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> Prior Authorization Reform
> Mental Health Services
> Solution for “Stuck” Kids
> Advancing Health Equity
> Nurse Licensure Compact

MONDAY REPORT

Healthcare Coalition Seeks to Improve Prior Authorizations

MHA, the Massachusetts Medical Society (MMS), and Health Care For All are strongly endorsing a bill that significantly reforms prior authorization processes. The House version of the bill, H.1143, An Act to Improve the Health Insurance Prior Authorization Process, is among many that will be heard during a Joint Committee on Financial Services hearing on Tuesday, September 12, beginning at 10 a.m.

A recent MHA report showed 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.

An MMS survey of its physician members in March found that one out of four doctors in the commonwealth plan to leave medicine within two years, with prior authorization cited as a primary administrative burden that contributes significantly to burnout. And a national physician survey by the American Medical Association concluded that 80% of physicians believe that prior authorization-driven delays and red tape cause patients to discontinue the use of prescribed medication or a physician’s orders.

Prior authorization has been the subject of increased scrutiny at both the state and national level in recent months. While the process from insurers was originally intended as a “gatekeeping” strategy to prevent claims for unnecessary medical services, its use has expanded and is used to routinely reject medical care that, after costly and timely appeals, is later found to be necessary. Providers are especially aggrieved that the insurance company personnel making medical decisions about prior authorizations often lack clinical knowledge.

MHA President & CEO Steve Walsh said, “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. 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.”

“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 healthcare 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 healthcare.”

Among other things, the bills would prohibit prior authorizations for generic medications and medications and treatments that currently have low denial rates. It would require a prior auth to be valid for the duration of a treatment or at least one year, meaning that insurers could not repeatedly require it with the for each practitioner within the treatment. And if a patient changes insurers, the new insurance company must honor the authorization for at least 90 days.

The bills also require more transparency from the insurance industry relating to approvals, denials, appeals, wait times, and more; requires the Health Policy Commission to issue a report on prior authorizations; and requires a 24-hour response time to authorize urgent care, among many other conditions.

“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 healthcare teams to deliver timely and efficient care with better quality outcomes,” MMS’s Spivak said.

Bill Would Expand Mental Health Services

In addition to the prior authorization bill (see above), the Joint Committee on Financial Services will also hear testimony on H.4058, An Act Expanding Access to Mental Health Services from Rep. Marjorie Decker (D-Cambridge). The Senate companion legislation, sponsored by Sen. Jake Oliveira (D-Ludlow), will be heard at a later date.

MHA strongly supports the bill, which builds on Chapter 177 of the Acts of 2022, also known as the Mental Health ABC Act. The legislation improves access to behavioral health services by expanding the number of behavioral health settings that must be covered without prior authorization by commercial insurers to include the newly established youth crisis stabilization services and behavioral health crisis evaluations delivered in emergency departments as part of the administration’s Behavioral Health Roadmap.

In addition, it aligns the approval process for psychiatric units in acute care hospitals with the approval process for freestanding psychiatric facilities. The bill also waives application fees for mobile integrated health services that have a behavioral health focus.

To address workforce challenges, H.4058 allows qualified physician assistants to admit psychiatric patients and codifies DPH regulations that expand the definition of licensed mental health professionals to include master’s level clinicians working towards licensure.

“This proposal represents an important next step in Massachusetts’ expansion of behavioral healthcare,” said Leigh Simons, MHA’s senior director of healthcare policy. “These reforms would make it easier for much-needed beds to come online and ensure that patients have proper professional and insurance supports along their care journey. As the behavioral health crisis persists, these changes would get us closer to a behavioral health system that is accessible to everyone who needs it.”

A Way Out for “Stuck Kids”

A March report from MHA and the Massachusetts Association of Behavioral Health Systems shed light on yet another aspect of the capacity crisis: dozens of “state-agency-involved” children are ready to be discharged but cannot access the next level of care they need. The scenario leaves them “stuck” in hospitals.

Legislation to address the persistent backlogs, An Act Ensuring Access to Behavioral Health Services for Children Involved with State Agencies, will be heard be heard by the Joint Committee on Children, Families and Persons with Disabilities on Tuesday. The bills are sponsored by Rep. Marjorie Decker and Senator Brendan Crighton (D-Lynn).

