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| 麻州州長Maura Healey要降低醫療費用，讓人民的享有可負擔的醫療保險。（周菊子攝） |
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| 麻州長率醫療業，保險業人士一同宣佈新政策。（周菊子攝） |
(Boston Orange編譯)麻州州長奚莉（Maura Healey）1月14日在州政府大樓宣佈，將修訂備受爭議的醫療保險「先期授權（prior authorizations）」，以消除患者獲取常規醫療服務及藥物的行政程序障礙，縮減醫療支出，因應聯邦政策劇烈變動，確保麻州居民醫療權益。
麻州保險局（Division of Insurance）將制定新法規，取消保險公司對多項「常規且必要服務」的先期授權要求。受影響範圍包括急診與緊急護理、基層醫療、慢性病護理、職能與物理治療，以及特定處方藥物。
奚莉州長表示：「醫療對太多人來說過於困難且昂貴。我們正採取全國最全面的行動，讓患者能更快速、更廉價、更輕鬆地獲得所需護理」。新制規定，保險公司必須在 24 小時內回覆緊急授權申請，並在患者更換保險計畫時，承認原有的授權，以確保治療不中斷。
奚莉州長還宣佈成立「醫療負擔能力工作小組（Health Care Affordability Working Group）」，由前麻州衛生與公眾服務部部長、前波士頓醫療中心執行長凱特·沃許（Kate Walsh）以及公民銀行（ Citizens Bank ）麻州總裁麗莎·莫瑞（Lisa Murray）共同領導，著手進一步解決醫療成本問題。小組成員涵蓋麻州衛生與醫院協會、麻州醫學會、麻州生物技術理事會、麻州護理師協會以及麻州健康計畫協會（MAHP）等核心組織，預訂今年六月提交初步建議。
奚莉州長推出的新措施，旨在因應聯邦醫療環境的劇變。川普（Donald Trump）政府最近宣佈了一系列針對「平價醫療法案（ACA）」的經費削減計畫，還要減少聯邦對各州醫療補助（Medicaid）的撥款，試圖透過市場化競爭取代政府管制。
奚莉州長上週已宣佈從州級信託基金增加撥款 2.5 億美元，以補貼聯邦補貼縮減後飆升的保險費。本次針對先期授權的限制，被視為麻州民主黨政府應對聯邦「去管制化」及預算緊縮的防禦手段，旨在透過降低醫院端的行政負擔（據 CAQH 統計，2023 年全美此項成本高達 13 億美元），來抵銷成本上升。
醫療界普遍歡迎奚莉州長的這些措施。Melissa 在發佈會上流淚分享，因爲神經系統疾病藥物的授權耗時三個月，導致她身體受到永久性損傷。Lown 研究院高級研究員保羅·哈蒂斯（Paul Hattis）博士對此舉改善消費者體驗表示讚賞，但認為這是否能實質降低整體醫療支出，還有待觀察。
保險業界則提出警告。麻州健康計畫協會執行長羅拉·佩萊格里尼（Lora Pellegrini）引述 Milliman 報告指出，取消先期授權可能導致每位會員每年的醫療支出增加 600 至 1,500 美元。她強調，先期授權是確保循證醫療、防止過度醫療的重要「負擔能力防線」。
新規定將適用於所有在麻州經營的保險公司，但根據現行法律，多數大型企業採取的「自我保險」（self-insured）模式將不受此限。
Governor Healey Takes Nation-Leading Action to Make It Easier, More Affordable for People to Get Health Care
Eliminates prior authorizations for essential care; announces Health Care Affordability Working Group to Further Lower Costs
BOSTON – Today, Governor Maura Healey announced nation-leading
action to make it easier and more affordable for Massachusetts residents to get the health care they need. The Division of Insurance (DOI) is issuing updated regulations to streamline prior authorization practices in the state, including eliminating
prior authorization for many routine and essential services. These changes will reduce unnecessary delays and cut administrative burdens to make it easier, cheaper and faster for people to get the medications and care they need. Governor Healey also announced the creation of a Health Care Affordability Working Group charged with advancing proposals to reduce health care costs across the system, ultimately reducing costs for people and businesses across the state.
“Health care is too difficult and too expensive for far too many people,” said
Governor Healey. “So we are taking the most comprehensive action in the country to make it faster, cheaper and easier to get the care you need. This is a moment of urgency, and today we are bringing together leaders from across health care, business and labor to find every possible step we can take to lower costs and improve health care in
Massachusetts.”
