Federal legislation to lift the burden of prior authorization with Rep. Michael Burgess, MD

. 14 MIN READ

AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.

A new bill at the federal level, called the GOLD Card Act of 2023, has the potential to fix prior authorization. One of the co-sponsors of the bill, Michael Burgess, MD, Congressman (R-Texas), joins to discuss the GOLD Card Act and what the bill means for physicians and their patients. AMA Chief Experience Officer Todd Unger hosts.

Speaker

  • Michael Burgess, MD, Congressman (Republican-Texas)

AMA Recovery Plan for America’s Physicians

After fighting for physicians during the pandemic, the AMA is taking on the next extraordinary challenge: Renewing the nation’s commitment to physicians.

Unger: Hello and welcome to the AMA Update video and podcast. Today, we're talking about the Gold Card Act, federal legislation that would help fix prior authorization and what it means for physicians and their patients. Here with me to discuss the act is representative Michael Burgess, a physician and Congressman from Texas who is joining us from Washington, D.C. I'm Todd Unger, AMA's chief experience officer in Chicago. Representative Burgess, it's an honor to have you. Thank you so much for joining us today.

Dr. Burgess: Thanks, Todd Thanks for having me on.

Unger: Well earlier this year you introduced legislation H.R. 4698, better known as the Gold Card Act of 2023 into Congress along with Representative Vincente Gonzalez, also from Texas. Before we get into the details of that legislation, let's start by talking about how prior authorization impacts patients.

Dr. Burgess: Well, prior authorization only slows down the delivery of care. And properly applied, it's actually not going to stop the care from being delivered, it's just going to make it more difficult. And I suppose if you were cynical, you could say that the patient may give up or drop out because the process has become too onerous.

But when you look in the grand scheme of things, if the care is medically indicated—assume that it is—if the care is medically necessary, then the payer—in this case CMS—the federal government should not be getting in between the doctor and the patient. That serves no one's benefit. And in fact, in the long run really doesn't save the government money.

Unger: There are so many stories that we hear of this barrier to care. Is there any one story that kind of sticks out in your mind?

Dr. Burgess: Well I can recall going to talk to a group of orthopedists several years ago. And the competitive joint bundle had just kind of come on the scene. And there was no question in talking to those docs, they were delivering great care. They were doing the right thing by their patients. So at the same time, CMS had interjected another layer of bureaucracy in between, really, what seemed to be good medical care and necessary care that the patients—it only slowed things down again. It didn't stop anyone from getting a joint replacement, it just made it harder for them to achieve it.

Unger: You're the rare combination of physician and congressman. I'm curious what you hear from your physician colleagues about the burdens of prior authorization.

Dr. Burgess: Well, prior authorization, of course, gets added to the other list of burdens that everyone in private practice, or private practice in medicine, well understands. It's not going to be the straw that broke the camel's back, but it's such an unnecessary step. And I think, really, through some of the hearings we've had at the committee level, we've shown that it doesn't save the government money.

The care is still going to be delivered. The care is still indicated the care was still medically necessary. And here's something that I'll tell you that I've pursued and I have not gotten an answer from the Center for Medicare and Medicaid Services, what is the cost of the care delayed? What is the cost of the care denied? Presumably, there is also a cost if someone needs a joint replacement and they're delayed in getting it. What has that cost the patient? What does it cost the practice that's involved? And what does it cost the payer, in this case, Medicare?

Unger: And that's a great question. Well, let's talk about the Gold Card Act. Tell us a little bit about how this would relieve some of the challenges for physicians and patients.

Dr. Burgess: Well, it's actually, to give full credit, this was a concept that was developed in the state of Texas. It's a bill that actually passed the Texas State legislature a term or two ago. As you know, Texas legislature only meets every other year. But the concept was look, here's the proposition, and we've all heard this I don't know how many times. 10% of the people are causing 90% of the problems. And by and large, that's true in almost any situation.

