinctive feature of ACP’s paper is its emphasis on ownership transparency. MA plans may be linked to complex corporate structures involving insurers, provider groups, pharmacies, and private investors. ACP argues that this complexity can obscure conflicts of interest and make public oversight harder.

The organization calls for greater disclosure of:

• Plan ownership structures
• Relationships between insurers and provider entities
• Investor involvement and financial incentives
• How administrative and clinical decisions are influenced by corporate arrangements

This recommendation reflects a broader concern in U.S. health care: when ownership becomes opaque, it is harder to know whether decisions are being made for patient benefit or financial return.

Expert Commentary and Points of Controversy

ACP’s position paper fits into a wider debate about the role of MA in Medicare. Supporters of MA argue that private plans can offer coordinated care, vision and dental benefits, and lower premiums. Critics counter that these advantages may be offset by narrow networks, authorization barriers, and inflated costs to the Medicare program.

ACP does not reject MA outright. Instead, it takes a reformist stance: MA should be preserved only if it can deliver on its promises without undermining fairness or quality. The paper implicitly challenges the assumption that higher enrollment alone is evidence of success.

Key controversies include:

• Risk adjustment: How to pay plans fairly without rewarding excessive coding.
• Star ratings: Whether current quality metrics truly capture patient experience and clinical value.
• Prior authorization: How to balance cost control with timely access.
• Network adequacy: Whether narrow networks reduce costs at the expense of continuity and choice.
• Transparency: How much disclosure is enough for regulators and beneficiaries to understand plan incentives.

From an expert perspective, the most important issue may be alignment: a well-designed MA program should reward prevention, coordination, and high-value care, not documentation games or blocked services.

Practical Implications for Clinicians and Health Systems

For clinicians, the paper is a reminder that health policy directly shapes patient care. Several practical implications stand out:

• Ask about plan limitations: Patients may not realize that specialist referrals, imaging, procedures, or rehab services could require authorization.
• Document medical necessity clearly: Strong clinical documentation may reduce avoidable denials and delays.
• Help patients compare plans: Especially during open enrollment, patients benefit from guidance about networks and cost-sharing.
• Watch for equity impacts: Patients with disabilities, multiple chronic illnesses, or limited transportation are most likely to be harmed by access barriers.
• Advocate locally and nationally: Clinicians can contribute data and experience to policy discussions about MA oversight.

Health systems may need to invest more in authorization support, plan navigation, and care coordination. At the policy level, ACP’s paper supports a shift from volume and complexity toward simplicity, transparency, and accountability.

Illustrative Patient Vignette

Consider Linda, a 72-year-old woman with diabetes, heart failure, and arthritis. She chooses a Medicare Advantage plan after seeing a low premium and hearing promises of extra benefits. Months later, she learns that her preferred cardiologist is out of network and that a recommended rehabilitation stay after hospitalization requires prior authorization. She spends hours on the phone trying to understand denials and coverage rules.

Linda’s experience illustrates the exact concerns ACP raises: a plan may look attractive on paper yet still create real barriers to care. Under ACP’s recommendations, she would be better protected by clearer plan information, more transparent network rules, faster authorization decisions, and quality measures that reflect whether she actually gets timely, appropriate treatment.

Conclusion

ACP’s position paper is a forceful call to realign Medicare Advantage with the needs of patients and the goals of Medicare. Its message is straightforward: if MA is to continue expanding, it must become more accurate in payment, more transparent in structure, more accountable in quality, and less obstructive in access to care.

The paper does not call for a return to traditional Medicare alone. Rather, it argues that MA should be judged on whether it truly improves care, protects beneficiaries, and uses public dollars responsibly. That standard is high—but appropriate for a program serving tens of millions of older adults and people with disabilities.

If policymakers adopt ACP’s recommendations, MA could better support coordinated, patient-centered care. If not, the gap between the program’s promise and the lived experience of beneficiaries may continue to widen.

References

1. Hallowell AL, Outland BE, Algase LF, Watkins C, Medical Practice and Quality Committee of the American College of Physicians. Protecting the Integrity and Quality of the Medicare Advantage Program: A Position Paper From the American College of Physicians. Ann Intern Med. 2026 May 19. PMID: 42150171.
2. Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Medicare Payment Policy. Washington, DC: MedPAC. Accessed via official MedPAC publications.
3. Centers for Medicare & Medicaid Services. Medicare Advantage and Part D Contract and Enrollment Data; Medicare Advantage Star Ratings and related program guidance. Official CMS resources.
4. Office of Inspector General, U.S. Department of Health and Human Services. Reports on Medicare Advantage risk adjustment, audits, and program integrity. Official OIG publications.
5. JAMA and related health policy literature on Medicare Advantage prior authorization, access, and risk adjustment practices. Peer-reviewed analyses in major medical journals.