S.2680/A.859 – Gold Card

This legislation, S.2680/A.859, would exempt health care professionals from preauthorization requirements when their requests are regularly approved by health insurers. Preauthorization is an important tool used to protect patients from unnecessary and potentially harmful care. The New York Health Plan Association (HPA) opposes S.2680/A.859 because it would undermine efforts to ensure patient safety by creating a “gold card” process that severely limits and largely bypasses preauthorization reviews.

Evidence has long shown that much of the health care delivered in the United States may provide little benefit to patients. Experts have reported that up to 30 percent of U.S. health care spending is duplicative or unnecessary and research shows that certain tests, procedures, doctor visits, hospital stays and other services may not be necessary and could cause harm. Preauthorization is an important tool used to protect patients from treatment that is inconsistent with national or local standards of care and could be harmful to them. This ensures that the clinician providing the care has the appropriate training to deliver the care being requested, and helps to promote equitable access to services and care to underserved populations. It also enables health plans to improve care coordination by making sure care management supports are in place as members navigate the system and assist with follow-up care and other services that help in the member’s recovery.

In developing preauthorization policies, which are supervised by medical professionals, health plans review information on the use of inappropriate treatments, practice variation for specific services, and the extent to which providers deliver care consistent with evidence-based criteria, safety concerns and other relevant factors. Health plans regularly review the medical services and prescription drugs that are subject to preauthorization and make changes based on new evidence and adherence to recognized standards. These reviews are conducted by health plans’ Pharmacy and Therapeutics committees that include local, practicing physicians and pharmacists with relevant clinical expertise.

Sponsors of the legislation cite a 2020 national survey of providers, conducted by the American Medical Association, that claims preauthorization polices result in delays of care. While that may be the experience in some states, it is not the case in New York. Current New York State law require plans – and their utilization review (UR) agents – to make preauthorization determinations “within three business days from the receipt of necessary information.”

Plans already exempt certain procedures or services that are regularly approved from prior authorization. However, there are also regular reviews of these to ensure they are being used appropriately and that there aren’t spikes in utilization or anomalies. The most common services and treatments subject to preauthorization include: Specialty drugs and high cost brand name drugs; high-tech imaging; genetic testing; and Durable Medical Equipment (DME).

Programs that relax certain preauthorization polices are already underway in New York. For example, health plans that are engaged in value based payment arrangements often have language in those contracts that largely remove preauthorization. Some plans also have so-called “gold card” programs for providers that consistently deliver high quality care and adhere to evidence-based medical guidelines. These programs are developed between the plan and a particular hospital or provider group, and are regularly revisited allowing for changes based on new evidence, adherence to recognized standards of care, and other criteria. However, gold carding is not a blanket exemption for an indefinite period, and it is not appropriate for all providers and all services.

HPA supports the current process of plans and providers developing specific programs that help ease the preauthorization process. We do not support legislating gold carding, as it would remove reviews of what treatments and services should be subject to preauthorization, which helps to ensure that the care members receive is safe, coordinated, and effective, and performed in the right setting.

For all these reasons, HPA OPPOSES S.2680/A.859.