The Impact on You of Medicare Advantage Goings-on (2026 Edition), With Betsy Seals

If someone makes more money when the patients or members they serve are worse off, call that profiteering. That's Stacey Richter's working definition heading into this conversation — and it's exactly the lens she applies to Medicare Advantage in 2026, a program she argues touches everyone, not just seniors. When big vertically integrated carriers negotiate their own Medicare Advantage rates and shift the difference to commercial employers through ASO contracts, research has put that markup at 4.7% above what employers would otherwise pay.

In this episode, Stacey Richter speaks with Betsy Seals, co-founder of Rebellis Group and former CEO of its parent company Alerion Advisors, and now a board member and startup advisor in the Medicare Advantage space, about where the program stands heading into 2027 — and what a back-to-basics, non-profiteering playbook actually looks like on the ground.

WHAT YOU'LL LEARN

✅ Why Medicare Advantage is currently in a stabilization and retraction phase — including market exits, benefit pullbacks, and an underwriting loss in the first three quarters of 2025 — and what that means for beneficiaries depending on whether plans cut flashy enrollment perks or outcomes-focused care

✅ How vertically integrated carriers use their full book of business to negotiate lower Medicare Advantage rates for themselves while cost-shifting to self-insured commercial employers through ASO contracts — and why health systems account for roughly 50% of most employers' total health spend

✅ Why a newly published prior authorization data report showed denial overturn rates of 95% or more upon appeal — with only 11% of denials ever appealed — and what the downstream incentives of AI-driven prior authorization actually look like when a clinician's eyes are removed from the file

✅ How Goodhart's Law applies to STARS quality measures: once a measure becomes a target, it ceases to be a good measure — and what distinguishes plans that lift STARS scores through genuine health outcome improvement versus box-checking for bonus payments

✅ Why chronic Special Needs Plans (chronic SNPs) saw nearly 50% growth in beneficiary enrollment and how they represent a legitimate back-to-basics strategy for plans that can identify and serve specific chronic condition populations well

✅ What independent primary care practices need to understand about how their own coding and prior authorization practices flow upstream into MA plan finances — including the perverse incentive that drives some PCPs to route patients to the ER rather than navigate an arduous prior auth process

WHY THIS MATTERS

Medicare Advantage is not just a seniors' issue. It shapes tax dollar stewardship, it shapes what happens to our family members and grandparents, and as Stacey spells out directly, it shapes what commercial employers pay for hospital care. Betsy Seals has spent decades watching executives make short-term decisions — upcoding, AI-driven prior auth denials, STARS box-checking — knowing they won't be around for the long-term consequences. Her message, and Stacey's, is that there are ample ways to make a fair profit in Medicare Advantage without any of that. Go back to basics. Do it right. Because sooner or later, you're gonna get caught with your hand in the cookie jar.

=== LINKS ===
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00:00 Introduction to this episode.

00:43 Past episodes on profiteering: EP481 with Benjamin Schwartz, MD, MBA, and EP495 with Mick Connors, MD.

01:25 How Medicare Advantage is relevant to everyone.

06:15 A preview of today's conversation.

07:49 The "state of the state" of Medicare Advantage plans.

08:49 Video by Eric Bricker, MD, on the financial performance of the U.S. healthcare system.

09:32 Does Medicare Advantage's losses matter to the patients?

10:29 A recap of Betsy's insights so far.

11:19 The underlying strategic through line that needs to be considered.

13:04 The impact of Goodhart's Law.

14:12 What the players that are succeeding right now are doing.

14:22 The first pillar of a back-to-basics strategy: Don't get caught with your hand in the cookie jar.

16:07 EP463 with Betsy Seals.

16:50 Why short-term strategies don't work.

18:26 Stats report on prior authorizations serving the beneficiary.

19:32 EP482 with Preston Alexander.

19:38 Why prior authorization needs change.

21:28 The better strategy to use.

21:43 EP462 with Scott Conard, MD.

23:17 The second pillar of a back-to-basics strategy: Focus on the beneficiaries you actually serve well.

24:37 What it looks like to implement this focus on the beneficiaries you serve well.

25:29 How special needs plans play into this.

27:43 The third pillar of a back-to-basics strategy: Think about how STARS in clinical programs improve health.

30:04 The ethical component to implementing a Medicare Advantage program.

31:04 Betsy's advice for independent practices dealing with prior authorizations.

33:37 STAT article by Bob Herman about the effectiveness of Medicare Advantage lobbying on policy.

34:08 Betsy's final notes for all players impacted by what's currently happening.