“This initiative is cutting unnecessary red tape that has delayed care for too many patients and drives up costs for our families and businesses,” said Lieutenant Governor Kim Driscoll. “If we are serious about lowering costs, we have to take on the waste and unnecessary barriers that are driving up the cost of health care.”
Prior authorization requires doctors to get approval from a patient's health insurance plan before providing a service or medication, which often causes long delays and increases
administrative costs, which can be passed down to patients. DOI’s updated regulations streamline and standardize prior authorization practices across the health care system, reducing red tape and unnecessary barriers to care. The changes will eliminate prior authorization requirements for a wide range of services, such as emergency and urgent care services, primary care, chronic care, occupational and physical therapy and
certain prescription drugs. The regulations also eliminate duplicative claims submissions and simplify approval processes, reducing
administrative costs and burdens on doctors, hospitals and insurers and
helping the system operate more efficiently while keeping the focus on delivering care.
For patients, these reforms mean faster, more reliable access to care and fewer delays caused by insurance paperwork. By eliminating prior authorization for many routine and essential services, requiring insurers to respond to urgent requests within 24 hours, and ensuring continuity of care when patients switch plans, the regulations reduce disruptions that can delay treatment or send patients unnecessarily to emergency rooms. Greater transparency and fewer administrative errors will also ease the burden on providers, allowing more time to focus on patient care, helping ensure people receive timely treatment when they need it most.
Some examples of how these updated regulations will impact patients include:
A patient with diabetes will no longer need a prior authorization for any services, devices and drugs associated with their chronic disease.
A patient with rheumatoid arthritis who has an existing authorization for his treatment but recently switched to a new insurer will have that prior authorization honored for at least 3 months.
An insurer will be required to respond to a prior authorization request from a multiple sclerosis patient experiencing a relapse and needing steroid injections to prevent permanent nerve damage within 24 hours.
A provider who recently diagnosed their patient with a new condition will more easily be able to identify if a prior authorization is required for a particular course of treatment.
The health care industry spent $1.3 billion on administrative costs related to prior authorizations in 2023, according to a report from the Council for Affordable Quality Healthcare. That is a 30 percent increase over the previous year and can be largely attributed to the rise in the volume of prior authorizations. It costs about $6 per transaction for physician practices, health systems and others to conduct prior authorization-related administrative functions that are HIPAA secure. Standardizing and restricting prior authorization use in Massachusetts will simultaneously improve access to care, decrease administrative burden for providers, and decrease costs in the health care system.
“Massachusetts residents deserve leaders who are pulling every lever possible to make it cheaper and easier to get care when they need it,” said Senate President Karen E. Spilka (D-Ashland). “Today, Governor Healey is doing exactly that — cutting through red tape to deliver the care people deserve. At a time when Donald Trump and his allies are inflaming everything that’s broken in our health care system, Massachusetts is moving in the opposite direction. I applaud the Governor, Commissioner Caljouw, and the team charged with putting these reforms into action.”
“A competitive economy depends on an affordable, efficient, and reliable health care system,” said Economic Development Secretary Eric Paley. “This action reflects a broader commitment to reducing inefficiencies and improving quality of life across the state by ensuring residents have timely access to the care they need.”
“Prior authorization requirements have grown in complexity over time, confusing patients and doctors and delaying important care,” said Commissioner of Insurance Michael Caljouw. “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.”
Governor Healey has also created a Health Care Affordability Working Group, co-chaired by former Health and Human Services Secretary Kate Walsh and Citizens Massachusetts President Lisa Murray. The group will be charged with developing concrete proposals to reduce health system costs and ultimately make health care more affordable for patients, families, and employers.
The Working Group will focus on the underlying drivers of high health care costs — including administrative waste, pricing practices and system inefficiencies — and will develop actionable recommendations for lowering costs while protecting access and quality.
“Our health care system has reached a breaking point where costs are outpacing our ability to pay for care,” said Health and Human Services Secretary Kiame Mahaniah, MD, MBA. “As a physician, I see first-hand how important it is to be able to access affordable health care. We have a shared responsibility across government, industry, labor, and academia to stabilize the health care ecosystem and ultimately build a better, more sustainable, more affordable system. We’re fortunate to be here in Massachusetts, where we have the right team to do it under Governor Healey’s leadership.”
“Access to affordable health care is a core component of strong communities and economic mobility,” said Lisa Murray, Massachusetts State President, Citizens. “I look forward to working with Governor Healey and former Secretary Walsh to help drive solutions that allow businesses to offer lower cost healthcare to attract and retain talent in Massachusetts.”
