Healey’s Grand Plan: (Potential) Relief in Store for Mass. Healthcare Prior Authorization

By: Jen McCormick and David Ostrowsky

Prior. Authorization. Lumped together, the two words have long been the bane of patients’ experience in navigating an often-byzantine healthcare system. Whether you’re a patient with diabetes waiting ever-so patiently for insulin or one suffering from multiple sclerosis and in dire need of steroid injections to prevent permanent nerve damage, prior authorization has often been deemed an extremely aggravating, drawn-out process riddled with complexities, ultimately representing a barrier to care and treatment.

However, earlier this month, Maura Healey, the governor of Massachusetts, took the podium at the Mass. State House and announced sweeping reforms to alleviate systemic issues inherent in her state’s prior authorization healthcare practices.

“We’re cutting the red tape that stands between you and health care,” the 73rd governor of Massachusetts, flanked by legislative leaders, declared on January 14. “From now on, a wide range of medical drugs, services, and equipment will no longer need any prior authorization at all.”

It was later revealed that the “wide range of services” will include emergency and urgent care, primary care, chronic disease management, reproductive and maternity care, physical therapy, and substance use treatment. Backed by the Healey administration, the proposed prior authorization reforms are engineered to not just reduce but essentially eliminate administrative burdens (i.e., the task of sorting through an avalanche of paperwork, which continues to be a major source of burnout for physicians) as a means of expediting the process by which patients receive care. Additionally, a 24-hour turnaround from insurers would be mandated for urgent requests while new continuity protections would be in place to ensure patients don’t forfeit access to treatments when they change insurance plans. Though all health insurers that conduct business in the Commonwealth will need to abide by the new regulations as part of this overhaul, there will be a public comment period prior to them receiving final approval and taking effect.

In just Massachusetts alone, the administrative waste stemming from prior authorization practices has been gargantuan: according to Healey’s office, in 2023, $1.3 billion was spent statewide on administrative costs related to healthcare prior authorization—a 30% spike over the prior year. But aside from the quantitative monetary impact, the reforms to “standardize prior authorization practices across the health care system” and “reduce red tape and unnecessary barriers to care”   could very well alter the provider-patient dynamic from the Berkshires to Cape Cod. If providers are less overwhelmed by paperwork, phone calls, and emails, they will naturally have more time to refocus their energy on providing optimal and timely care for their respective patients.

Lora Pellegrini, CEO of the Massachusetts Association of Health Plans, is one of many Massachusetts leaders who have expressed support for the reforms, while explaining that 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.”

(In addition to the aforementioned prior authorization reforms, Healey also announced the formation of a working group laser-focused on managing healthcare costs. The group, co-chaired by former state Health and Human Services Secretary Kate Walsh and Citizens Bank Massachusetts President Lisa Murray, will be responsible for devising specific means to reduce systemic health costs for families and businesses.)

The potential elimination of prior authorization requirements for select essential services may not be a panacea for the litany of issues plaguing Massachusetts healthcare. But it’s a promising step in the right direction, and if it comes to fruition, promises to be one of the landmark achievements of the Healey administration that is hyper-focused on providing relief for cash-strapped residents grappling with escalating household costs.