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Annotated Bibliography
Chris LaFontsee
Liberty University
BUSI 650: Operations Management
Professor F. Nolan
April 7, 2025
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Annotated Bibliography:
Biniek, J. F., Freed, M., & Neuman, T. (2023). Half of all eligible Medicare beneficiaries are now
enrolled in private Medicare Advantage plans. Kaiser Family Foundation.
https://www.kff.org/policy-watch/half-of-all-eligible-medicare-beneficiaries-are-now-
enrolled-in-private-medicare-advantage-plans/
The authors of this article aim to describe the growing role of Medicare Advantage plans.
It highlights the enrollment trends, benefits, and touches on current challenges, such as
needing better data to evaluate performance, especially regarding value and equity for
diverse populations. Based upon released data from 2023, the authors found that
Medicare Advantage now covers over half of eligible Medicare beneficiaries which
amounted to 30.19 million individuals. Enrollment increased by 19% since 2007 and was
noted to be driven by extra benefits and lower costs of these plans. Operations
management focuses on optimizing processes and by leveraging the article’s insights,
benchmarking would refine the operational processes, enhance efficiency, and ensure
equitable, high-quality care delivery.
Aaron, D. G., Cohen, I. G., & Adashi, E. Y. (2024). Medicare Advantage Under Fire: Public
criticism and implications - journal of general internal medicine. SpringerLink.
https://link.springer.com/article/10.1007/s11606-024-08876-7
In this article the authors critique the methods of Medicare Advantage plans and examine
whether the profit-driven model aligns with public interest. The author’s discussion stems
from a 2023 Senate hearing, in which lawmakers had accused the plan of overbilling
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patients while simultaneously denying necessary care via the restrictive prior
authorization process. It was discovered that these privatized plans on average cost 22%
more than original Medicare without the proportional benefits and in 2022 alone resulted
in overbilling costs exceeding $88 billion. The issues identified within this article
highlight the dire operational challenges hindering its efficiency, cost control, and
delivery and the need for a service process overhaul.
Jacobson, G., Cicchiello, A., Sutton, J., & Shah, A. (2021). Medicare Advantage vs. traditional
Medicare: How do beneficiaries’ characteristics and experiences differ? The
Commonwealth Fund.
https://www.commonwealthfund.org/publications/issue-briefs/2021/oct/medicare-
advantage-vs-traditional-medicare-beneficiaries-differ
In this publishing, the authors examine the demographic differences between
beneficiaries of both Medicare Advantage plans and original Medicare. By analyzing data
from the 2018 Medicare Current Beneficiary Survey and the Commonwealth Fund 2021
International Health Policy Survey of Older Adults, the findings show that factors such as
race, income and age did not differ among beneficiaries of either plan. The study further
indicated similarities between beneficiaries experiencing difficulties surrounding
appointment wait times and the difficulty out-of-pocket expenses has led to obtaining
care. Medicare Advantage plans are expected to further increase in enrollment over the
next decade and operational innovation will be critical in maintaining enrollees,
facilitating care and managing expenses.
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Meyers, D., Trivedi, A., Wilson, I., & Rahman, M. (2021). Higher Medicare Advantage Star
Ratings Are Associated With Improvements In Patient Outcomes. Health Affairs.
https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.00845
In this study, the authors examines whether Medicare Advantage star ratings reflect true
care quality by leveraging contract consolidation (2012–2016) as a natural experiment. It
studies whether moving enrollees to higher-rated contracts improves access to quality
hospitals/nursing homes, reduces disenrollment, and enhances care outcomes. It was
found that by consolidation contracts, star ratings were raised by 0.7 stars versus 0.1 for
non-consolidated contracts. While it was found that higher ratings did improve access,
they did not impact overall quality measures. The misaligned ratings of Medicare
Advantage plans signal inefficiencies in quality monitoring. Benchmarking high-rated
contracts can enhance care coordination, reduce access barriers, and ensure equitable
outcomes for all enrollees.
Stephenson, J. (2022). Federal investigators find Medicare Advantage plans too often deny,
delay needed care. Jama Health Forum. https://jamanetwork.com/journals/jama-health-
forum/fullarticle/2792414
In this article, the author sourced a study conducted by the Office of Inspector General
investigating whether Medicare Advantage plans inappropriately denied medically
necessary treatment and payments to physicians. The goal was to assess whether the
Medicare Advantage payment model incentivized cost-cutting over patient care and to
recommend improvements to ensure beneficiaries received Medicare covered services. It
was found that 13% of prior authorization denials involved medically necessary care
meeting Medicare coverage rules and 18% of payment denials to clinicians were
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improper, mostly from human errors in manual reviews. Even so, only 3% of care denials
and 6% of payment denials were reversed after the appeals process. These findings
highlight deficiencies in which the operational management role of information
technology could benefit by automating processes, optimizing compliance and
minimizing delays.
