Gold Carding Policies

Abstract

A central approach to achieving high-quality neurologic care is to reduce the burden on providers in accessing services needed to achieve this level of care. Neurology-based practices across the continuum (solo, multispecialty, hospital, or health system–based) have adopted different methods to mitigate the impact of gatekeeper methods of prior authorization and related mechanisms. We discuss ways to partner with payers through innovative Gold Carding programs that reduce the burden of gatekeeper mechanisms on neurology providers, thereby allowing them to consistently focus their efforts in the provision of high-quality neurologic care.

The Burden of Prior Authorization Policies

Utilization management strategies, such as prior authorization (PA), are used to facilitate a safe and standardized approach to clinical management. However, these approaches impose a significant administrative burden on multiple stakeholders. Providers and care delivery organizations must invest in staffing and other resources to address the burdensome requirements for PA and the frequent rejections. As evidence of the onerous burden of PA, a national survey was conducted in early 2021 targeting 925 physicians of all specialties and clinic staff.¹ Survey respondents reported that one in 3 physician-administered drugs and one in 4 self-administered medications are subject to PA requiring an average of 14 hours per physician per week.¹ Additional personnel required to conduct PAs ranged from 1.5 to 3.0 per year averaging annual costs of $75,927.¹ Patient care is affected as PA affects timely access to services and medications and causes delays in critical care. Over one third of physicians from the 2022 American Medical Association's PA survey reported that PA led to serious adverse events including avoidable hospitalizations for their patients.² PA also affects provider satisfaction leading to a negative impact on their well-being due to burnout. At the current time, with the increased approval and widening pipeline for neurology drugs, it is expected that the burden of PA will place a much higher burden on neurologists than other specialties, although we are yet to fully capture this burden.

In early 2023, the US Surgeon Dr. Vivek Murthy as part of the conversation with the American Medical Association President stated that “Eliminating bureaucratic requirements such as prior authorization or other workflow tasks that keep providers from caring for patients will go a long way toward addressing the nationwide crisis of clinician burnout.”³ Finally, PA policies have resulted in inequitable care between Medicare fee for service and Medicare Advantage beneficiaries as outlined in a recent report by the Department of Health and Human Services which found that 13% of PA denials by Medicare Advantage plans were for services that should otherwise have been covered under Medicare.⁴

Reforming Prior Authorization

Several efforts have been underway to reform PA. At the federal level, the Center for Medicare and Medicaid Services approved a federal rule in 2022 that placed new requirements on Medicare Advantage organizations and state Medicaid fee-for-service programs to improve the electronic exchange of health care data and streamline processes related to PA.⁵ CMS is taking further steps with a 2024 Medicare Advantage and Part D Final Rule.⁶ The 2024 Final Rule provides additional clarification and guidance on regulations related to PA policies and procedures for Medicare Advantage plans.⁶ These regulations are designed to promote publicly available, detailed medical policy information for Medicare Beneficiaries. The regulations also share new definitions for how PA must be reviewed and how decisions must consider medical necessity and continuity of care. At the state level, over 30 states have proposed and or passed legislation to reform PA that include quicker response time by payers, simplifying PA forms, encouraging the use of electronic PA, and requiring a new payer to honor a patient's prior authorization from a previous payer.⁶

Gold Carding Programs

On the payer side, the effort to design and administer increasingly complex PA systems to balance value and appropriate use of these treatments is unappealing. Payers have started to recognize the dissatisfaction and unhappiness because of PA and are looking for ways to collectively redesign utilization management as a transparent and collaborative system.⁷ Gold Carding programs relax requirements for services that are traditionally governed by PA criteria and either exempt providers from PA or provide a more streamlined process for providers who have a demonstrated track record for complying with PA requirements. Gold Carding is intended to provide administrative relief to all stakeholders touched by PA processes. As Gold Carding is based on proving a practice or health system's ability to provide efficient and effective care, this becomes a powerful motivator for providers to place time and effort in health care value efforts. Gold Carding programs were recommended in a consensus statement on improving the PA process jointly drafted by the American Medical Association, American Health Insurance Plans, BCBS Association, and the American Hospital Association in January 2018.⁸

“We agree to encourage the use of programs that selectively implement prior authorization requirements based on stratification of health care providers' performance and adherence to evidence-based medicine.”

