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Health System Integration and Prior Authorization in Medicare Advantage.

¹Department of Health Policy and Management, University of Georgia, Athens, Georgia, USA.

Health Services Research

|June 2, 2026

Summary

This summary is machine-generated.

Medicare Advantage (MA) plans linked to health systems use fewer prior authorization (PA) requirements than independent plans. This suggests organizational structure impacts utilization management in MA plans.

Keywords:

Medicare Advantage health system affiliation prior authorization utilization management vertical integration

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Area of Science:

Health Services Research
Health Policy Analysis
Healthcare Management

Background:

Prior authorization (PA) is a utilization management tool used by health plans.
Medicare Advantage (MA) plans have varying PA policies.
The relationship between health system affiliation and MA PA policies is not well understood.

Purpose of the Study:

To investigate whether Medicare Advantage plans affiliated with health systems have less restrictive prior authorization policies compared to non-affiliated plans.
To analyze the impact of organizational structure on PA intensity within MA plans.

Main Methods:

A descriptive analysis compared PA policies of system-affiliated and unaffiliated MA plans from 2016 to 2023.
Enrollment-weighted measures of PA intensity were created using Plan Benefit Package data.
Robustness was assessed using alternative measures and examining results by plan type.

Main Results:

System-affiliated MA plans demonstrated less restrictive PA policies than unaffiliated plans.
In 2023, enrollees in affiliated plans faced PA for 51% of service categories versus 82% in unaffiliated plans (a 31 pp difference).
Greater differences in PA intensity were observed for behavioral/mental health services and dialysis.

Conclusions:

Health system affiliation is linked to less stringent prior authorization policies in Medicare Advantage plans.
Organizational structure is a significant factor influencing utilization management strategies in MA.
Findings underscore the importance of considering plan affiliation when evaluating PA practices.