Prior authorization 'gold card' bills spark conversations in states

Prior authorization has long caused professional strife for Dr. Zeke Silva, a San Antonio-based radiologist. But last year it became personal.

His wife had breast cancer, and her doctors wanted to schedule a MRI. Their insurer denied the request. She eventually got the procedure approved, but it was delayed.

Silva hopes to see these situations less now that Texas passed a statewide prior authorization “gold card” law. The measure requires insurers to exempt providers from pre-authorization for certain services if they achieve a 90% approval rate for the service over six months.

“I’m looking forward to a time where, because of that gold carding status and satisfying that 90% threshold, that I can look a patient in the eye and tell them confidently ‘This is what I’m recommending. … Oh, and by the way, you and I don’t have to go through a prior authorization process to make this happen,’ ” Silva said.

Nearly 90% of providers said prior authorization felt very burdensome, according to a 2021 Medical Group Management Association survey. And it’s not just a burden issue—24% of physicians surveyed by the American Medical Association last year said their patients often abandon care after facing pre-authorization.

The AMA and other groups have endorsed gold card policies since 2017, and limited programs from payers existed before then.

The policies are picking up steam. West Virginia was first to pass a statewide exemption law in 2019. Providers are exempt from prior authorization for a service if they achieve 100% approval for that service over six months. Then Texas passed a more lenient law, requiring a 90% approval rate, last year.

At least eight other states including Connecticut and Kentucky introduced gold card bills this year, though some legislative sessions ended without the bills passing. Other state medical associations, including in Ohio, are working on bills.

Rep. Michael Burgess (R-Texas) thinks a gold card program could work on a national level. He hasn’t introduced specific legislation, but he cosponsored a bill to improve Medicare Advantage prior authorization that would allow plans to create exemption policies.

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Data on the programs’ effectiveness is hard to find, though. Vermont Medicaid’s gold card program for radiology services did provide “a notable example of success in improving clinical results and reducing administrative burden for healthcare professionals,” according to a 2020 report from the Vermont Department of Health Access.

But gold cards could potentially worsen health inequities, the American Heart Association and the Duke-Margolis Center for Health Policy said in a 2020 report. Smaller practices might not have the same resources as larger health systems to put into earning approvals and appeals.

More outcomes information should be available soon, as Texas providers become eligible for gold cards starting this summer. Vermont also began running a statewide pilot program for private insurers earlier this year, separate from its Medicaid gold card program. Insurers will submit reports on their programs to the state by January, including data on costs and savings.

Prior authorization often divides insurers and providers. The Texas Association of Health Plans said in a 2021 document that the state’s new law could cause an “inappropriate ‘guarantee of payment’ for potentially inappropriate or even harmful care.” And health insurance trade group AHIP cautioned against placing too much weight on gold cards.

“Gold carding isn’t a silver bullet, and it’s not appropriate for every care provider,” AHIP Spokesman David Allen said in an email. Gold carding should be used to recognize excellence and incentivize best practices, Allen added.

However, some insurers have turned to gold cards to promote efficient care. For example, SelectHealth just rolled out preauthorization leniency for hysterectomies and plans to expand to other services.

Providers know gold cards aren’t the only solution. Jessa Barnard, executive director of the Vermont Medical Society, said policies around electronic prior authorization help too.

States are looking at a wide range of prior authorization reforms, said Todd Baker, Ohio State Medical Association CEO. “I don’t know (that) there’s too many states right now that don’t have some kind of insurance administrative reform, all in little bits of different flavors,” Baker said.

But as states debate gold cards, providers are optimistic. Dr. Chris Phillips, a Kentucky rheumatologist, said he felt relieved to see his state consider a gold card bill.

“It would save several hours a day of work by my staff, which could be better directed toward patient-centric activities, and actually taking care of the patients,” Phillips said.