This kind of turns that around and say, "Hey, if you're one of the 90% that is doing everything right and by the book, and your procedures are always approved, or 90% of the time approved, you don't need to keep going through this process. We're going to trust you that the next case will be just as indicated as the last case." So that was the concept behind the Gold Card.

And it in fact has passed the Texas legislature. One of the things I'm trying to keep a close eye on is now that we're two or three years into the implementation at a state level, how has it done? What are some of the problems that they've encountered? And what are some things that we might do to anticipate that if we begin to implement it at a federal level? But as you point out, the bill has been introduced. It's been a bipartisan bill. Myself and Vincent Gonzales down in Brownsville have introduced this bill, both having experience with the bill at the level of the Texas legislature.

And quite honestly, I get a lot of positive reinforcement from doctors that say yeah, sure. We don't think it should be necessary anyway for us to go through this prior authorization process. But look, if you could just look at our history and see that we've been conforming all along, there's no reason to keep reinventing the wheel on this.

Membership Moves Medicine™

  • Free access to JAMA Network™ and CME
  • Save hundreds on insurance
  • Fight for physicians and patient rights

Unger: I mean, the logic of the way that you laid that out makes so much sense. And that's why the AMA and other health care organizations are largely in favor of gold carding as a component of prior authorization reform. You talked a little bit about the experience that's happening down in Texas. When you think about stumbling blocks and barriers to getting the legislation passed at a federal level, what are those?

Dr. Burgess: Well it's largely on the implementation side. And look, we've all had experience with the No Surprises Act and the Department of Health and Human Services, and how they interpret congressional intent, which was completely at cross purposes of what the Congress passed. So we know that there can be implementation problems in Texas. Again, we're only a couple of years into the experience so it does, I think, behoove us to watch what happens at the state level.

But are there places where it seems to work better than others, and are there ways that we can streamline the process and make it even a little bit less burdensome for physicians? Make the collection of data automatic, not something that someone has to actually collect and submit, but make it automatic through an automated claims process. There are things that can be done to make it more straightforward.

Unger: Absolutely. Again, back to your unique perspective of being a physician. How has that helped you address the roadblocks that you run into as a lawmaker?

Dr. Burgess: Well look, it was a long time that I practiced. And it has been a few years since I've been in active clinical practice. And I know some things have changed since that time. But a lot of things are just still the same as they were then. I'll never forget a day I was in my office seeing patients, and the front desk said, "We've got your mother on the telephone." Well my gosh, my mother never calls me in my office when I was in practice. What the heck could be going wrong? And I figured it was some problem in the family.

And she gets me on the phone and she said, "Do you take Medicare?" And I said "Yes, Mom, I always have, and I always will." And she said, "Well, good. Don't ever let me hear that you're turning down Medicare patients, because I'm tired of hearing from my friends that their doctors won't see them anymore." So that's what started me down the path of investigating things. Like at the time we had the sustainable growth rate formula, some of the things that were obstacles to physicians us continuing to see their long-term patients that have now transitioned into Medicare.

And while I don't think my mom understood that I was in an OB/GYN practice and didn't have a large number of Medicare patients, I still had some. And the intent of my practice was we would never turn a patient away simply because they had a federal payer.

Unger: That's such a great story. Tell us a little bit more about where the federal legislation currently stands and the next steps.

Dr. Burgess: Well, the bigger bill, probably the more important bill that everyone's focused on right now, is the Patient Timely Access to Care Act. And that's the bigger sort of prior authorization that would require the collection of data from electronic medical records and make the submission automatic, and not make it quite so burdensome for the physician and for their office.

Look, we all know we've got a significant manpower problem in the practice of medicine. And to the extent that we tie docs up with making them do paperwork or busy work, or to the extent that we drive productive physicians out of their practice because they just see the federal government as being an existential threat to them continuing in practice, we got to stop that sort of stuff. We've got to stop making the environment so hostile for the practicing physician.

