Austin oncologist Debra Patt, MD, has seen patients with advanced breast cancer wait for more than a month to start much-needed treatment because of onerous prior authorization requirements.
Dallas public health specialist John Carlo, MD, says health plans sometimes approve prior authorization requests for only two of three medications in an anti-HIV cocktail, leaving his patients unknowingly taking an incomplete regimen until their follow-up appointment. San Antonio internist Jayesh Shah, MD, has patients with diabetic foot ulcers for whom prior authorizations can delay care, leading to costly hospital stays, limb amputation, and even premature death.
These and other well-documented harms are what helped get House Bill 3459 by Rep. Greg Bonnen, MD (R-Friendswood), and Sen. Dawn Buckingham, MD (R-Lakeway), across the finish line during the 2021 legislative session. Under the new law, physicians who earn approvals on at least 90% of prior authorization requests for a given service or medication can earn a “gold card” exempting them from the onerous preapproval requirements for that service or medication.
Now, physician advocates, alongside the Texas Medical Association, are looking to this fall’s legislative races as they monitor the rulemaking underway to implement the law and prepare to push for additional reforms during the 2023 legislative session that kicks off in January.
Although the law applies only to state-regulated plans, which account for about 20% of the Texas market, Dr. Patt says it already has had an impact, inspiring similar legislation in other states and promising long-awaited relief. (See “Gold Card Benefits,” page 38, and “The New Gold Rush,” March 2022 Texas Medicine, pages 14-19.)
“The gold-carding policy in Texas is incredibly meaningful,” she said.
And Texas physicians intend to keep it that way, ensuring the proposed rules the Texas Department of Insurance (TDI) issued in mid-April reflect the law’s intent as passed. While the draft regulations include some positive developments, TMA has concerns certain portions deviate from HB 3459 as written.
Dr. Carlo, who serves on TMA’s Board of Trustees, says rulemaking is as critical as the lawmaking that precedes it.
“We owe it to be diligent in making sure that what we had argued for and what was passed by the legislature is implemented,” he said.
“We understand that there is nuance and interpretation, but there is also concern that other groups might have influence, or the rulemaking may change … the [law’s] intent.”
Proposed problems
The gold-card provisions of HB 3459 technically apply to prior authorization requests as of Jan. 1, 2022, onward but have yet to take effect with rulemaking still in progress. In a September 2021 comment letter submitted to TDI, TMA and 13 other Texas state medical organizations expressed several concerns that nevertheless remain in the draft rules.
For instance, physicians would have to earn approvals on at least 90% of at least 20 prior authorizations on a given service over a six-month period to earn a gold-card exemption. The law, however, does not stipulate a minimum of 20 prior authorizations, which TMA staff point out may be overly burdensome for some physicians given the time constraints.
The law also requires peer-to-peer calls, which occur before a preapproval request is denied, to be conducted by a Texas-licensed physician in the same or similar specialty as the physician who requested the service. TMA and the others argued in their comment letter that “for the functions performed by the physician to truly be ‘peer-to-peer,’ the reviewing physician must have full authority to practice clinical medicine in this state.”
Rather than requiring a full license, however, the draft regulations would allow physicians with a more limited administrative license from the Texas Medical Board to fill this role.
The proposal also indicates that notice of the first gold-card exemptions could be provided as late as Oct. 1 of this year. However, because the related provisions in the law took effect on Jan. 1, that date is a good three months later than the end of the first six-month review period on June 30.
“What we’re hearing from physicians, and what we heard going into session is, ‘We need help now,’” said Zeke Silva, MD, a radiologist in San Antonio and a member of the TMA Council on Legislation who also testified in support of HB 3459. “‘We’re seeing patient harms today.’”
Medicine’s advocacy did not go entirely unnoticed. The proposed rules expressly mention the inclusion of prior authorization requests for prescription drugs, despite health plans’ attempt to exclude them from the health care services eligible for exemptions.
Dr. Silva says this is critical for patients who are left waiting on an appropriately prescribed, commonly used generic medication.
“It feels sort of opportunistic for insurance companies to push [such prescriptions] through the prior authorization process,” he said.
As of this writing, TMA was preparing to highlight its reservations and push for a quicker implementation timeframe in a comment letter and testimony the association planned to submit to TDI in mid-May. The final rules will be published after TDI considers comments from interested parties and may include changes to the proposed rules.
Reforms, cont’d
While the gold-card law is precedent-setting, physicians are mindful it is not a panacea for physicians’ prior authorization woes.
Clayton Stewart, TMA’s vice president of public affairs and chief lobbyist, says the association expects to revisit the recurring the issue during the 2023 legislative session.
Priority legislation includes eliminating prior authorizations altogether for patients with autoimmune disorders, who can find themselves waiting for health plans’ approval each time their prescriptions are renewed. Another goal is requiring health plans to provide 24/7 prior authorization processing.
TMA board member Dr. Carlo called these reforms “commonsense approaches to [addressing] these overly bureaucratic steps.”
The American Medical Association House of Delegates in 2020 passed a resolution advocating for health plans that require preauthorization to have staff available to process those approvals 24/7, including on holidays and weekends.
“If you are expecting doctors and hospitals to be on call, why are insurance companies not on call?” asked Dr. Shah.
The San Antonio internist was one of several AMA house members to speak on the policy, which he says would work in concert with Texas’ gold-card law to prevent care delays and other life-changing – or life-ending – consequences.
“This process has to change,” he said. “Our patients deserve better.”
Tex Med. 2022;118(6):37-39
June 2022 Texas Medicine Contents
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Emma Freer
Associate Editor
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