Health System Integration and Prior Authorization in Medicare Advantage

Health Serv Res. 2026 Jun;61(3):e70137. doi: 10.1111/1475-6773.70137.

ABSTRACT

OBJECTIVE: To examine whether Medicare Advantage (MA) plans affiliated with health systems adopt less restrictive prior authorization (PA) policies than non-affiliated plans.

STUDY SETTING AND DESIGN: We conducted a descriptive analysis comparing PA policies between system-affiliated and unaffiliated MA plans from 2016 to 2023. Using Plan Benefit Package data, we constructed enrollment-weighted measures of PA intensity based on the share of service categories requiring PA. We assessed robustness using alternative measures, including service-specific PA requirements, service mix-adjusted overall intensity, and measures without enrollment weights, and also examined results by plan type.

DATA SOURCES AND ANALYTIC SAMPLE: Analyses included 6480 MA health maintenance organization and preferred provider organization plans operating during the study period.

PRINCIPAL FINDINGS: Enrollees in system-affiliated MA plans faced fewer PA requirements than those in unaffiliated plans. In 2023, the difference was 31 percentage points (pp): among 23 service categories, enrollees in affiliated plans were enrolled in plans that required PA for 51% of categories, compared with 82% in unaffiliated plans. Differences were especially pronounced for behavioral and mental health services and dialysis (52-59 pp).

CONCLUSIONS: System affiliation is associated with less restrictive PA policies in MA, highlighting organizational structure as an important dimension of utilization management.

PMID:42228552 | DOI:10.1111/1475-6773.70137