“Much as Massachusetts led the country in adopting universal access to health care for our residents, under the leadership of Governor Healey a coalition of business leaders, policy makers, labor leaders, providers and insurers are coming together to address this national challenge,” said Kate Walsh. “This group is in a unique position to work together to rebalance toward a more sustainable health care system that works for everyone.”
Working Group Members:
Kate Walsh (Chair), Former Health and Human Services Secretary
Lisa Murray (Chair), Massachusetts State President, Citizens
Senator Cindy Friedman, Senate Chair, Committee on Health Care Financing
Representative John Lawn, House Chair, Committee on Health Care Financing
Matt Gorzkowicz, Secretary of Administration and Finance
Commissioner of Insurance Michael Caljouw
Amy Rosenthal, Undersecretary for Health, Executive Office of Health and Human Services
Mike Levine, Undersecretary for MassHealth and State Medicaid Director
Dr. Robbie Goldstein, Commissioner, Department of Public Health
David Seltz, Executive Director, Massachusetts Health Policy Commission
Andrew Jackmauh, Interim Executive Director, The Center for Health Information and Analysis
Matt Veno, Executive Director, Group Insurance Commission
Audrey Morse Gasteier, Executive Director, Massachusetts Health Connector
Steve Walsh, President & CEO, Massachusetts Health and Hospital Association
Lois Cornell, Executive Vice President, Massachusetts Medical Society
Michael Curry, President & CEO, Mass League of Community Health Centers
Tara Gregorio, President & CEO, Mass Senior Care Association
Kendalle Burlin O’Connell, President & CEO, MassBIO
Cari Medina, Executive Vice President, 1199SEIU
Joe-Ann Fergus, Executive Director, Massachusetts Nursing Association
Sarah Iselin, President & CEO, Blue Cross Blue Shield of Massachusetts
Lora Pellegrini, President & CEO, Massachusetts Association of Health Plans
Doug Howgate, President, Massachusetts Taxpayers Foundation
Jon Hurst, President & CEO, Retailers Association of Massachusetts
JD Chesloff, President & CEO, Massachusetts Business Roundtable
Ashley Blackburn, Interim Executive Director, Health Care for All
Danna Mauch, President & CEO, Massachusetts Association for Mental Health
Zirui Song, Associate Professor of Health Care Policy and Medicine, Harvard Medical School
Bela Gorman, health care actuary, Health Connector Board member
Chris Koller, health policy researcher & former RI DOI Commissioner
Statements of Support:
Senator Cindy Friedman (D-Arlington), Senate Chair of the Joint Committee on Health Care Financing:
“Prior authorization has become a tool used by insurers to delay and deny care. 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. 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.”
Representative John Lawn (D-Watertown), House Chair of Joint Committee on Health Care Financing:
“Providers and patients should be at the forefront of health care delivery, not paperwork. Removing prior authorization for essential services respects medical judgment and empowers patient voice. The working group will advance a stable, supported health care workforce and expand access to equitable care. These reforms reflect the Commonwealth’s ongoing commitment to an affordable and transparent health care system.”
Lora Pellegrini, President & CEO, Massachusetts Association of Health Plans:
“We applaud Governor Healey’s leadership in convening a health care affordability workgroup and share her focus on advancing practical, data-driven solutions that will lower costs for employers and consumers. The Massachusetts Association of Health Plans stands ready to partner with the Administration and other stakeholders to identify and implement meaningful reforms that address the drivers of health care costs.
“In that spirit, MAHP supports the Division of Insurance’s efforts to reduce administrative complexity related to prior authorization. Prior authorization plays an important role in ensuring patients receive the right care, at the right time, and in the right setting, and 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.”
JD Chesloff, President & CEO, Massachusetts Business Roundtable:
“In a recent survey of Massachusetts Business Roundtable members on the most pressing policy priorities for 2026, the cost of health care emerged as a top concern. Rising costs are felt across the health care ecosystem, by our world-renowned providers and payers, by families, and by employers and employees alike. With health care being a foundational industry to our economy, and a lifeline for patients across Massachusetts, we must bring urgency, bold thinking, and a strong spirit of collaboration to addressing this issue. The Roundtable is grateful to the Healey-Driscoll Administration’s for convening the Health Care Affordability Working Group to do just that.”
Ashley Blackburn, Interim Executive Director, Health Care For All:
“We are honored to join with other stakeholders in the Healey-Driscoll Health Care Affordability Workgroup and commend the Governor and her team for pursuing solutions to help individuals and families in Massachusetts who are grappling with often impossible health care cost challenges. We are confident this group will work collaboratively to advance bold solutions to help bring down costs for those who need it most at a time when access to affordable coverage is facing direct and meaningful threats. We are also excited to see Governor Healey’s administration take critical steps today to tackle an issue fundamental to improving access to care – prior authorization. Overuse of prior authorization often causes delays in medically necessary care and creates costly administrative burdens for patients and providers.”
