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Health System Integration and Prior Authorization in Medicare Advantage
Eunhae Shin. Health Services Research, 2026
Topic: Risk, prevention and care in population studies
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.
Cite this study APA, Vancouver, BibTeX · download .bib or .ris
APA 7th
Shin, E. (2026). Health System Integration and Prior Authorization in Medicare Advantage. Health Services Research. https://doi.org/10.1111/1475-6773.70137
Vancouver
Shin E. Health System Integration and Prior Authorization in Medicare Advantage. Health Services Research. 2026. doi:10.1111/1475-6773.70137.
BibTeX
@article{shin2026-adeb37ac,
author = {Shin, Eunhae},
title = {{Health System Integration and Prior Authorization in Medicare Advantage}},
journal = {Health Services Research},
year = {2026},
doi = {10.1111/1475-6773.70137},
url = {https://doi.org/10.1111/1475-6773.70137}
}
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Key findings
- 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.
- 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.
- Conclusions System affiliation is associated with less restrictive PA policies in MA, highlighting organizational structure as an important dimension of utilization management.
Why it matters
This analysis found that Medicare Advantage plans affiliated with health systems required prior authorization for fewer service categories than unaffiliated plans. It contains no research findings on treating, curing, or preventing Alzheimer's disease.
Study details
- Participants6,480
- Evidence strengthLow
How this study scored 40/100
Published in a peer-reviewed journal. Scored zero for study design, effect reported and randomised / blinded because the record does not state it.
| Component | Points | Why |
|---|---|---|
| Journal tier | 7 / 10 | Tier 3 — peer-reviewed journal (Health Services Research) |
| Journal's citation record | 2 / 4 | Health Services Research: journal h-index 166 (OpenAlex, 2026-10-29) |
| Study design | 0 / 12 | No study design recorded — scores zero, not guessed (not stated in the record — scored 0) |
| Strength of evidence | 1 / 5 | Rated “low” in our summary |
| Peer-review validation | 10 / 10 | Peer-reviewed. Published as an article in a named peer-reviewed journal. |
| How recent | 5 / 5 | 2026 — within 1 year(s) of the newest study here |
| Sample size | 3 / 4 | 6,480 participants |
| Effect reported | 0 / 3 | No effect size reported — scores zero (not stated in the record — scored 0) |
| Studied in people | 3 / 3 | Studied in people (participant count stated) |
| Randomised / blinded | 0 / 2 | No randomisation or blinding stated — scores zero (not stated in the record — scored 0) |
| Times cited | 1 / 7 | Cited 2 times (OpenAlex, 2026-10-10) |
| Citations per year | 1 / 5 | 1.0 citations a year over 2 year(s) since 2026 |
| Impact for its field and year | 4 / 6 | Cited 14.8× the average for papers of its field and year (OpenAlex FWCI) |
| Cited by studies here | 0 / 6 | No other study in this library cites it |
| Still being cited | 0 / 4 | Cited 2 times in 2024–2026 (2026 still in progress; OpenAlex) |
| Senior author's track record | 1 / 4 | Last-listed author Eunhae Shin: h-index 5 (OpenAlex, whole career) |
| Institution's track record | 1 / 3 | University of Georgia: institution h-index 904 (OpenAlex) |
| Multi-centre collaboration | 0 / 3 | OpenAlex lists 1 institution(s) in 1 country — scores zero (affiliation lists can be incomplete) |
| Indexed in PubMed | 1 / 2 | Not in PubMed, but has a DOI |
| Free to read | 0 / 2 | Behind a paywall — scores zero |
| Total | 40 / 100 | — |
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