Current Examples of Gold Carding Programs

Vermont's Gold Carding program, which uses a tiered approach to Gold Carding, was legislatively passed in 2020 and requires each insurer to implement a PA pilot program and report the results to various House committees and the local society for primary care physicians.⁹ Subsequently Blue Cross Blue Shield in Vermont developed a pilot program in 2020 to streamline, advanced imaging, magnetic resonance imaging, computerized tomography, positron emission tomography scans, echocardiography, and angiography using a tiered approach.¹⁰ The 3 tiers correspond to the amount of information required to get a PA approved and whether the PA approval can be automated. The Texas “Gold Card bill” passed in 2022 enabled physicians who had a PA approval rate of 90% or more, exempt from future PA for a minimum of 6 months on certain services.¹¹ Providers do not have to apply to a gold carding program. Instead, health plans assess their data to determine whether a provider meets the 90% threshold. The plans are then responsible for notifying the provider of whether they qualify. After each six-month review period, new providers or new services for existing providers are added or removed based on the results. West Virginia's Gold Carding Legislation which goes into effect in 2024 has a similar Gold Carding structure.¹² Currently, all the above-mentioned Gold Carding legislation is limited to specific groups of employers or types of health plans. Finally, United Healthcare has announced the launch of its National Gold Carding Program starting in 2024 across all its products: Commercial, Medicare Advantage, and Medicaid. Qualifying care provider groups will follow a simple notification process for most procedure codes rather than the prior authorization process.¹³

Gold Carding and Advanced Radiology Services: A Case Study

An American Health Insurance Plan's national survey conducted online from February to April 2022 completed by 26 commercial health plans representing 122 million covered lives has provided preliminary data on the utilization of gold carding programs.¹⁴ Gold carding popularity is increasing in 2022 vs 2019, almost doubling its use for medical services (58% vs 32%) but far less used for prescription drugs (21% vs 9%). The most common procedure subject to Gold Carding is advanced imaging services (in 44% of plans surveyed) while 19% of plans used it for orthopedic, elective inpatient, and cardiology services.¹⁴

The adoption of Gold Carding programs in neurologic services has been slow. The Coding, Payment and Policy, and Health Care Delivery Subcommittees at the American Academy of Neurology have been exploring how they can influence national-level and state-level payers on ways to partner on Gold Carding programs.

A case study of a large health care system in the Midwest provides an example of how such a program may be developed with a potential application in neurology. For confidentiality purposes, this system will be referred to as Health System A which is a not-for-profit health system that staffs 11,500 physicians and advanced practice providers along with 15,000 nurses providing care and services in 22 hospitals, 300 outpatient locations, and several postacute facilities.¹⁵ Health System A partners with a provider-sponsored health plan in the area, which we shall call Insurance Plan X, serves more than 1.2 million members, and offers a Gold Carding program focused on advanced imaging services for all lines of business including Medicare, Medicaid, commercially insured, and individually purchased health policies. Health System A, which once delayed all advanced imaging services for a minimum of 3 days, pending the processing of each PA request adopted the Gold Carding program of Insurance Plan X in 2022.

Participants commit to the management of advanced imaging services through decision support programs as part of the Gold Carding program of Insurance Plan X. As context, CMS introduced the Protecting Access to Medicare Act (PAMA) in 2014.^16,17 Section (b) of this Act requires the use of decision support services for high-tech radiology ordering.¹⁸ The implementation date for section 218(b) requirements has been delayed several times, most recently because of the Public Health Emergency. Despite this delay, some health systems have purchased and implemented resources to manage and monitor the ordering of advanced imaging services. Care Select is one such clinical decision support tool that integrates with the electronic health record system EPIC and prompts the selection of the appropriate imaging study through a logic-based algorithm.¹⁹ Advanced imaging studies include computerized tomography scans, cardiac, magnetic resonance imaging, and positron emission tomography studies. When a physician orders an imaging study in the EMR, Care Select prompts the individual through a series of questions to determine the appropriateness of the imaging study and applies an appropriateness score followed by a traffic light color code. Green indicates a clear score of testing appropriateness. Yellow is a flag to consider alternatives, and red indicates that the study is either not appropriate or that criteria have not been built within Care Select for rare diseases.