Eric Dickson, MD, President & CEO, UMass Memorial Health:
“We are tremendously grateful to Governor Maura Healey and Massachusetts Division of Insurance Commissioner Caljouw for their commitment to studying the impact of prior authorization practices on health care in our state and taking bold regulatory action to reduce administrative burden, enhance continuity of care, and protect patients. While prior authorizations are necessary in some cases, they often complicate and delay the delivery of high-quality, medically necessary care, making it difficult for clinicians to gain approval for recommended diagnostics and treatments, and for patients to understand and navigate. The DOI’s decision to eliminate prior authorization for particular services and in certain circumstances, expedite approvals, and require improved transparency is a great first step in improving primary care access by allowing primary care physicians to spend more time caring for patients and less time on prior authorizations.”
Anne Klibanski, MD, President & CEO, Mass General Brigham:
“Mass General Brigham supports these reforms to reduce the burden of prior authorization and make insurance approvals faster and more predictable for patients and clinicians. We appreciate the Healey-Driscoll administration’s leadership in addressing unnecessary administrative requirements so physicians can spend more time focused on patient care and ensure patients receive high-quality care when and where they need it.”
Dr. Olivia Liao, President, Mass Medical Society:
“The Division’s report and draft regulations are a critical first step in addressing a key facet of systemic access challenges. The proposed regulations directly respond to concerns raised by the Medical Society and others and will have a meaningful impact by reducing delays, ensuring continuity of care for patients, and alleviating physician burnout associated with unnecessary and burdensome prior authorization requirements. We are grateful for the leadership of the Healey Administration and Commissioner Caljouw in taking these important regulatory steps. The Medical Society looks forward to engaging in a robust regulatory comment process and advocating for additional legislative reforms to achieve the best possible outcomes for patients and physicians.”
Eneida Román, President & CEO, We Are ALX:
“Access to timely, affordable health care is not a luxury, it is a foundation for thriving families, a productive workforce, and a stronger Massachusetts. We applaud the Administration for eliminating unnecessary barriers to care and for putting patients, families, and small employers at the center of policy solutions. These reforms expand opportunity and well-being across the Commonwealth, particularly for communities that too often shoulder disproportionate burdens in navigating the health system.”
Julie Burns, President & CEO, RIZE Massachusetts Foundation:
“Individuals seeking treatment for substance use disorder frequently encounter numerous obstacles. By eliminating prior authorization requirements, we can enhance access to care and significantly increase the likelihood that individuals receive the necessary support when they need it most. RIZE Massachusetts commends the Healey-Driscoll administration for its continued responsiveness to the opioid overdose epidemic and those impacted by it.”
Danna Mauch, PhD, President and CEO, Massachusetts Association for Mental Health:
"MAMH salutes Governor Healey's announcement on the Health Care Access and Affordability initiative. In particular, the Administration's steps to eliminate prior authorization for urgent care, emergency services, and inpatient hospitalization are welcome relief for individuals and families living with behavioral health conditions."
Steve Walsh, President and CEO, Massachusetts Health & Hospital Association (MHA):
“Our hospitals and health systems applaud the Healey-Driscoll Administration for this important day of action – all centered around supporting patients, businesses, and affordable care. These new prior authorization reforms are a tremendous step toward breaking down roadblocks that are proven to drive patient care delays, drive healthcare workers out of the field, and drive up costs for everyone. Commissioner Caljouw and his team should be commended for their months of thoughtful listening and resolve to remove harmful and unnecessary complexity from everyday care.For too long, stasis and division have stood in the way of what patients, caregivers, and employers truly need. We are honored to be a part of the Governor’s new workgroup to make meaningful progress on affordability and access using our commonwealth’s greatest strengths: innovation and partnership.”
Sarah Iselin, President and CEO, Blue Cross Blue Shield of Massachusetts:
"Health care costs are growing at the fastest rate in more than 20 years, putting incredible strain on families, employers, and government. We appreciate the administration convening this group to address the affordability crisis. Real change requires action at every level of the health care system, and as a state, we have a proud history of collaboration and innovation in health care. We look forward to partnering with the administration and other stakeholders on meaningful, long-term solutions that will help ensure Massachusetts residents can get the care they need at the most affordable cost.”
