Utilization Management
This has been a slow legislative session for utilization management issues. This is in part due to the success of step therapy and prior authorization reform efforts over the past several years. The one issue we had hoped for movement on is prior authorization gold card legislation.
Gold card legislation requires payers and PBMs to exempt providers from prior authorization requirements for a period of time, typically six months or a year, if they have an approval rate at or above a benchmark, typically 80–90%, for a given procedure or prescription. Texas was the first state to approve this kind of legislation. There was a lot of excitement among the provider community about this concept, but the difficulty in implementing the program for prescriptions became immediately apparent. The challenge for insurers and providers to keep track of what they have a gold card for has emerged as the primary pain point for making this concept workable.
A recent survey by the Coalition of State Rheumatology Organizations bore this out. They found that 88% of rheumatologists in Texas had not yet qualified for a gold card. There was a reported decrease in administrative burden with prior authorizations for procedures. The takeaway is that gold card programs are a work in progress. Being the first at anything is never easy. Advocates in Texas can certainly tell you a list of things they wish they had done differently. We hope to apply those lessons to state and federal gold card legislation moving forward so that the concept evolves into something more workable and more impactful for rheumatology practices.
Wrapping Up
This progress report may make this legislative session sound relatively inactive, which may be true compared to recent legislative sessions. However, recent action on our previous key issues means that many of the current high-priority issues are newer. These will take time to gain momentum.
We are also monitoring emerging issues, such as biomarker testing and post-public health emergency telehealth reforms. It might seem like legislative action is slower, but there is a strong argument that state-level policy innovation is more robust than it has ever been. Prior authorization gold cards, rebate pass-through reform, manufacturer drug price reporting requirements, biomarker testing coverage requirements and copay accumulator reform were only wishful thinking a few short years ago. Now in 2023, they are becoming reality. We might hope for faster movement, but the wheels of progress turn at their own speed. At least for now, they are slowly moving in the direction we want.
