INSIDE THE ISSUE

> Shield Law Strengthened
> Fixing Prior Authorizations
> MGB’s NOVA Award
> Cutting Red Tape
> Steward Sues Former CEO
> Quote of Note

MONDAY REPORT

Massachusetts Takes Another Step to Protect Patients

The Massachusetts legislature took another step last week to protect caregivers and patients – both those from the commonwealth and those traveling to it for care – from anyone prying into their health records.

Lawmakers deemed a strengthened Massachusetts “shield law” is needed as more and more states enact laws against abortion and reproductive rights as well as gender-affirming care, and then attempt to track if their citizens are leaving the restrictive states to receive such care. The bill that the House approved last week 136-23, and which the Senate approved in a slightly different version in June, builds on the original Massachusetts shield law passed in 2022 after the U.S. Supreme Court overturned Roe v. Wade.

An Act Strengthening Health Care Protections in the Commonwealth prohibits state and local actors from providing information or assistance to another entity, state, or federal government if that info is related to legally protected healthcare services. It prohibits the Department of Public Health (DPH) from collecting or disseminating personally identifiable data relating to reproductive or gender-affirming care performed in the commonwealth. The state’s Center for Health Information and Analysis and Health Policy Commission also would be prohibited from providing information to other governments regarding legally protected healthcare activities. Among other things, the law would allow labels on prescribed controlled substances to list the name of dispensing health practice, rather than the prescribing practitioner to help protect caregivers, and it would direct Massachusetts courts not to consider laws relating to gender-affirming care from other states when determining requests to alter custody and visitation arrangements.

MHA has been a strong supporter of strengthening the shield law and offered an amendment, which was adopted, to create a technical advisory group to make recommendations on how to implement certain aspects of the law. A workgroup of MHA member Chief Medical Information Officers noted that clarity is needed over such issues as how services are defined across health information technology so that differing platforms are able to communicate allowable clinical information with each other, with the patient’s consent. For example, the CMIOs want to maintain privacy in the EHR for a drug that may be used in, say, gender-affirming care, but that also may need to remain visible in the patient record if the drug has interactions with another aspect of a patient’s care. A report from that advisory group on such technical issues would be due on January 1, 2026.

Don’t Eliminate Prior Authorization. Fix It.

Prior authorization serves a purpose in the healthcare landscape and should not be eliminated entirely. But can healthcare stakeholders agree that the prior auth system is tragically flawed?

That’s the main thrust of the argument that hospitals, physicians, and patient advocates made last Tuesday during a series of hearings on prior authorization bills now pending at the State House.

When used appropriately, prior authorization can prevent unnecessary care, such as when an evidence-based best practice discourages use of an MRI for a simple headache. But what if a clinician determines that a particular test or treatment is medically necessary and the insurer denies the request for coverage. The clinician then must get on the phone with the insurance company and plead the case. And that entails reaching the insurer in the first place – which may mean waiting through the weekend since insurers are often not staffed 24/7. And once a hospital physician finally gets in touch with her insurer “peer,” she may find that the doctor on the other end of the line is not a peer at all; that is, the insurer’s doctor may not be trained in the specialty best able to determine if an MRI is needed for the specific condition. (An entirely separate issue involves the prior auth being run through an AI program, meaning that a human being at the health insurance company has absolutely nothing to do with the approval or denial.)

“While prior authorization requirements are intended to reduce wasteful and inappropriate healthcare spending by determining medical necessity before a service is rendered, it has become a process that too often delays or denies access to care, requires physicians and hospitals to employ staff solely to focus on obtaining authorizations and appealing subsequent denials, and is a primary factor in both clinician burnout and exacerbating hospital transitions of care to post-acute settings.” MHA’s Senior Director of Managed Care Policy Karen Granoff testified before both the Joint Committee on Health Care Financing and the Joint Committee on Financial Services last Tuesday.

She was advocating for passage of H.1136, An Act Improving the Health Insurance Prior Authorization Process, sponsored by Rep. Marjorie Decker (D-Cambridge), and a companion bill from Senator Cindy Friedman (D-Arlington) – S.1403, An Act Relative to Reducing Administrative Burden. Also testifying on the bills were representatives from the Massachusetts Medical Society and Health Care For All, which worked with MHA and the legislators to craft the prior auth bills.

Those bills would require, among other things, prior authorization to be valid for the duration of treatment and would establish a 24-hour response time from the insurer. Importantly, the legislation requires insurers to state upfront what services, items, or medications are subject to prior authorizations, and prohibits an insurer from retrospectively denying prior authorization once that authorization is given. It would also put guardrails around the use of artificial intelligence in the prior auth process.

