Health care industry players remain at odds over whether and to what extent providers should get clearance from an insurer before beginning treatment or providing a medication, and they’re once again pressing lawmakers to get involved in a dispute that carries massive consequences for patients.
Influential groups including the Massachusetts Medical Society, which represents doctors and other providers, and the Massachusetts Health and Hospital Association on Tuesday renewed their call for reforms to “prior authorization,” arguing that the practice delays medically necessary care often only for administrative reasons.
But insurers represented by the Massachusetts Association of Health Plans contend that premiums — which are already a pressure point for many consumers — could rise if Beacon Hill handcuffs their ability to mandate additional review of medical decisions.
The perennial debate returned to the spotlight at a Financial Services Committee hearing, teeing up a cycle of finger-pointing and handwringing at a time when top lawmakers, patients and businesses have been sounding the alarm about health care costs.
Leda Anderson, director of advocacy and government relations for the Mass. Medical Society, told lawmakers that prior authorization is “the number-one issue that we hear about from our members.”
“[Prior authorization] really started as a way for insurers to control spending on really expensive or novel treatments, but it has become so pervasive and so overutilized at this point that it creates more waste than it saves,” Anderson said. “It’s really shifted the cost burden onto the provider community, onto the hospitals and medical practices, and is forcing practices to recruit and retain staff exclusively to process prior authorizations when they’re struggling to pay for enough clinical staff to support direct care.”
Supporters of reining in the practice showed up in numbers for Tuesday’s hearing. Several doctors, including former MMS President Hugh Taylor, shared accounts of their patients experiencing delays in treatment because of an insurer’s mandatory review.
Wayne Altman, vice president of the Massachusetts Academy of Family Physicians, said he and his colleagues go back and forth with an insurance company to secure approval for a path forward — later than they wanted to take action — “on a weekly basis.”
“Almost every day, you are guaranteed to hit at least one brick wall with the prior auth,” Altman said.
Lora Pellegrini, president of the Mass. Association of Health Plans, argued that prior authorization is “used selectively and thoughtfully.” About 2% of behavioral health services are subject to the additional review, as are about one-quarter of prescription medications, Pellegrini said.
She pointed to a 2023 study, which MAHP funded, by the actuarial and consulting firm Milliman that found commercial premiums could increase between roughly $600 and $1,500 per member each year if Massachusetts eliminated prior authorization.
“Health plans are already held to strict timelines under Massachusetts law, required to respond to completed prior authorization requests within two business days, or the request is automatically approved,” Pellegrini said in a statement. “However, delays often result from missing clinical information, incomplete submissions, or lack of response to outreach efforts by the plan. It is critical to address these process issues rather than eliminate an important tool that promotes both quality and affordability.”
Several speakers backed legislation (H 1136) before the Financial Services Committee that would streamline, but not eliminate, prior authorization practices by insurers and implement guidelines around the use of artificial intelligence to process those requests.
Under the proposal filed by Rep. Marjorie Decker of Cambridge, carriers would need to make publicly available a searchable list of all services, medications and other medical items subject to prior authorization requirements. They would be prohibited from denying payment for necessary covered services over administrative or technical issues, unless they have reason to believe the claim is fraudulent.
Other sections would require an insurer’s authorization to remain valid for the duration of a treatment or at least a year, and would create a “grace period” of continuing coverage when patients switch insurers, according to advocacy group Health Care for All, which backed the bill.
Insurers would also need to handle prior authorization cases more quickly. The bill would require a response within 24 hours for urgent cases, taking aim at concerns that some doctors raised about delays in treatment.
Taylor told lawmakers about a woman who came to see him seeking help for worsening pain about a week after she had been diagnosed with shingles. He prescribed a patch that required prior authorization, but, Taylor said, “since this was late on Friday afternoon, we were not able to get a response from her insurer until the next week.”
“She understandably did not want to wait that long and elected to buy a weaker formulation that you can get without a prescription. But this did not control her pain, so she needed an increased dose of her existing pain medicine, as well as a new prescription for a mild opioid, both of which increased her risk for confusion, unsteadiness and falling,” Taylor said. “Finally, after a week, the [original patch treatment] was approved, and since this was the prescription version, and therefore stronger and more effective, she was able to stop the other pain meds, and her pain was controlled on the patch alone.”
“So I was very happy that the patch worked so well, but unhappy that it took over a week to get it approved, during which my patient continued to be in pain,” he added.
Both the Financial Services Committee and the Health Care Financing Committee favorably recommended similar legislation last term. The earlier version of the bill died in the Senate Ways and Means Committee without receiving a vote in either chamber.
Sen. Cindy Friedman, who co-chairs the Health Care Financing Committee, in March flagged prior authorization as one area lawmakers might target for reform as they work to fix a health care system that she described as “falling apart.”
“We still have this huge issue of private equity and for-profit in health care, and it’s driving a lot of this, a lot of these costs,” she said. “We’re going to do that, and then we’re going to attack primary care again and the prior authorization pieces, which is really driving people out of the business because they can’t provide the care that they trained for.”
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