The bills aim to improve access for children in the care of the Department of Children & Families (DCF) who have mental health needs by making placements into congregate care settings easier. The bills would also require DCF and the Department of Developmental Services to create a plan to address access to behavioral health services and evaluate alternative placements for children who require an intermediate level of care, who have complex needs, and who need school-based services. The legislation tasks the Department of Mental Health (DMH) with taking primary responsibility in matching children involved with both DMH and the Department of Developmental Services with specialized mental health services. A commission would also be created to examine alternative placements that are not accounted for within existing models.

The MHA/MABHS survey showed that state-agency involved pediatric patients were disproportionately stuck in an ED (49%) or an inpatient psychiatric unit (37%). The longest wait times for stuck pediatric patients were between 61 and 100 days, with more than half of patients waiting over 10 days. While these children wait to be discharged, they occupy inpatient psychiatric beds that other children are waiting for as they board in EDs and on medical/surgical floors. The Boston Globe published an editorial shortly after the report’s release, urging the state to devote additional resources to the problem.

Mark Your Calendars: Health Equity Bill Hearing Set for September 20

The Health Equity Compact’s legislation – H.1250/S.799, An Act to Advance Health Equity – will receive a hearing before the Joint Committee on Health Care Financing on Wednesday, September 20. The lead sponsors of the bill are Rep. Bud Williams (D-Springfield) and Rep. Judith Garcia (D-Chelsea), and Sen. Pavel Payano (D-Lawrence) and Sen. Liz Miranda (D-Boston).

The omnibus bill seeks to address racial justice and health equity solutions by creating a new cabinet-level Executive Office of Equity. The new Equity Office would be responsible for developing a “multi-year equity strategy to improve equity across government and the commonwealth, including improved access to affordable healthcare, quality food and housing, safe communities, quality education, employment for which people are paid a living wage and that includes good working conditions, and affordable transportation and childcare.”

The bill would also require the use of standardized health equity data metrics across provider and payer organizations and new accountability mechanisms for reporting the data. According to a one-page summary document from the Compact, the bill would also expand MassHealth coverage, address how the medication cost burden affects communities of color, require parity for telehealth services for primary care and chronic disease management, authorize a career ladder program for diverse workers, and require provider organizations to “meet or exceed national standards for culturally and linguistically appropriate services and multicultural healthcare.”

The Health Equity Compact is made up of 80 leaders of color, including many from MHA member organizations as well as MHA’s V.P. of Health Equity Izzy Lopes.

Massachusetts is a Nurse Licensure Compact Outlier

The total is now 41. That’s the number of states that are part of the Nurse Licensure Compact (NLC) that allows qualified nurses to have one compact state nursing license that gives them the ability to practice in other states that are part of the agreement. Massachusetts is one of the eight states that are not part of the Compact. Pennsylvania joined last week. The Bay State’s neighbors – Maine, New Hampshire, Vermont, and Rhode Island – are also NLC states.

Linda Aiken, founding director of Penn Nursing’s Center for Health Outcomes and Policy Research, said of Pennsylvania joining the NLC, “This is a great thing. It takes away the bureaucratic delay…There is not a strong rationale for having all these separate licenses.”

In addition to allowing nurses to practice in multiple states without maintaining multiple licenses, the NLC would permit Massachusetts nurses to use telehealth to care for patients who originally sought care at a Massachusetts hospital and then returned to their home state. The compact would also provide much needed relief to Bay State providers that currently struggle to recruit and retain nursing staff by lessening reliance on expensive travel nurse agencies.

In addition to allowing nurses to practice in multiple states without maintaining multiple licenses, the NLC would permit Massachusetts nurses to use telehealth to care for patients who originally sought care at a Massachusetts hospital and then returned to their home state. The compact would also provide much needed relief to Bay State providers that currently struggle to recruit and retain nursing staff by lessening reliance on expensive travel nurse agencies.

MHA strongly supports H.1016/S.2113, An Act Relative to Nurse Licensure Compact in Massachusetts, sponsored by Rep. Kay Khan (D-Newton) and Sen. Barry Finegold (D-Andover). The Compact has also received support from the Health Policy Commission and the Boston Globe.

John LoDico, Editor