Healey unveils reforms to speed health care access

BOSTON – State insurance regulators unveiled sweeping prior authorization reforms that would scrap pre-approval requirements for “many routine and essential” health care services, Gov. Maura Healey announced Wednesday.

The proposed changes aim to eliminate administrative burdens, streamline the prior authorization process, mitigate surging costs and ensure patients can receive access to care without running into insurance obstacles. The planned regulations will require public comment and final approval, said Healey spokesperson Karissa Hand. The regulations are expected to be filed this week, with the public comment period likely starting in February, Hand said.

Healey also announced the launch of a Health Care Affordability Working Group, led by former Health and Human Services Secretary Kate Walsh and Citizens Massachusetts President Lisa Murray.

“Prior authorization requirements have grown in complexity over time, confusing patients and doctors and delaying important care,” Insurance Commissioner Michael Caljouw said. “Similarly, insurers and patients are too often forced to deal with duplicative bills that create additional complexity and cost for the health care system. The Division of Insurance’s balanced standards will reduce and simplify these processes, increasing overall transparency and improving the timeliness of patient care.”

The regulations would nix prior authorization for services including emergency and urgent care, primary care, chronic care, occupational and physical therapy, and certain prescription drugs. The changes would remove “duplicative claims submissions,” simplify approval processes, and “standardize prior authorization practices across the health care system, reducing red tape and unnecessary barriers to care,” Healey’s office said.

Insurers must respond to urgent requests within 24 hours and ensure continuity of care when members switch plans under the proposed changes, with the aim of reducing delays in care and preventing avoidable emergency department visits.

“These new regulations by the DOI are a major step in reducing the burden prior authorization has created and in allowing providers to spend more time doing what they are trained to do and want to do: deliver care and take care of patients,” said Sen. Cindy Friedman, co-chair of the Health Care Financing Committee. “I applaud the DOI for issuing meaningful regulations that will immediately reduce administrative burden and burnout for our providers, allow them to refocus energy on delivering direct care, improve health outcomes for patients, and ultimately reduce healthcare costs.”

Highlighting the impact of the changes, Healey’s office said a patient with diabetes would no longer be subject to prior authorization for any care, devices or drugs tied to their chronic condition. Among other examples: A patient with rheumatoid arthritis who’s received approval for treatment but recently switched to new insurer will retain that authorization for at least three months, and an insurer would face a 24-hour deadline to handle a prior authorization request from a multiple sclerosis patient who’s experiencing a relapse and needs steroid injections to prevent permanent nerve damage.

The Division of Insurance changes are expected to lower patient costs “since there will be reduced overhead costs for both providers and insurers alike through streamlined processes, while ensuring that appropriate care is provided and utilization does not increase,” Healey’s office said. 

Lora Pellegrini, CEO of the Massachusetts Association of Health Plans, expressed support for the reforms. She said plans “have been actively working to streamline and modernize these processes, with the goal of advancing electronic prior authorization and automation to make the process more efficient for providers and patients alike.”

“We look forward to working with the Division through the regulatory process to ensure that reforms are implemented thoughtfully, preserve appropriate clinical safeguards, and build on the progress already underway to simplify prior authorization across the system,” Pellegrini said.

Healey also announced the 30-member Health Care Affordability Working Group – composed of state, health care, insurance and business leaders — tasked with producing recommendations to cut systemwide costs.

Members include Friedman, Health Care Financing Committee Co-chair Rep. John Lawn, Caljouw, Health Policy Commission Director David Seltz, Center for Health Information and Analysis Interim Director Andrew Jackmauh, Group Insurance Commission Executive Director Matt Veno, Undersecretary for Health Amy Rosenthal, Undersecretary for MassHealth Mike Levine, Department of Public Health Commissioner Dr. Robbie Goldstein, Massachusetts Health Connector Executive Director Audrey Morse Gasteier, Administration and Finance Secretary Matt Gorzkowicz, Pellegrini, and former Rhode Island DOI Commissioner Chris Koller.