The coming year is expected to be an even more “intense and disruptive” period for Medicare Advantage, as rising utilization, pharmacy costs and shifting market dynamics put new pressure on plans, while also creating opportunities for provider-sponsored models.
Becker’s connected with Don Antonucci, CEO of Providence Health Plan, to discuss how the organization is thinking about benefits, market strategy and deeper provider integration for its 490,000 members, including 80,000 MA enrollees.
Where is MA utilization pressure coming from?
“We’re seeing the same national trends, where there’s a significant uptick in utilization of benefits and an increase in pharmacy benefit spend as well. GLP-1s are definitely part of the story. Because we are a provider-sponsored plan, we noted a lot of these trends sooner and saw things coming, probably because of the relative size of our book of business compared to some of the larger ones.
We’re really making sure that we’re investing in core benefits, whether medical or pharmacy. Anything “nice to have” in terms of supplemental benefits, we’ve taken a hard look at those. We’re also looking at where we are geographically. Our goal is to be even more tightly aligned with key providers — obviously, Providence would be in that bucket — and in areas where we don’t have the type of integration needed for success, we’ll be evaluating those marketplaces.”
Growth perspective
“Deeper integration with the health system. 2026 is a year of doubling down on our footprint with Providence in particular, more so than anything else. We’ll continue to focus on star ratings — that’s a year-round focus for us — and making sure we’re solid on accurate risk adjustment. That’s really important in this space. We continue to work with Providence and our partners on those things, as well as on the experience and onboarding of Medicare Advantage members.”
Opportunities ahead
“There’s a real opportunity for provider-sponsored plans to stand out. For Medicare Advantage to work, it’s a combination of having the right benefits, the right experience, the right integration, accurate risk coding, and a focus on stars. Provider-sponsored or regional plans that can bring that together, and that can create a deeper connection with the doctors and nurses providing care, are going to have an advantage as long as they’re doing the stars and the risk adjustment at the same level. It is definitely not getting easier. We’re seeing that from a national perspective, but it’s going to take doubling down on the things we know we need to do to be successful in the program as it’s outlined today.
We’re also paying attention to sentiment, because another piece of this is how providers view Medicare Advantage. We saw it last year, and it will be interesting to see this year with some providers deciding not to accept MA based on their financial situations. With Providence, we’re committed to areas where we have substantial presence with our delivery system.
Fasten your seatbelt because 2026 is going to be very, very intense and disruptive on a lot of fronts across Medicare Advantage, Medicaid, and commercial. We’re seeing that quite a bit out there.
The good news for us is a rebound from 3.5 stars to 4 stars, which was a big feat to pull off because it has only become more difficult to do that. Now our attention is on the next cycle, and fingers crossed we maintain that star rating.”
What’s new at Providence Health Plan?
“We’ve made significant investments in our large, self-funded business platform. We do that on our own platform today, and we’ve created a unique partnership with a third-party administrator called Collective Health.
We’ve also done a lot of work on our data, which will be complete before the end of this year, to make sure it’s clean and usable in a way other health plans strive for. That will enable us to take advantage of meaningful AI and technology capabilities over time. We’re now starting to evaluate AI-enabled capabilities we think could be meaningful with our new data infrastructure.”
