THE ISSUE
Physicians of the Commonwealth are committed to providing excellent and timely care for their patients. Unfortunately, administrative complexity in health care can impede this goal, putting patients at risk and causing additional stress for physicians,
clinicians, and patients. Physician practices and health systems spend significant time and expense addressing administrative complexities, which diverts resources that could otherwise be invested in valuable patient care. Prior authorizations alone
consume roughly two business days (14 hours) of work, to process on average 45 prior authorizations per week, requiring 35% of physicians to hire staff to work exclusively on prior authorizations.[1] Physician practices have reached a crisis
point, identifying administrative burdens, particularly prior authorization, as the biggest challenge to providing high-quality and cost-effective care.[2]
OUR STANCE
The MMS supports a range of reforms aimed at reducing administrative complexities in health care, which would include greater cross-payer standardization of policies, programs, and processes to reduce administrative complexity, enhance affordability,
and improve equity. Additional administrative burdens include increased Electronic Health Record documentation/charting (not always related to clinical care) and a proliferation of quality measure reporting, which could be controlled and limited through policy changes. Collectively, these administrative complexities increase waste in health care
spending and undermine the quality of care for patients, while contributing significantly to physician burnout.
OUR ADVOCACY
The MMS is focused on comprehensive reforms to prior authorization. Health plans routinely require providers to obtain prior authorization to justify why a recommended treatment is necessary before a prescription medication or medical service can be provided
to the patient. Prior authorization began as a tool to monitor and control spending on very costly or novel treatments but has methodically proliferated to apply broadly to many services and treatments, including generic medications. The prior authorization
process has become unwieldy, unnecessarily delaying access to medically necessary care for patients in the Commonwealth and causing undue administrative burden on our physicians at a time of unprecedented challenges and strains in the health care
system.
In the 2023–24 legislative session, the MMS is leading the charge, along with partners including the Massachusetts Health & Hospital Association (MHA) and Health Care for All, to push for significant prior authorization reforms through An Act relative
to reducing administrative burden (S.1249), and An Act to improve the health insurance prior authorization process (H.1143). This legislation would enact comprehensive reforms to prior authorization protocols, striking a thoughtful balance
that maintains PA as a utilization management tool but institutes smart, data-driven reforms that will reduce waste, improve efficiency, and, most importantly, eliminate delays and disruptions in access to care for patients. To learn more about our legislation,
check out our legislative fact sheet.
[1] 2022 AMA Prior Authorization (PA) Physician Survey. American Medical Association
[2] 2022 Physicians Foundation Survey of America’s Physicians Part Three of Three.
