Medicare Advantage Prior-Authorizations Are Linked to Racial Differences in End-of-Life Home Health Use

Medicare-funded home health care is providing critical care to homebound older adults, especially those in the last year of life. In Medicare Advantage, Hispanic and Asian or Pacific Islander decedents are less likely to receive Medicare home health compared to their counterparts in traditional Medicare.

We aim to investigate if prior authorization contributes to racial and ethnic differences in Medicare home health use at the end of life. In this cross-sectional study, we used a 100% Medicare cohort of adult's age ≥ 66 who died in 2019 and were enrolled in Medicare Advantage. We fit a logistic regression model with and without a Medicare Advantage plan-level fixed effects and tested interactions between decedent race and ethnicity and whether the Medicare Advantage plan required prior authorization for Medicare home health care. All models adjusted for individual and regional characteristics.

In our sample of 369,195 decedents (49.3% female, mean age 84.9), 240,339, or 65.1%, were in Medicare Advantage plans that required prior authorization for home health care. Racial and ethnic differences were primarily driven by between-plan differences, with prior authorization increasing differences in utilization between racial and ethnic groups. For example, prior authorization was associated with a 5.60% (95% CI 0.08-0.03) decrease for Hispanics and a 4.05% (95% CI 0.07-0.01) decrease for Asian/Pacific Islanders.

Our findings suggest that prior authorizations contribute to racial and ethnic differences in the Medicare Advantage program.