Insurance Plan X developed a Gold Carding program for advanced imaging services that used the Care Select tool. To avoid underdoing the burden of a traditional PA, a participating group such as Health System A is required to purchase and implement the Care Select tool which in turn would allow physicians to bypass the nonautomated fax-based PA process for most of the advanced imaging services and allow point-of-care decisions to be made in real time. Independent physicians, serving patients, within Health Plan A's, can also access Care Select decision support using an Epic Care Link which is another product that provides Epic patient record access and allows independent physicians to place orders and review results with ease. With each advanced imaging order placed in Epic Care Link, independent physicians are led through Care Select criteria for a stop light and appropriateness score rating. The Care Select program is comanaged by Health System A's Radiology and Informatics teams. The initial build and implementation were guided by multiteam Steering and Operational workgroups. Currently within Health System A, the Care Select decision support tool has used an average of 29,000 advanced imaging radiology services per month. By adopting Insurance Plan X's Gold Carding program for advanced imaging services, Health System A physicians were able to schedule the appropriate imaging service immediately at the time of the order. The annual cost to license Care Select is $130,000 which raises the issue of affordability of a Gold Carding Program for smaller neurology providers, practices, and those serving primarily as a safety net system. It is important to note that Gold Carding programs have no requirement to use an electronic decision support system and can function using existing resources and tools already in place. These could include electronic medical records, claims data, and other performance metrics data collection tools used by the payer or the provider.

Continued demonstration of efficient care is required to maintain Gold Carding status. Health System A uses monthly data and analytics to monitor efficient care performance from multiple sources including cost of care and utilization. Goal setting is used by Health System A to maintain Gold Carding status through the establishment of a 95% compliance rate on a monthly basis. What this means is that 95% of providers ordering an advanced imaging services are required to have chosen an appropriate study captured by a green or yellow color code within Care Select. Other monitoring measures include the cost of advanced imaging services measured as a percent of the total cost of care and as per member per month costs and utilization of these studies as a rate per 1000 members. No target goals are set for these measures, but their trends are examined over time to determine performance with the Gold Carding program. Care Select data can also be examined by ordering provider and specialty type. The figure is a recreated screenshot of the Care Select compliance dashboard in 2022 since its inception showing that provider compliance with the ordering of appropriate advanced imaging services started at 91% in April 2022 and reached 95% in August 22. Action plans are developed when changes in care are noted, particularly when efficiencies erode, which could cause ineligibility in a Gold Carding program.

Figure. Performance Metric for Provider Compliance With Advanced Imaging Services.

Conclusion

As the burden of gatekeeper mechanisms such as prior authorizations continues to erode the potential ability to provide consistent high-quality neurologic care, the time has come to find solutions that involve forming partnerships between payers and providers. One solution to reducing variability through pathway development for clinical standardization notably in advanced imaging services for neurologic care. The concept of Gold Carding described is one such approach to standardize evaluation and management through a provider-payer partnership. As Gold Carding programs can vary based on individual state legislation, private insurer policies and emerging insurer-provider partnerships, some provider groups and patients may not have access to these programs at the current time. An extension of this approach is to leverage the American Academy of Neurology's practice guidelines in partnership with payers to codevelop electronic medical record–based algorithms that can also contribute to administrative burden reduction for neurologists. Gold Carding programs like the one described in the case study integrates technology within the health care system/practice's own electronic medical record dashboard, allowing for a fully automated PA process providing real-time decision in minutes. These payer-provider partnerships require investment and trust from multiple stakeholders, honor the physician who merely wants to do the right thing, the payer who wants to manage utilization, and the patient who deserves the highest quality of neurologic care.

Appendix. Authors

Name	Location	Contribution
Kavita V. Nair, PhD	Department of Neurology and Pharmacy University of Colorado Anschutz Medical Campus	Drafting/revision of the manuscript for content, including medical writing for content; study concept or design; analysis or interpretation of data
Laura Stuursma, MBA	Corewell Health West, Grand Rapids, MI	Drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; analysis or interpretation of data
Meghan Eigenbrod, MPH	American Academy of Neurology, Minneapolis, MN	Drafting/revision of the manuscript for content, including medical writing for content
Desiree Cremeen, MA	American Academy of Neurology, Minneapolis, MN	Drafting/revision of the manuscript for content, including medical writing for content
Aiesha Ahmed, MD, MBA	Corewell Health West, Grand Rapids, MI	Drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; analysis or interpretation of data

Study Funding

The authors report no targeted funding.

Disclosure

M. Eigenbrod is employed by the American Academy of Neurology; D. Cremeen is employed by the American Academy of Neurology. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.