UnitedHealth hysterectomy decision pits payers against providers

Insurer's requirement for prior authorization irks gynecologists

UnitedHealth's recent decision to require doctors to get prior authorization before performing most inpatient hysterectomies has sparked a debate about whether insurers or doctors know patients better, according to the Washington Post.

UnitedHealth announced the chane, effective April 6, in a network bulletin to healthcare professionals and facilities earlier this year. Prior authorization is not required for outpatient hysterectomies.

The insurer said it based its decision on the recommendation of the American Congress of Obstetricians and Gynecologists (ACOG), which has linked vaginal hysterectomies to better outcomes and fewer complications than laparoscopic or abdominal hysterectomies. These procedures use electric blades that can sometimes miss cancerous tissue, which then grows into new tumors, the Post pointed out.

The idea of insurers limiting certain types of medical procedures isn't new, Sabrina Corlette, a senior research fellow at the Center on Health Insurance Reform at Georgetown University, told the Post. However, the limits usually apply to new or elective procedures, not something done as frequently as a hysterectomy.

Likewise, it's not uncommon for insurers to seek prior authorization for certain treatments. However, those cases usually involve repeated services such as chiropractic visits, pain medications or acupuncture, FierceHealthPayer previously reported.

"Is it appropriate for the insurance company to stand in the shoes of the doctor and say, 'We know better?," Corlette asked in the Post. "Well, evidence has built up over years that suggests--as much as we hate to think this--that doctors are motivated by financial reasons. When doctors are paid per procedure, you see they perform lots of procedures."

ACOG, despite its recommendation, disagreed, and told the Wall Street Journal, "These decisions are best made between a physician and a patient, not a third party administrative decision-maker." One gynecologist added, "I don't really want [UnitedHealth] telling me what type of hysterectomy I should be doing."

Major insurers remain split on prior authorization for hysterectomies. Along with UnitedHealth, Anthem requires it, while Aetna and Cigna do not, according to the Journal. Anthem began the practice last year amid concerns that doctors don't always consider alternatives to hysterectomies to treat fibroids, which are benign growths that can be hard to distinguish from cancerous uterine sarcoma.

For more:
here's the Washington Post article
read the UnitedHealth bulletin
here's the Wall Street Journal article

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