UnitedHealth's recent decision to require special approval for certain types of inpatient hysterectomies, citing medical evidence, has raised eyebrows in the medical community over the insurer expanding its role in medical decision-making.
The company says it is promoting vaginal hysterectomies over the use of laparoscopic power morcellators on the basis that they result in better outcomes and not because they are also less expensive.
Sam Ho, chief medical officer for UnitedHealth's insurance business, told the Wall Street Journal, "We needed to do more on behalf of our members to ensure that they would get the safest and most effective method" of hysterectomy.
The Food and Drug Administration is in the same camp, having recently written that physicians should not use morcellators on most women.
While insurers have long been limiting procedures to control medical costs, those limits typically apply to new or elective surgeries, Sabrina Corlette, senior research fellow at the Center on Health Insurance Reform at Georgetown University, told the Washington Post.
Among other major insurers, Anthem is the only other company that requires pre-authorization for hysterectomies. An Anthem spokeswoman told the WSJ that the company began to limit hysterectomies just last year due to concerns that physicians were jumping to them as a solution to treat fibroids, without fully considering other options.
Cigna and Aetna do not require any insurer authorization for hysterectomies. "We believe this is best left up to the physician and patient based on clinical circumstances," an Aetna spokeswoman told the WSJ.
Impact on insurance industry
The question now is whether any insurers will continue to push limits in driving medical choices alongside physicians and patients—essentially developing a role as medical watchdogs—and whether there will be push-back or appreciation if they do.
As for whether it's appropriate for an insurer to take a watchdog role, experts are voicing concerns, but also some potential benefits.
Corlette said that she can't say whether UnitedHealth's decision is setting a precedent.
"Is it appropriate for the insurance company to stand in the shoes of the doctor and say, 'We know better?'" Corlette told 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."
Mark Miller, director of business development at Marina Del Rey Hospital in California, does not see the decision as a precedent given that prior authorization guidelines are very common and that this new policy is based on ACOG recommendations.
"Payers, like UnitedHealth, are protectors of the member's premium dollar and take the role of appropriate procedures and payments very seriously," Miller tells Healthcare Dive. "I believe providers appreciate clear prior authorization guidelines versus no guidelines at all. Also, a guideline or policy can also be viewed as the catalyst for a healthy discussion about this procedure."
Miller suggests that while this may appear as a "watchdog" approach, the physician still has the opportunity to help set policy through advocacy if any confusion exists regarding procedures and outcomes.
Impact on medical industry
Experts suggest that UnitedHealth's policy is indeed likely to drive physicians toward selecting vaginal hysterectomies, though it will also depend on how the policy is implemented.
Catherine Matthews, a board member for the American Urogynecologic Society, suggests there could be both pros and cons to the decision.
She told the WSJ that while she has reservations about an insurer guiding physicians' choices, this move could drive training improvements, because gynecologists often receive insufficient instruction on vaginal procedures.
"It's a huge deal," Matthews said. "It is a concern about precedent that an insurance company will be dictating mode of access without knowing all the details about the case, but at the heart of the matter, it's interesting that an insurance company may be driving evidence-based medicine."