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Speeding up prior authorization: What is the gold card program? How does prior authorization affect patients? What is prior authorization in health care?
Ezequiel (Zeke) Silva III, MD, a radiologist at the South Texas Radiology Group, the chair of the Texas Medical Association (TMA) Council on Legislation and member of the AMA Council on Medical Service, joins to discuss the Texas Gold Card Law, its impact on the prior authorization process, as well as the TMA's and AMA's ongoing advocacy efforts to improve health care legislation. AMA Chief Experience Officer Todd Unger hosts.
- The AMA is your powerful ally, focused on addressing the issues important to you, so you can focus on what matters most—patients. We will meet this challenge together. Join us.
- Learn how the AMA is fighting prior authorization.
- Get involved! Patients and physicians can share prior authorization stories.
- AMA prior authorization survey (PDF)
- Googling "prior authorization laws by state"? Use AMA prior authorization state law chart (PDF).
- AMA prior authorization physician advocacy examples (PDF).
- AMA prior authorization model bill (PDF).
- Access AMA prior authorization legislation resources and research.
- AMA prior authorization reform and model legislation.
- Stay up to date on AMA efforts to fix prior authorization policy.
- Learn more about the AMA Health System Program.
- Learn more about our AMA advocacy priorities, including:
- Reforming Medicare payment
- Fighting scope creep
- Fixing prior authorization
- Reducing physician burnout
- Making technology work for physicians
Speaker
- Ezequiel (Zeke) Silva III, MD, chair, Council on Legislation, Texas Medical Association; member, Council on Medical Service, AMA
Transcript
Unger: Hello and welcome to the AMA Update video and podcast. Today, we're talking about the legacy of the Texas Gold Card law and the influence that this piece of legislation has had on the fight to fix prior authorization at the federal level. Our guest today is Dr. Zeke Silva, a radiologist at the South Texas Radiology Group and the chair of the Texas Medical Association Council on Legislation. Dr. Silva is also a member of the AMA Council on Medical Service, and he's calling us today from San Antonio, Texas. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Silva, welcome.
Dr. Silva: Great thanks, Todd. It's great to be here.
Unger: I follow you on social media. I see a lot of what you post. So how great to talk to you today and especially about this topic of gold carding. Back in 2021, you and your colleagues at the Texas Medical Association were instrumental in helping to get the Gold Card law passed. Before we dive in, though, why don't we just start with a brief explanation of what gold carding is and how it helps physicians.
Dr. Silva: In general, gold carding as it relates to prior authorization is basically a physician who earns an exemption from prior authorization going forward. It's usually based on a threshold of previous services being approved, not being denied in the prior authorization process. And it just alleviates for that physician the burden of going through that process every time that he or she orders a service that is really common within their practice or with their patient population.
Unger: Well, you've now got three years under your belt in terms of that legislation. And I'm curious what's changed for physicians in Texas.
Dr. Silva: Yeah, on the one hand, the numbers have not been overwhelming. The figure we have from the Texas Department of Insurance is only about 3% of physicians have earned Gold Card status. But I think on the other hand, I think it's important to note the attention that this issue, that this legislation, that this broader discussion has brought to the topic of prior authorization. And for that, I think we're most proud. And I think that's the real legacy is.
We think about the downsides to prior authorization, which is certainly 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. 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. And certainly what I anticipate we'll talk about later, which is activity at the federal level, to address just those shortcomings, as I described.
Unger: It definitely kind of set off and amplified this whole movement around prior auth. I'm curious talked about 3%. What's it take to get bigger than that?
Dr. Silva: Yeah, anytime we pass a law, and this is true at the state or federal level, the implementation of the law is always an uncertainty—and that's a regulatory process, a bureaucratic process, if you will. And we've done a lot to influence at the TMA how this legislation was rolled out at the practical level. But there were shortcomings.
How services are defined, the threshold being somewhat difficult to reach, and just a little bit of resistance—imagine that—from the health plans to implement this at a full scale that we continue to work both at the legislative level through future potential legislation, but also directly at the regulatory level with the Department of Insurance. And I think, importantly, educating our physicians. 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.
Unger: I'm curious how this is all playing out in your own practice. Is there an example or a story that you can share?
Dr. Silva: Yeah, thanks for asking. When I testify, and this goes back to 2021, I described a procedure that I performed, which is embolizing the gonadal vein. And 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. 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. But I think equally important, just from a greater awareness by these payers of the shortcomings this brings to patient care, and we're enabling greater and more frequent approvals can ultimately lead to better care and quality.
Unger: Now you mentioned that the Texas law was kind of a model in which other states have then acted upon. Given your experience over the past three years, do you have any advice for other states looking to do something similar?
