Health System Integration and Prior Authorization in Medicare Advantage
研究了2016至2023年间，隶属于卫生系统的医疗保险优势计划是否比非隶属计划采用更宽松的预先授权政策，发现隶属计划对参保者的授权要求更少，尤其在行为健康和精神健康服务及透析方面差异显著。
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.