As the 2022 legislative year is winding down, two states marked significant legislative successes in healthcare policy. Utilization management reform bills, years in the making, were recently enacted in Pennsylvania and Massachusetts. Both efforts labored across multiple legislative sessions, sometimes falling just short of the finish line, and offer case studies in how substantive policy change can take persistence, patience and a bipartisan approach to achieve success.
Pennsylvania Utilization Management Reform
In Pennsylvania, S.B. 225 passed by unanimous votes in both chambers and was signed by Gov. Tom Wolf on Nov. 3. Importantly, S.B. 225 reformed both prior authorization and step therapy protocols in state-regulated health plans. Both prior authorizations and step therapy override requests are now subject to standardized timelines for approval: Urgent requests must be decided within 24 hours and non-urgent requests must be decided within 15 days. Importantly for rheumatology professionals, urgent prescription requests must be decided within 24 hours, and all other prescription requests must be decided within 72 hours. There are no prior authorization requirements for emergency services.
S.B. 225 also includes important step therapy exception criteria that will provide protections for patients and streamline the step therapy process. The notable exceptions are for:
- Contraindications, including adverse reactions;
- Expected clinical outcomes of the required step;
- Expected clinical outcomes of the requested therapy or prescription; and
- Instances in which a patient has previously received and failed to respond to a “step” on the same or previous insurance.
Massachusetts Step Therapy Reform
In Massachusetts, step therapy reform bill H. 4929 passed both chambers by unanimous vote and was signed by Gov. Charlie Baker on Nov. 1. H. 4929 requires a response within 24 hours for emergency step therapy requests. A response within three business days is required for all other step therapy requests. Additionally, the legislation carves out important step therapy exceptions for patients, including exceptions for:
- Contraindications or adverse reactions;
- Instances in which the required prescription is likely to be ineffective;
- Patients who previously received and did not respond to the required medication; and
- Patients who are currently stable on another medication.
Lessons Learned & What’s Next
These reforms will have significant impact on patients who are currently enrolled in state-regulated health plans in Massachusetts and Pennsylvania. These states serve as reminders of what can happen when leaders work in a bipartisan manner to tackle serious policy problems. If you are wondering if this approach can succeed in Washington, D.C., the Safe Step Act (H.R. 2163) and Improving Seniors’ Timely Access to Care Act (H.R. 3173) show that the answer is a resounding and emphatic, “Yes!” Both federal bills currently enjoy strong bipartisan support. The Improving Seniors’ Timely Access to Care Act had 326 bipartisan cosponsors in the House before it passed by a voice vote—more cosponsors than the required votes needed for passage. The Safe Step Act currently has 191 bipartisan cosponsors.
