By: TAHP | Thursday, May 13, 2021

May 13, 2021

By: Jamie Dudensing

When people visit a hospital, they are often in the most vulnerable position of their lives. They need to be able to trust that tests and treatments ordered for them are both safe and medically necessary.

Unfortunately, that is not always the case. Every 80 seconds, a hospital in the U.S. delivers a low-value test or procedure to an older adult. Not only is this practice expensive and inefficient, but it also puts hundreds of thousands of patients at risk due to complications, side effects and other consequences of overtreatment.

While not all hospitals are guilty of such overuse, far too many are. The recently released Lown Institute Hospital Index highlights which hospitals are doing well and which are failing their patients. Unfortunately, the news is bad for Texas.

No Texas hospitals ranked in the top 50 for avoiding overuse. In fact, 10 of the 50 worst hospitals for overuse are in the Lone Star State. This problem is not isolated to one area of the state or one type of hospital—poorly ranked hospitals included both large operations in major urban areas and local medical centers in rural parts of Texas.

One of the most effective ways to stop overuse, both intentional and unintentional, is the use of prior authorization (PA). PA is a management process used by insurance companies to determine if a prescribed product or service will be covered. Applied to less than 15% of treatments, PAs are developed under the supervision of medical professionals to promote safe and medically necessary care.

Insurance providers only use PA when there is a significant risk to a patient’s health. In certain cases, PAs have allowed health plans to stop the prescription of deadly drug combinations; halt the use of particular laparoscopic equipment for certain use because it was found to cause and spread cancer; and prevent the use of vaginal mesh, which was eventually pulled from the market by the FDA because it caused infections, incontinence, and chronic pelvic pain.

Texas could be in for even more bad news as the Legislature considers legislation that severely limits or prohibits the use of PAs. HB 3459 proposes a “gold carding” mandate that would eliminate PA for doctors who have 80% of PA requests approved—a very low bar. The “gold card” status would last for a full calendar year even if a provider abuses the system or provides unsafe care.

65% of physicians themselves report that overtreatment is common and at least 15-30% of medical care is unnecessary or unsafe. 71% of respondents, who are doctors themselves, believe that physicians are more likely to perform unnecessary procedures when they profit from them. Eliminating PAs would allow such dangerous care to run unchecked.

Texas law already provides significant protections through the PA process to ensure patients have access to medically necessary and appropriate care. PA standards must be evidenced-based and developed and adopted by the medical community, and there is a complaint and appeals process with a quick review by an independent physician. Texas also requires some of the fastest turnaround times for PA response in the country, and the Texas Department of Insurance has testified that there are few patient and provider complaints about the PA process.

Efforts to eliminate and restrict PAs are solutions for a problem that does not need to be addressed, unlike the costly and dangerous overuse of care seen in Texas hospitals.

For more information, see TAHP’s page on smart health care utilization.