Dr. Silva: There's one piece of advice that I would give. First of all, this is a national problem. The prior authorization shortcomings and the data we have from the AMA are not state specific. So every state has this problem. So my advice would be and when you find yourself in the circumstance of testifying on this matter before, imagine, a House insurance committee. When I went to those committees, I had plenty of stories in my pocket, both about my patients, even personal.
But what carried the day was the stories from the lawmakers. When I testified at Senate Finance, no less than four different senators told stories about their own families experiencing prior authorization challenges. One was even as dramatic as her granddaughter having a head injury and the CT of the brain or the head being denied initially. When you're a senator, you have some power locally and in your state. She was able to get the study approved and there actually was an injury that was important to diagnose.
So count on those stories. Stories matter. We're physicians. We bring that experience to the table. We can enable those discussions. And the stories about our own patients and their shortcomings oftentimes will carry the day.
Unger: Gosh, I hear that same thing over and over again from different physicians that I talk to. Whether it's on prior auth or Medicare payment reform. It's those stories from physicians and from their patients in terms of how that impacts them. Dr. Silva, you mentioned that although there's a lot of work going on at the state level, this is also a big federal issue. Can you talk to us a little bit more about how the AMA's advocacy at the federal level has impacted you and your patients?
Dr. Silva: Yeah, indeed. Indeed. It's no coincidence that two authors of probably the most significant prior authorization legislation at the federal level, which is H.R. 4968, are both from Texas. One is Michael Burgess, who's from the Dallas area, and the other is Vincent Gonzalez, who's from South Texas, from the Rio Grande Valley—Republican, Democrat, respectively. So this is a bipartisan issue.
And I said, I mentioned earlier the sort of universal nature of this. It's something that when we see the parties come together on this type of an issue where improvement is definitely needed and possible, I think that's important. So what we're going to see at the federal level, when we talk about health insurance, you have state regulated plans and then you have federally regulated plans. Medicare Advantage is a good example. ERISA plans are another.
So our ability to implement successfully legislation at the federal level to help curtail these shortcomings on what is, in many states, the majority of our insured patients and physicians really stands to make a difference on a larger scale than any individual state can achieve. And I think the more we can support that as physicians, both at the state level, but also at the federal level, I think has the power to truly make a difference and improve these circumstances.
Unger: Absolutely. And in a few months, the Texas legislature is going to be back in session. I'm curious, what are the advocacy priorities for the TMA when it comes to prior auth?
Dr. Silva: It's such an important question. So in Texas, our legislature meets every other year, odd numbered years for only six months. So as we go into 2025, we really look to gain momentum on a number of legislative issues. We go into each legislative session with priorities already established, and this is based on feedback from our members. It's based on discussions at the state level, with our state specialty societies, our county medical societies, our leadership. So we know going into the session what those priorities are.
And when you're in the heat of battle, proverbially, at the legislative level, it makes a difference. No surprise, prior authorization is near the top of that list. So I think we'd like to achieve some ability to make this law more far reaching. We think there's a need for transparency. We think there's a need to better understand which physicians are being exempted and which aren't, and why. We think there's a better—there's an opportunity for oversight from the state, from the Department of Insurance, to better understand how this is being implemented with the respective plans.
We think there's some sort of small definitional things. Imagine our ability to better define the services which could be exempt from prior authorization. Think medications or think inpatient treatment—or even in my space—imaging and testing, how we can better define those. So at a practical level, the physicians that are affected by this, those physicians that are having 43 prior authorizations a week, literally that burdensome, can see some relief to allow them to do what they are best at doing, and that's providing high quality care to their patients, earning the trust in that patient physician relationship, and making sure that treatment is as optimal as possible so the outcomes that we can achieve together are as meaningful as possible.
Unger: Dr. Silva, it feels like there's momentum on this topic at both the state and the federal level. What do we need to do to keep that going?
Dr. Silva: I think communication. I think the AMA does a tremendous job of translating one state's successes to another state that aspires to achieve the same. Our legislation, I think, was among the first in the country. 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.
Our forum, if you will, to share these ideas in many ways is our Annual Meeting. It's our Interim Meeting. It's our House of Delegates. It's our ability to communicate with each other and understanding what those shortcomings are and where we can achieve success. And I've always said the AMA's greatest task is to represent not just physicians collectively, but to represent individual physicians. To represent physicians that have themselves a challenge or see an opportunity.
Prior authorization is a perfect example. I mentioned stories earlier. I mentioned the ability for a single physician to bring their story forward, to have it make a difference at the state or federal level. And at the end of the day, to see that lead to improvement in the patient care, that they as physicians are the best enabled and the best trained to deliver.
Unger: Dr. Silva, I want to just say thank you to you and the Texas Medical Association for being such strong advocates on this important issue. It's such a clear demonstration of the power of belonging to both a State Medical Society and the AMA. Fixing prior authorization is a top priority for us at the AMA and to support that work, we encourage you to become an AMA member at ama-assn.org/join. That wraps up today's episode and we'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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