Van De Water, P. N. (2025). Growth in Medicare Advantage Raises Concerns. Center on Budget
and Policy Priorities. https://www.cbpp.org/research/health/growth-in-medicare-
advantage-raises-concerns
The author of this article examines overpayments in the Medicare Advantage system,
which was found to be an estimated 22% above original Medicare costs and the potential
implications for access, equity, and program sustainability. These plans receive a fixed
payment per beneficiary enrolled regardless of services rendered and the author argues
the plans financial incentive to restrict care and the need for added consumer protection.
A study conducted by MedPac found these inflated payments stemmed from coding
intensity, favorable selection and quality bonuses. These overpayments result in an
increase in Medicare part B premiums which affect all enrollees, and the taxpayer share
of Part B. Operational challenges continue to persist in care delivery and resource
allocation. Medicare Advantage would benefit from focusing on their capacity for
planning services to ensure operations align with beneficiary needs over profit.
Lipschutz, D. (2024). Special report: The Real Impact of Medicare Advantage for Beneficiaries
and Medicare funding. Center for Medicare Advocacy.
https://medicareadvocacy.org/report-real-impact-of-medicare-advantage/
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While this article critiques Medicare Advantage overpayments, it provides support in
advocating for the strengthening of original Medicare. It argues that Medicare Advantage
plans fail in improving health outcomes and affordability for its beneficiaries. By
redirecting funds to strengthen original Medicare, beneficiaries could gain advanced
coverage and equity resulting in better care. Several studies are noted which provide
quality of healthcare measures between both plans that yield similar outcomes but finds
beneficiaries in rural locations experience financial burdens within Medicare Advantage
plans. The inefficiencies of Medicare Advantage highlight operational flaws in payment
systems and care delivery. Brainstorming methods in which original Medicare could
lower overhead to enhance efficiency, equity, and quality could attract beneficiary
enrollment and save taxpayer dollars.
Isaacson, G., Jamieson, D., Pedersen-Green, S., Pender, E., & Repasky, C. (2024). The future of
Medicare Advantage. McKinsey & Company.
https://www.mckinsey.com/industries/healthcare/our-insights/the-future-of-medicare-
advantage
In this article, the authors explore the evolving Medicare Advantage brokerage landscape
amid market shifts, focusing on brokers’ strategies to adapt to rising member churn, payer
profitability pressures, and potential regulatory changes. It aims to guide brokers in
rethinking engagement and partnerships to remain competitive and valuable to
beneficiaries and payers. More than ever, beneficiaries are shopping for the latest benefits
in financial, health and wellness from their plans. The brokerage landscape is caught
between the urgency to retain beneficiary enrollment and the payers demand of growth to
retain profit margins. The brokerage challenges reflect operational inefficiencies in
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distribution and retention. Benchmarking high-retention field brokers can enhance
efficiency, reduce churn costs, and ensure sustainable service delivery amid market
pressures.
Hnath, J., McWilliams, J. M., & Chernew, M. (2024). Medicare Advantage: National carriers
expand market share while regional carriers without affiliation decline, 2012–23 | Health
Affairs Journal. Health Affairs.
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2024.00577
In this study, the author analyzes the evolving competition in Medicare Advantage
assessing national and local market perceptions from 2012–2023. The goal is to assess
whether increasing Medicare Advantage penetration enhances local competition and
informs policy debates on payment reforms. Nationally, the top five major carriers
increased their market share from 46% in 2012 to 66% by 2023, while regional carriers
dropped from 25% to 6% as many became acquisitions of these national carriers. The
study shows that national carriers expanded via acquisitions and new markets, while local
gains plateaued. Medicare Advantage market dynamics highlight operational challenges
in competition and efficiency. Venturing into the economies of scale and scope may
enhance local market relevance by focusing on cost competitiveness. Benchmarking
against less concentrated markets can improve resource allocation, benefit design, and
enrollee value, aligning operations with competitive policy goals.
Xu, L., Welch, W. P., Sheingold, S., De Lew, N., & Sommers, B. (2023). Medicare switching:
Patterns of enrollment growth in Medicare Advantage, 2006–22 . Health Affairs.
https://www.healthaffairs.org/doi/10.1377/hlthaff.2023.00224
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In this study, the authors investigate the sources of Medicare Advantage enrollment
growth from 2006 to 2022, focusing on the switching patterns between Medicare
Advantage and original Medicare. It was found that switching from original Medicare to
Medicare Advantage had tripled between 2006 to 2022, while the alternate switching
declined. The discovery found that ethnic and rural populations, as well as disabled
beneficiaries switched more in favor of Medicare Advantage plans. It was also found that
those considered healthy favored Medicare Advantage plans. Most of these enrollments
to Medicare Advantage plans occur during the open enrollment period and suggest that
heavy marketing has fueled growth. To remain competitive, Medicare Advantage must
continue to optimize marketing during open enrollment, tailor plans for diverse
demographics, and streamline switching processes. By utilizing a supply chain strategy to
broaden provider access can improve network design, enhance efficiency in resource
allocation and beneficiary satisfaction.