And I know there are plenty of people within the halls of Congress who look at the situation and say, hey, you know what, we'll be a lot better off when we don't have private practice docs, when everybody's in an ACO or everybody's taken care of by a mid-level. But honestly, you need the private practice of medicine.

We are the ones—us, the doctors who are in individual practices and small group practices—we are the ones that are the advocates for the patient. If you work for the government, you're going to be an advocate for the government. If you work for an insurance company or work for a hospital, you're going to be an advocate for the insurance company or the hospital. If your work for the patient, if your contract, your obligation is directly to the patient, then that's to whom you are you are obligated. And the entire system will lose and not be as responsive to the needs of the patient, regardless of where they get their care, if you don't have the influence of doctors who are in the private practice of medicine.

Unger: Do you have any message for the physicians out there, how they might help you get this act passed?

Dr. Burgess: Well, when you talk to your members of Congress—and you should by the way. If you're not, you should talk to your members of Congress. And that doesn't necessarily mean coming up to Washington. Of course, the AMA has their ... has the fly-ins that you all do every year, and they're important. And that certainly, before I began my political career, that was a place where I always tried to participate myself.

But even if you're not going to be able to do that, you can still visit with your member of Congress or your Senator—you've got two senators and one member of Congress in each congressional district—and you can reach out and schedule a time to go in and talk to your member of Congress about whatever problem you want to address. And I'd certainly appreciate bringing up the Gold Card concept, because it's one that if we can get enough co-sponsors on the bill, then we can get it to move in the legislative process. Right now there are so many things that sort of compete for attention. As former Speaker Newt Gingrich used to say, up here it's so chaotic that the urgent drives up the important.

So make it important to your member of Congress. Go visit with them. Perhaps take a patient or two with you. Don't make it all about doctors and how Congress is making our lives tougher, but how it's affecting the care of the patient and why it's important to continue to have that doctor-patient relationship play the significant role that it does. And the best thing about seeing your member of Congress when they're home on what's called a district work period, or one of the longer breaks like July 4 or Memorial Day, month of August, there's not as many things that are competing for the member's time and attention.

I mean we're all familiar. We come up to Congress. We do a big fly-in and we've got a visit schedule with our member of Congress, taking time off of our practice, taking time away from our family, incurred the expense of coming up here, flying up here and staying in a hotel. And then when the big moment comes, you're about to go into the member's office, and a buzzer goes off and a bell rings. And oh my gosh, there's a vote on the floor. And the member of Congress has to run out of the office and go tend to whatever the legislative issue of the day is.

Well, you don't have that interference in the member's office in the district. And every member of Congress does have at least one district office, and they can entertain constituents, visitors. Doctors and patients count as constituents. It's possible to set that time up well in advance. Don't wait till the week before Memorial Day and say, "Hey, I wonder if I can catch him next week while he's home." Set it up significantly in advance.

And again, choose wisely. Maybe more than one doc comes in. But it doesn't hurt to have more patients than doctors in the group that's bringing this issue to the attention of their member of Congress. And that can be so powerful, and I would tell people don't discount the individual meetings that can take place home in the district. They're equally as important as the meetings that take place during a big fly-in with your specialty society or with the AMA itself.

Unger: That's great advice. Representative Burgess, thank you so much for joining us today and for all the work that you're doing on behalf of physicians and patients. I think all the listeners out there can understand, based on this conversation, how important the perspective of a physician is to have in Congress. So it's really, really meaningful. That's it for today's episode. Fixing prior authorization is part of the AMA Recovery Plan for America's Physicians. Learn more about our work at ama-assn.org/recovery. We'll be back soon with another AMA Update. In the meantime, you can 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.

Subscribe to AMA Update

Get videos with expert opinions from the AMA on the most important health care topics affecting physicians, residents, medical students and patients—delivered to your inbox.

AMA Update podcast logo

FEATURED STORIES