June 21, 2021
“Gold Card” Law Means Less Waiting for Patient Care
Care for countless Texas patients will happen more quickly by reducing certain health plan bureaucratic delays, thanks to a bill Gov. Greg Abbott allowed to become law.
The Texas Medical Association (TMA) prioritized curbing onerous prior authorization practices by many state-regulated health insurers and health maintenance organizations (HMOs) this legislative session. The result was passage of House Bill 3459 by Rep. Greg Bonnen, MD (R-Friendswood), and Sen. Dawn Buckingham, MD (R-Lakeway), with considerable support by Sen. Jane Nelson (R-Flower Mound). The bill will allow physicians to earn a “gold card” exemption from certain health plans’ prior authorization review requirements for certain care – if the physician achieves a track record of enough previous approvals from the insurers or HMOs.
“We are excited about the gold-carding process in this law because it will provide an easier way for patients to get care they need, and reduce the administrative burden for physicians who care for them,” said Debra Patt, MD, an Austin oncologist and immediate past chair of the TMA Council on Legislation.
Health insurers and HMOs use prior authorization to scrutinize the medical services and medicine physicians order for their patients. The patient’s health plan issuer decides whether it wants to pay for the treatment or prescription the physician orders, and awaiting that decision often delays care. Physicians say prior authorization delays are too often unnecessary.
As an oncologist who treats breast cancer patients, Dr. Patt has frequently faced those approval delays.
“It interrupts the care of patients moving forward, and delays appropriate care,” she said. “Whenever I order things like imaging, it’s to evaluate response to chemotherapy, usually in patients with advanced cancer. [Waiting for authorization] can delay appropriate care decisions, sometimes by a month or more – which can have a significant impact on the care of those patients.”
Physicians who had prior authorization requests for prescriptions and treatments approved by an affected insurer or HMO at least 90% of the time in the most recent six-month review period would achieve “gold-card” exemption status from that insurer or HMO, for the same treatment. Also, the person on the peer-to-peer review call with the treating physician must be a Texas-licensed physician of the same or similar specialty.
The practice of prior authorization was started years ago by insurers and HMOs to check on the medical necessity of expensive and less common care, prescriptions, and treatments; however, insurers increasingly apply it to basic and routine patient care.
Eight in 10 Texas physicians reported having to obtain prior authorization for medical procedures and even common, generic prescriptions. Four-fifths (85%) reported prior authorizations delayed patient care, often leading to an adverse event for their patient.
“The prior authorization burden is real,” said Dr. Patt, who looks forward to being able to provide more timely care for her cancer patients who need it, as her care approval rate would meet the 90% prior authorization approval threshold.
The gold-carding provisions of the law apply to state-regulated 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. It takes effect in September.
TMA is the largest state medical society in the nation, representing more than 55,000 physician and medical student members. It is located in Austin and has 110 component county medical societies around the state. TMA’s key objective since 1853 is to improve the health of all Texans.
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Contact: Brent Annear (512) 370-1381; cell: (512) 656-7320
Marcus Cooper (512) 370-1382; cell: (512) 650-5336
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