McCormack, G., & Trish, E. (2024). Growing divergence between Medicare Advantage plan bids
and payments to plans. Oxford Academic.
https://academic.oup.com/healthaffairsscholar/article/2/8/qxae093/7727328
The authors of this study examine Medicare Advantage payments, bids, and benchmarks
from 2010 to 2023, analyzing why federal payments to Medicare Advantage plans exceed
original Medicare costs despite lower plan bids. It was discovered that Medicare
Advantage payments in 2023 were 6% higher per enrollee than original Medicare. These
plans leverage county-level benchmarks to receive the maximum amount the federal
government will pay for an enrollee. It is policy, not just market factors, that drive high
Medicare Advantage payments. This topic continues to be vastly debated, calling for
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policy reform and evaluation of the payment system. Medicare Advantage plans should
leverage supply chain strategies to address cost inefficiencies and align incentives.
Lipschutz, D. (2024). Medicare Advantage Industry Blames 2025 Service Cut-Backs on Policy
Changes That Hold Them More Accountable. Center for Medicare Advocacy.
https://medicareadvocacy.org/medicare-advantage-2025-service-cut-backs/
In this article, the author discusses the released summary of the 2025 Medicare
Advantage and Part D changes as open enrollment is on the horizon. The Centers for
Medicaid and Medicare Service projects the 2025 Medicare Advantage premiums,
benefits, and enrollment growth will remain stable. While CMS projects stability, an
article by ABC News alleges over one million beneficiaries will face coverage changes as
insurers cut costs and pull out of Medicare Advantage markets. CMS also introduced
policy shifts with the aim for increased protections for Medicare Advantage beneficiaries
and adjustments to payment rates and star ratings which were met with insurer scrutiny.
While Medicare Advantages processes remain under fire, it provides space for innovative
processes revisions that will optimize cost-effectiveness and enhance transparency to
align with CMS goals.
Sadagopan, D. (2024). Understanding the signals amid the noise: What’s really happening with
medicare advantage? HFMA. https://www.hfma.org/payment-reimbursement-and-
managed-care/medicare-payment-and-reimbursement/finding-the-signal-amid-the-noise-
whats-really-happening-with-medicare-advantage/
In this article, the author investigates contrasting surveys in which one declares providers
are mass exiting Medicare Advantage plans due to administrative burdens, while the
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other reflects a deepened commitment to Medicare Advantage as enrollment continues to
grow. The article finds that 19% of providers have dropped Medicare Advantage plans in
2023 and an additional 60% are considering exit by 2025 due to prior authorization
denials and slow payments. In contrast Medicare Advantage enrollment hit 54% in 2024,
driven by low premiums and enhanced benefits. These simultaneous trends highlight
operational inefficiencies in payment and process management. Service processes need to
be streamlined to ease the administrative burdens and enhance provider retention amid
market shifts.
Albanese, J. (2024). Improving Medicare through Medicare advantage. Paragon Health Institute.
https://paragoninstitute.org/medicare/improving-medicare-through-medicare-advantage/
In this article, the author evaluates Medicare Advantage versus original Medicare,
highlighting Medicare fee-for-service inefficiencies and Medicare Advantages strengths
in competition and choice. Medicare Advantage plans continue to outperform the fee-for-
service model in choice, outcomes, efficiency and now cover over half of Medicare’s 60
million beneficiaries. The author recommends several policy reforms that aim to save
$250 billion over 10 years by capping benchmarks, refining risk adjustment, and easing
restrictions. If there is no reform, the current design raises cost concerns despite lower
bids, due to high benchmarks and bonuses. Medicare Advantage can optimize resource
allocation by aligning bids with Medicare’s fee-for-service costs and enhancing benefit
flexibility. Benchmarking the fee-for-service inefficiencies can drive process
improvements, boosting efficiency and beneficiary satisfaction amid regulatory shifts.
Wright, B. (2024). Structural Inequities in Medicare Advantage—A Growing Cause for Concern.
JamaNetwork. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2821394
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In this article, the author examines structural inequities in Medicare Advantage plan
offerings that have faced significant criticism in recent years. Growing evidence indicates
Medicare Advantage plans continue to engage in cherry-picking beneficiaries for cost
saving and profit driven measures. A cross study using 2023 CMS data found evidence of
lower-rated plans in socially vulnerable areas, limiting access to high-quality coverage.
This trend worsens with increasing vulnerability. Racial and ethnic minorities are less
likely to access high-rated plans, driven by plan availability rather than individual choice,
exacerbating disparities as enrollment grows among these groups. The findings highlight
inefficiencies in plan distribution. An analysis of the service process design could ensure
equitable access, and align incentives with quality improvements, addressing disparities
through targeted operational strategies.
