WALTHAM - The Massachusetts Medical Society, the Massachusetts Health & Hospital Association, and Health Care For All have worked with state Senator Cindy Friedman and former state Representative Dr. Jon Santiago to introduce new legislation this session, “An Act relative to Reducing Administrative Burden,” that significantly reforms prior authorization processes, prioritizing patient care first – ahead of paperwork and waiting for time-sensitive decisions to be made often by insurance personnel with little to no clinical knowledge.
All three health care organizations will offer testimony in support of the bill at a hearing in front of the Massachusetts Joint Committee on Mental Health, Substance Use and Recovery, scheduled for 1 p.m., Monday, Dec. 4.
A March survey of Massachusetts Medical Society physician-members found that 1 out of 4 physicians in the Commonwealth plan to leave medicine within two years, with prior authorization cited as a primary administrative burden that contributes significantly to burnout. A national physician survey by the American Medical Association concluded that 80 percent of physicians believe that prior authorization-driven delays and red tape cause patients to discontinue the use of prescribed medication or physician’s orders.
An estimated 1,200 patients are "stuck" in Massachusetts hospitals because they cannot access the next level of care they need -- with administrative delays and prior authorization decisions serving as the most frequently-cited cause. A recent Massachusetts Health & Hospital report illustrated how those excessive administrative burdens affect patient care, provider wellbeing, and overall healthcare costs. It shows that an estimated $1.75 billion in wasteful costs could be eliminated from the local healthcare system through a series of sensible reforms like the ones contained in this proposal.
“The physicians of the Massachusetts Medical Society have long recognized the impact of burdensome and convoluted prior authorization policies in delaying and denying medically necessary care for patients, increasing waste in the system, and driving members of health care teams away from clinical practice,” said Massachusetts Medical Society president Dr. Barbara Spivak. “Too often prior authorization decisions override the evidence-based recommendations of medical professionals and harm patients, while sapping time and resources and, ultimately, driving up the cost of delivering and receiving timely, quality health care. While providers and patients are often frustrated by prior authorization procedures, we want to make clear that we are eager and willing to work with all stakeholders to improve prior authorization and to create a streamlined and patient-first system that allows our health care teams to deliver timely and efficient care with better quality outcomes.”
“Reforming prior authorization policies is critical to ensuring that providers can deliver quality care to their patients, while keeping costs down,” said Joint Committee on Health Care Financing chair Senator Cindy F. Friedman. “Administrative burden is one of the highest contributing factors to burnout – something that is happening at an alarming rate among our healthcare providers. It is of the utmost importance and urgency that we provide relief to them, and this legislation is a very important place to start that work.”
“Patients need solutions that remove unnecessary barriers to their care, control their costs, and alleviate the pressures on their caregivers. This legislation gives Massachusetts a way to address all three of those priorities while opening up beds for those who need them most,” said MHA president and CEO Steve Walsh. “Our hospitals and health systems are proud to support sensible prior authorization reforms in partnership with elected officials, patient advocates, and clinical leaders. This is something we can get done using the same collaborative spirit that got us through the most trying days of the pandemic.”
"We regularly hear from HelpLine callers who have experienced a break in treatment or long wait times for critical medical services due to prior authorization. These disruptions are particularly harmful for People of Color and underserved populations who are more likely to have chronic conditions," Health Care For All executive director Amy Rosenthal said. " This legislation strikes the right balance of preserving prior authorization as a tool to keep health care costs down while streamlining the process to reduce disruptions and delays in people’s care."
The Massachusetts Medical Society conducted survey of member-physicians asking them to share their stories on how the challenges of existing prior authorization processes impact their patients and affect their ability to deliver care. Below is a sample of responses:
PA due to change of insurance
I have two patients on the autism spectrum who were stable for more than 7 years on their stimulant medication. When they changed insurances, their insurance required trials of FIVE other stimulants before agreeing to the medication they were currently stable on. Both patients decompensated in significant ways. One patient's manageable trichotillomania deteriorated so much that he pulled out all of the hair on his head and is now bald.
PA for a blood thinner that led to missed doses for a life-threatening clot -PA on a psychiatric medication that patient had been taking for years and can cause severe withdrawal symptoms if not taken for one day. PA was due to a change in insurance and required a phone call. -PA for specialist referrals with whom patient was already established, due to insurance change -The most frequent trigger for PA is inhalers, some of which require a written form/fax, leaving COPD and asthma patients at high risk of exacerbation and ED visits -These above examples do not even include the bulk of prior auths handled by our PA team with turnaround time of 1 week. The time that it takes to address the above scenarios has led me to consider reducing patient-facing hours even further.
Delay of discharge and access to Rx
As a palliative care physician working with cancer patients, I frequently encounter challenges with prior authorizations when my patients need changes to the drug or dosage for their pain management regimen to be effective. While inpatient, this can often delay a discharge by 24-48 hours, but worse than that is when they are outpatient. Many of my patients have found themselves in the difficult position of having their essential prescription denied coverage by their insurance or experience delays, meaning that they are in uncontrolled pain for the period of time that the prior authorization takes to go through, or sometimes they find themselves paying out of pocket for these essential medications. This is especially common over the weekend, when on call physicians and pharmacy staff are not as familiar with the prior authorization process, which leads to patient distress and suboptimal patient care.
Common medications that shouldn’t require PA
Every single inhaler prescription - whether it’s new or a refill - needs a PA now in the pedi pulmonary practice. This is HUNDREDS of PAs a week when you take into account all our different offices. It’s placed an insurmountable burden on our nurses. Something has to change. Our patients wait WEEKS for medically necessary prescriptions all because of insurance hold ups.
Interrupts treatment for substance use disorders
Every time a patient wants to increase the dose or switch pharmacies or formulations for their suboxone (which is a lifesaving medication for people with opioid use disorder), we have to do a PA. This takes away time from our providers and leads to mistrust of the system since patients cannot reliably pick up a medication that helps with cravings.
