Ezequiel Silva, MD, a radiologist at San Antonio-based South Texas Radiology Group and chair of the Texas Medical Association's Council on Legislation sat down with the American Medical Association to discuss Texas' gold card law and its impact on the prior authorization process.
Here are five takeaways from the discussion:
1. Gold card PA exemption: The gold card law allows physicians who have a high approval rate for PAs to bypass the PA process for future requests for the same services. This can alleviate administrative burden and speed up care delivery for physicians.
2. Eligibility: According to the Texas Department of Insurance, only about 3% of physicians in the state have achieved gold card status. Despite this, the law remains an important catalyst in the broader discussion around PA, Dr. Silva said.
He explained some of the factors contributing to the low gold card membership in the state.
"[We've] done a lot to influence at the TMA how this legislation was rolled out at the practical level. But there were shortcomings," he said. He noted that the bureaucratic and regulatory processes behind a program like this involve a significant amount of adjustment and uncertainty, and underscored the importance of physicians being fully educated on these programs.
"How they can understand what this law enables for them and where they see shortcomings, how they can bring that to the attention of the state, but also the attention of their insurers," he said.
3. Impact on patients: Lengthy PA processes can cause patient care to suffer, Dr. Silva said.
"We think about the downsides to prior authorization, which is certainly [a] burden to physicians, financial strain on physicians, but it's also patient harms. It's abandoning treatment, loss of bodily function, even death in the most dramatic of cases," Dr. Silva said. "The fact that we've been successfully able to bring attention to those shortcomings at both the state level, but also other states. For example, Mississippi, Alaska, are two places I've had the good fortune of testifying on this topic."
4. Broader advocacy and influence: More adjustments remain to for future PA programs, such as closing gender gaps that exist within approval processes, Dr. Silva said.
"[In] men and women, the anatomy is analogous. The symptoms are different. And I made the comment how I've struggled to get approval in my female patients, whereas my male patients, because it's a bit more of an established procedure, have been successful," he said. "And so I'm pleased to report that I've seen some improvement with a couple of the larger payers, largely from my own individual efforts."
5. Better definition of procedures and future reforms: The slow uptake of Texas' gold card program highlights the need for more widespread and comprehensive reforms to PA processes, Dr. Silva said. This includes determining procedures that should be exempt from PA and sharpening processes to ease the burden on physicians and harm to patients.
"Our legislation, I think, was among the first in the country," he said. "And I think it was a great initial blueprint. But as I'm expressing and as we're learning, there's always room for improvement. So our ability to translate that at the state level, I think, is important."