Health System Integration and Prior Authorization in Medicare Advantage

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

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.

Analyses included 6480 MA health maintenance organization and preferred provider organization plans operating during the study period.

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).

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