“This bill makes 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,” Granoff said.

Mass General Brigham Presented Prestigious NOVA Award

One of the most highly sought after national recognitions for the hospital community is the American Hospital Association’s (AHA’s) Dick Davidson NOVA Award, which recognizes a facility’s collaborative efforts to improve community health.

Last Wednesday the AHA announced that Mass General Brigham was among the five 2025 recipients of the award. MGB was recognized for its Community Behavioral Health Workforce Development Program in which the health system partnered with 13 community-based agencies and schools of higher education to develop programs to address mental health needs. The program, which began in January 2022, already has met its five-year-goal of supporting 835 students across several academic disciplines.

The NOVA Award (renamed in 2022 to honor long-time AHA President Dick Davidson) has been presented previously to Baystate Health System (2000), Brockton Hospital (2004), Cambridge Health Alliance (2005), UMass Memorial Health (2007), Boston Medical Center (2007), Brigham and Women’s Hospital (2009), and Boston Children’s Hospital (2012).

This year’s other recipients were Endeavor Health, Evanston, Ill.; IU Health, Indianapolis, Ind.; MedStar Health, Baltimore, Md.; and Rochester Regional Health, Rochester, N.Y.

MHA Red-Tape Letter Focuses on Telehealth, Prior Auth, Care Transitions

In May, U.S. Health & Human Services published a Request for Information in the Federal Register seeking information on how the department could dramatically reduce regulatory and administrative burdens. Last week, MHA sent a letter focusing specifically on digital health, prior authorizations, and post-acute care transitions.

Digital health administrative fixes, MHA wrote, would involve removing telehealth originating site restrictions within the Medicare program to allow patients to receive telehealth in their homes. Among the other telehealth fixes MHA discussed entail removing the in-person visit requirements for behavioral health telehealth, and expanding the list of eligible practitioners to furnish telehealth services to include occupational therapists, physical therapists, speech-language pathologists, and audiologists. MHA wrote, “A change in legislation is necessary to permanently allow this expanded list of providers to deliver and bill for telehealth services as they have been doing for the past five years.”

Under prior authorization, MHA endorsed standardizing the prior auth process across all plans and establishing electronic prior auth in Medicare Advantage, the health insurance marketplaces, and Medicaid.

MHA also included a series of recommendations to improve post-acute care transitions, including repealing the nursing home staffing rule and eliminating the Medicare 3-midnight rule for qualifying skilled nursing facility stays.

Bankrupt Steward Sues Its Former CEO and Board

The bankrupt Steward Health Care system has filed suit in bankruptcy court against its former CEO Ralph de la Torre, members of the Steward Board of Trustees, along with other entities, alleging that the “former insiders,” through “their greed and bad faith conduct, operated Steward with the aim of enriching themselves at the expense of the Company, its creditors, and the patients and communities that Steward served.”

Specifically, the suit claims that while Steward was reeling financially, de la Torre and the board orchestrated a $111 million dividend payment to themselves. De la Torre received $81 million of that total, through which he bought the $30 million “superyacht” Amaral, according to the suit. It also alleges that Steward purchased hospitals in the Miami area in 2021 for a grossly inflated price based solely on “de la Torre’s personal desire to build a hospital empire in the Miami area, rather than on any independent financial analysis.” Finally, when Steward sold assets related to its Medicare Advantage business to CareMax, Inc., the suit alleges that de la Torre and the other defendants steered the majority of the sale proceeds not to Steward but to “a separate entity owned indirectly by Steward insiders.”

The 70-page suit seeks to recoup the $100-plus million dividend payment and the $1-plus billion payment to purchase the Florida hospitals.

Quote of the Week

Sen. Cindy Friedman (D-Arlington), co-chair of the Joint Committee on Health Care Financing, noting at last Tuesday’s committee hearing the rise of uninsured and underinsured individuals in the commonwealth:

“This is causing enormous stress and financial instability across our hospital systems because our hospitals do not turn anyone away when they are sick – nor do they want to. And yet someone must pay for this care so the hospitals that serve the poorest can actually remain open to provide that care. We pride ourselves on having the greatest number of residents with health insurance, but it turns out that simply having health insurance does not guarantee access or affordability. And it is abundantly clear that a healthcare system that is less and less affordable and accessible, that is driving away providers at an alarming rate, when most really want to provide that healthcare, and at the same time where cost continue to rise at a dizzying pace, cannot nor will it ever be, an equitable system where everyone can receive the care they need when they need it.”

John LoDico, Editor