RIGHT NOW, hospitals and physician practices across the Commonwealth are facing unprecedented capacity and workforce issues while patients continue to face barriers to care. We as a state must address the underlying issues contributing to the challenges that affect the sustainability of medical practices and hospital systems. These include excessive administrative burdens, which contribute to patient wait times, lead to caregiver burnout, and increase overall costs.
With the current crisis at Steward Health Care, policymakers are rightly focused on how private equity and the financialization of health care affects patients and our health care system. These trends are a symptom of a destabilized system, not the cause. The challenges facing the Massachusetts health care system and its patients are multifaceted, and while there is no single solution, there are steps that can be taken now that will reduce the red tape and improve the delivery of quality health care.
A key issue impeding the delivery of health care is prior authorization – or the permission health care providers must get from insurance companies before delivering certain types of care or prescriptions. Inefficient and overutilized prior authorization practices create inordinate stressors and unsustainable workloads on physician practices, hospitals, and health care professionals, but there are legislative levers that can be pulled to make changes.
The Massachusetts Medical Society, the Massachusetts Health & Hospital Association, and Health Care for All Massachusetts have worked with state Sen. Cindy Friedman to put forth legislation that provides a blueprint for meaningful and sustainable prior authorization reform. S.1249 is a multifaceted, data-driven approach that would make common-sense changes to the prior authorization process that increase access and continuity of care, promote transparency and fairness, and improve timely access to treatment and administrative efficiencies — all while maintaining prior authorization as a cost control tool.
Prior authorization began as a tool to monitor and control spending on costly or novel treatments and, when applied narrowly for those purposes, is a worthwhile and effective cost control measure. But that is not how prior authorization is utilized today. Instead, the tool has proliferated to apply broadly to many medications, services, and treatments, including common life saving devices like inhalers.
Prior authorizations can negatively impact patient care by causing dangerous delays in access to medications.
“As an emergency doctor for children, we see patients regularly who present to the emergency room with preventable illness, such as asthma attacks, as a result of prior authorizations impeding their ability to obtain medically necessary prescriptions in a timely manner,” said Dr. Eli Freiman, a board-certified pediatric emergency medicine physician practicing in Massachusetts. “This also leads to harmful ER overcrowding, prolonged wait times, and significant dissatisfaction among patients, families, and providers.”
When prior authorization determinations override evidence-based decisions and recommendations of medical professionals, quality of care is reduced, costs go up, and waste is increased, forcing health care teams to spend more time on the phone and the computer than with patients at a time when systems are already stretched beyond capacity. The increased staffing needed to process prior authorizations means increased expenses and overhead unrelated to patient care.
The Massachusetts Medical Society report “Supporting MMS Physicians’ Well-being Report: Recommendations to Address the Ongoing Crisis” found an astounding 55 percent of physicians reported experiencing symptoms of burnout, with an alarming one in four physicians planning to leave medicine in the next two years and 27 percent of Massachusetts physicians having already reduced their clinical care hours.
One of the easily identifiable and fixable stressors identified by physicians is prior authorizations for medicines and testing. Particularly, prior authorizations for items that are frequently ordered (and in the end, usually approved) need to be reconsidered as adding little value and be discontinued in a consistent, standardized manner across all plans.
Hospital capacity issues, which have been widely reported across the nation, are also affected by prior authorization requirements. It’s not unusual for a hospital case manager to wait days for a response from an insurer on a request to transfer a discharge-ready patient to a rehabilitation facility, while the patient remains stuck in an acute care bed. The Massachusetts Health & Hospital Association’s monthly “Throughput Reports” clearly show that insurance issues were the number one problem in timely discharges from acute care to post-acute settings.
A 2021 McKinsey & Company study estimates that about one-quarter of the $4 trillion spent on health care annually in the United States – $950 billion – is administrative. Recognizing some administrative spending is necessary, the report identifies simplification opportunities that could deliver $265 billion in annual savings from roughly 30 interventions, including prior authorization reforms.
MHA’s brief on billing and insurance-related expenses shows that sensible administrative reforms could remove as much as $1.75 billion in cost waste from the Commonwealth’s health care system that, in turn, could improve affordability, care access, and delivery of services.
Moreover, the prior authorization impact on patients is significant. Health Care For All provides direct consumer assistance through a toll-free help line, staffed by enrollment counselors in five different languages, that takes over 20,000 calls a year. One of the most difficult issues they deal with is assisting callers with lags or unnecessary breaks in treatment due to prior authorizations, particularly for patients with complicated medical needs and/or chronic diseases for whom adherences to a medical treatment plan is critical.
For people with limited English proficiency, language barriers further complicate the ability to understand and navigate the prior authorization process, which can further exacerbate the negative impacts of delayed or denied care.
Today, the burdens associated with the prior authorization process far exceed the stated benefits of cost and quality control, leading to avoidable delays for patients, clinician burnout, and waste throughout the system. The Commonwealth has an important opportunity to fix that.
Reducing the burden prior authorization places on hospitals, physician practices, caregivers, and patients is an immediate and attainable way Massachusetts can continue to address the underlying challenges in our health system, support our provider community, and, ultimately, protect our patients, especially our most vulnerable.
Dr. Hugh Taylor is president of the Massachusetts Medical Society. Steve Walsh is president and CEO of the Massachusetts Health & Hospital Association. Amy Rosenthal is executive director of Health Care for All.
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