Why some payers, physicians object to the Texas physician 'gold card'

A new law that took effect Sept. 1 in Texas aims to ease the administrative burdens that insurance companies place on physicians, but some payers have voiced their opposition to the legislation, claiming it will put more patients at risk.

Under the legislation, physicians in Texas who are approved 90 percent of the time for certain procedures, treatments or drugs will receive "gold card" status and will no longer require prior authorization from insurers.

The idea is that top-performing physicians will be able to bypass the approval process for certain services, eliminating a significant administrative burden, and thus spend more time with patients.

The legislation, written by State Sen. Greg Bonnen, MD, R-League City, a spinal neurosurgeon with Houston Physicians' Hospital, has received support from several Texas physician societies and could prove very beneficial for providers, as many insurers require prior authorization for various imaging, medications and procedures.

Payers opposing the gold card, including Cigna, Blue Cross Blue Shield Texas and Superior HealthPlan, claim that it will put patients at risk, arguing that prior authorization is necessary to minimize costly procedures and act as a check on potentially unnecessary, inappropriate or unsafe medical treatments.

"A lot of time what goes on with patient safety isn't really just what happens with one physician," Jamie Dudensing, CEO of Texas Association of Health Plans, told Houston Public Media. "Health plans tend to be one of the few entities watching a patient's role in healthcare where you have a 360-degree view of what's happening."

Some physicians don't see the legislation as streamlining the care delivery process and expect insurers to find another way of moving the goalposts.

"In my opinion, the insurance industry will simply enunciate a new series of excuses and provide new hoops and hurdles for the practitioner's office to deal with," Robert A. Peinert Jr. MD, a Harlingen, Texas-based orthopedic surgeon, told Becker's. "When profit for the insurance industry is the main goal of the industry, I expect they will focus on maximizing profit, and the best way to create profit in health insurance is to decrease utilization of expensive tests, procedures and surgeries.

"The best way to do that is to create a statistical analysis of all tests, procedures and surgeries and declare that their propriety statistics prove that certain expensive tests, procedures and surgeries do not provide either enough diagnostic information or do not result in sufficiently meaningful life or function improvements so as to justify payment. In other words, there are many ways to deprive patients of care."

Despite some opposition, insurers in Texas are now analyzing which physicians qualify for "gold card" status, but some provisions in the law may be too challenging for insurers to implement, according to Ms. Dudensing, which could lead to prior authorization being eliminated across the state, not just a verified group of physicians.

But many physicians are hopeful of the changes the physician gold card may bring, and success in Texas could lead to other states adopting similar laws.

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