Prior authorization is a pain. A paper by Howell et al. (2021) found that the total cost of various utilization management schemes is $93.3 billion of which physicians devote $26.7 billion worth of time to navigate utilization management systems. Payers would argue that prior authorization helps to control costs and stop the prescribing of unnecessary medications. Is there a better way?
Based on a recent state law, Texas physicians may be able to circumvent prior authorization with a ‘gold card’. The American Medical Association reports:
Under a law that took effect this month and is the first of its kind in the U.S., physicians who have a 90% prior authorization approval rate over a six-month period on certain services will be exempt—or “gold carded”—from prior authorization requirements for those services.
These gold-carding provisions apply to commercial HMO plans, preferred-provider benefit plans, exclusive-provider benefit plans, and certain Employees Retirement System of Texas and Teacher Retirement System of Texas plans.
This Texas law in part was drawn from AMA’s Prior Authorization and Utilization Management Reform Principles. The document states that:
…“health plans should restrict utilization management programs to ‘outlier’ providers whose prescribing or ordering patterns differ significantly from their peers after adjusting for patient mix and other relevant factors.” The principles further elaborate that health plans should offer a “physician-driven, clinically based alternative to prior authorization, such as…‘gold card’…programs.”
While Texas is the most recent state to enact gold carding, it is not the first. As reported at Becker’s Healthcare, in 2019, West Virginia passed its own “gold card” provision, whereby providers are exempt from prior authorization rules if they have a 100 percent approval rate on a certain service criteria over a 6 month time frame. Vermont is piloting a similar program and New York, Colorado, Indiana, Kentucky, Mississippi and Oklahoma have all introduced gold card legislation.
Further, Texas my no longer be an outlier. U.S. Rep. Michael Burgess (R-TX) recently sponsored a bill introduced June 9 known as the Gold Card Act of 2022 (H.R. 7995). This act would mirror the Texas law, exempting qualifying providers from prior authorization requirements under Medicare Advantage plans.
A key question of course is who determines the gold card criteria and are do they adequately distinguish between physicians who are outlier compared to non-outlier prescribers. Would physicians at tertiary care centers or academic health centers be less likely to get a gold card due to treating more complex patients? Much is yet to be ironed out, but expediting the prior authorization process is one that patients and physicians would certainly be happy about.