Matt Veno, Executive Director, Group Insurance Commission:
"The severe health care affordability challenge we are facing calls for serious, ambitious reforms that directly address the core, underlying drivers or rising premiums. Absent these reforms, the GIC and all others who seek to provide quality health insurance benefits to employees will continue face a never-ending list bad choices that erode benefits and shifts costs to consumers. I applaud the Healey-Driscoll Administration for taking this challenge on head-on by, I and am eager to get to work with my colleagues.”
David Seltz, Executive Director, Massachusetts Health Policy Commission:
“It has never been so imperative to safeguard health care affordability and accessibility – work that Governor Healey is committed to tackling across the Commonwealth with this Workgroup. The Healey-Driscoll Administration’s affordability priorities, including establishing the Health Care Affordability Workgroup, limiting health care premium increases, and capping deductibles and drug costs, directly align with the policy recommendations and mission of the Health Policy Commission. Now is the time for the Commonwealth to build on this momentum with renewed resolve to urgently pursue the shared goal of a health care system that puts patients first, and cement our status as a national leader in health care affordability efforts.”
Tara Gregorio, President and CEO, Massachusetts Senior Care Association:
“Access, affordability, and quality are fundamental to our healthcare system, especially for older adults and their caregivers. I commend Governor Healey’s bold leadership and commitment to addressing these challenges, and am confident that the Health Care Affordability Working Group will identify sustainable solutions that manage costs while ensuring access to high-quality care and services for older adults.”
Kendalle Burlin O’Connell, CEO & President, MassBio:
“It is a privilege for MassBio and this state’s life sciences industry to be a part of this working group that Governor Healey has charged with tackling such an important issue as health care affordability. As an industry that drives innovation for patients, we’re looking forward to being a part of finding creative solutions that can drive down costs and translate into savings for the Commonwealth’s residents.”
Cari Medina, Executive Vice President, 1199SEIU:
“I am honored to be a part of the Healey-Driscoll Health Care Affordability Workgroup representing over 80,000 healthcare and homecare workers across the state. 1199SEIU members are experiencing the brunt of this crisis both as patients and as caregivers. While dealing with their own healthcare costs rising, caregivers are struggling within a health system where staffing is short, the MassHealth budget is strained, affordable access to care is being reduced and delayed, and ER visits are ballooning. It’s critical that Massachusetts leads in this moment to stabilize our healthcare system and protect our health.”
Michael Curry, Esq., President and CEO, Massachusetts League of Community Health Centers:
“No family should have to choose between their health and putting food on the table or keeping the lights on. When health care is unaffordable, it becomes inaccessible, and that harms individuals, families, and communities across the Commonwealth. We must seize this opportunity to address the financial fragility in our health care system and the strain on our state budget caused by the loss of federal funds, while holding true to our commitments to quality, access, and equity. I'm grateful to Governor Healey for bringing together patients, providers, payers, and policymakers to meet this challenge. Massachusetts’ health care system is a national leader in quality and innovation, and I am confident this working group has the expertise and resolve needed."
Steve Walsh, President and CEO, Massachusetts Health & Hospital Association:
“Our hospitals and health systems applaud the Healey-Driscoll Administration for this important day of action – all centered around supporting patients, businesses, and affordable care. These new prior authorization reforms are a tremendous step toward breaking down roadblocks that are proven to drive patient care delays, drive healthcare workers out of the field, and drive up costs for everyone. Commissioner Caljouw and his team should be commended for their months of thoughtful listening and resolve to remove harmful and unnecessary complexity from everyday care. For too long, stasis and division have stood in the way of what patients, caregivers, and employers truly need. We are honored to be a part of the Governor’s new workgroup to make meaningful progress on affordability and access using our commonwealth’s greatest strengths: innovation and partnership.”
Jon B. Hurst, President & CEO, Retailers Association of Massachusetts:
“Our 4000 small business members exist to serve Massachusetts consumers; and they are clearly telling us that the most important step we can take to lower both the cost of living for their customers and the cost of doing business for their own bottom lines--is to lower health insurance premiums. Twenty years after the passage of Massachusetts healthcare reform with Chapter 58, we have unfortunately failed miserably to contain healthcare costs. There are no easy policy and political solutions, but real reforms are long overdue which will force the costs to reflect the rest of the economy for our premium payers and taxpayers. The Healey/Driscoll Administration should be congratulated for tackling this most difficult and costly competitive issue, and working to end 20 years of punting the political football.”
Bela Gorman FSA, MAAA, Actuary:
“I am excited to collaborate with this group and to find viable solutions to the Commonwealth’s health care cost challenges.”
