Imagine a world with fewer prior authorizations. A new Texas law aims to make this dream a reality. House Bill 3459(HB 3459), or the “Gold Card Act,” grants prescribers a “continuous prior authorization exemption” if they have a 90% approval rating on previous authorization requests.
The “gold card model” is not a new concept. The American Medical Association(AMA) recommended a similar model in its Prior Authorization and Utilization Management Reform Principles. The AMA stated, “Health plans should offer providers/practices at least one physician-driven, clinically based alternative to prior authorization, such as but not limited to “gold-card” programs.”
In 2019, Virginia became the first state to pass a gold card law, followed by Texas passing HB 3459 in September 2021. Other states have initiated gold card pilot programs or have introduced similar legislation.
Let’s discuss why prior authorization reform is urgently needed, the details of Texas’ prior authorization gold card law, and the future of prior authorization reform.
Why is Prior Authorization Reform Needed?
Prior authorization (PA) reform has been discussed for years, but the recent Virginia and Texas bills represent active progress. PAs delay patient care, increase a patient’s risk of an adverse event, steal provider time away from more patient-centric activities, and increase administrative costs for doctors and hospital systems.1,2
A recent survey of cardiologists discovered that 77% of the cardiologists felt PAs “compromised the total time spent on patient care and stood as a barrier to trying new therapies.”2 Similarly, the results of a 2021 AMA survey of physicians reported the following about PA delays:
- 34% led to severe adverse events.
- 24% led to patient hospitalization.
- 8% led to a patient’s disability or death.
Figure 1 reveals additional results of the 2021 AMA PA survey. 91% of physicians believe PAs negatively impact patient clinical outcomes and 93% report care delays.
The survey results unanimously indicate that PA reform is essential to prevent patient suffering.
An additional benefit to fewer PAs is administrative cost reduction.1 A 2019 report from the Council for Affordable Quality Healthcare (CAQH) discovered PA administrative costs for health care plans and providers totaled $631 million.
Gold card programs aim to reduce the time providers spend on PA paperwork, the time patients must wait for life-saving therapies, and the cost of PA management.
Who Qualifies for a Texas Gold Card?
The Gold Card Act requires commercial, state-regulated health plans grant Texas prescribers a continuous PA exemption on services for selected healthcare services if, in the previous year they:
- submitted at least five PA requests for the same healthcare service; and
- the health plan approved at least 90% of those PA requests.
Improving the PA process has been a top priority for multiple medical associations and insurance companies, including the AMA, Blue Cross Blue Shield, the American Pharmacists Association, and the Medical Group Management Association.
These professional associations and stakeholders created a consensus statement promoting an incentive program for prescribers who use evidence-based prescription guidelines and have high PA approval rates.
The Texas Gold Card Act aligns with the goals of the consensus statement. However, the Texas gold card does not apply to Medicaid and CHIP. In addition to insurance limitations, the gold card covers a limited number of healthcare products and services.
What Healthcare Services Will the Texas Gold Card Cover?
HB 3459 doesn’t grant PA exemptions for every surgery, medical device, or therapy. The PA exemption only applies to specific services, which can include:
- laboratory services, and
- medical equipment.
As of July 2022, the law has not been fully implemented and is waiting for the Texas Department of Insurance (TDI) to establish rules, including which specific prescriptions, laboratory services, and equipment will be included in the exemption.
Who Decides Which Physicians Qualify for a Texas Gold Card?
The primary concern among providers is who will grant a physician gold card status. Ultimately, the insurance companies will determine gold card status, and many physicians believe insurance companies will only create new obstacles for providers.
Blue Cross Blue Shield of Nebraska started offering a gold card program for their physicians in 2018.1 Gold card physicians use a special fax cover indicating a medical review is unnecessary for the patient.1 While this is an example of a successful collaborative relationship, the process of manual prior authorization still burdens most physicians.2
In an AMA survey, 22% of physicians report spending over 20 hours weekly on PAs, and 90% report care delays. The current PA process risks patients’ lives, but will the gold card improve patient care? A lack of real-world evidence (RWE) is an obstacle to evaluating gold card programs’ impacts on patient care.
Is the “Gold Card Model” the Future of Prior Authorization?
The “gold card model” is supported by many medical associations. However, other strategies for improving the current PA process have been proposed. PA reform strategies can fall under the following three categories:
- Rewarding prior authorization success:1 The gold card model falls under this category. Another program similar to the gold card program is the sunset program, which eliminates PAs for common drugs and services.
- Reducing the manual burden of prior authorization:1 By utilizing machine learning and algorithms, the time-consuming process of filling out forms, faxing, and waiting for a response can be significantly reduced.
- Addressing prior authorization early:1 When a patient is diagnosed with a condition, a “prior authorization bundle” would allow physicians to submit one PA request to cover the full episode of care.
Though this list of PA reform strategies is not comprehensive, it does imply more than one strategy is required to solve the PA crisis. Effective reform will require collaboration among providers, patients, payers, and the government to ensure policy creates real-world clinical improvements. While the Texas gold card program is a step forward for PA reform, the quest to reduce the burden of PAs for providers and patients remains.
To learn more about PA reform, visit the American Medical Association(AMA) website, which provides resources on PA legislature, join the AMA’s grassroots prior authorization reform campaign, and read other blog posts on the National Board of Prior Authorization Specialists website, including the Definitive Guide to Prior Authorization.
- Psotka MA, Singletary EA, Bleser WK, et al. Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in Healthcare Initiative’s Prior Authorization Learning Collaborative. Circ Cardiovasc Qual Outcomes. 2020;13(7):e006564. doi:10.1161/CIRCOUTCOMES.120.006564.
- Sharma SP, Russo A, Deering T, Fisher J, Lakkireddy D. Prior Authorization. JACC: Clinical Electrophysiology. 2020;6(6):747-750. doi:10.1016/j.jacep.2020.04.022.