Prior authorization, by any other name, threatens Washingtonians’ health
As tens of millions of Americans struggle with gastrointestinal diseases such as colorectal cancer and ulcerative colitis, health insurance company UnitedHealthcare (UHC) is making life more challenging for its more than 27 million commercial beneficiaries.
Through a series of ill-informed policy moves, UHC is laying the groundwork to delay patients’ time-sensitive upper endoscopy and colonoscopy procedures, increasing the risk of deferred care and disease progression.
Initially, UHC announced it would place arbitrary prior authorization requirements on all endoscopy services for patients with symptoms ranging from diarrhea to trouble swallowing to bleeding. Then, in a sudden reversal in response to impassioned advocacy from the American Gastroenterological Association (AGA) and its physician members, the insurer introduced its poorly defined “advance notification” program.
The GI community was caught off guard since UHC provided little information on the program’s requirements or a rationale for its implementation.
There are red flags all over this process that suggest UHC is not acting in good faith.
Gastroenterology providers and patient groups should not be fooled. This new program would more aptly be called “prior” prior authorization. It is simply a way for UHC to lay the groundwork for future prior authorization requirements in 2024, a program many fear will disrupt urgent care and overburden physician practices.
Several states have enacted legislation to tamp down on this practice, Washington included. In May, House Bill 1357 became law and will help ensure timely access to care by streamlining prior authorization practices. Washington state physicians and patients can expect some relief from prior authorization policies when the law is implemented this month. Let’s be mindful, though, that states are taking the issue of prior authorization into their own legislative considerations because the insurers remain aggressive in attempting to delay and deny care.
Meanwhile, UHC continues marching towards prior authorization of GI procedures with its nebulous advance notification program. While details remain murky, gastroenterologists now must input excessive (and often duplicative) patient data when performing most endoscopic procedures. According to UHC, the data collected will help determine the criteria for its so-called “Gold Card” program, a process for physicians to “get permission” to bypass prior authorization requirements.
The fact that UHC needs the data to inform future prior authorization requirements suggests that they never had adequate data in the first place. UHC refuses to release the data it says it has showing overutilization by deeming it “proprietary.”
If there is an overutilization problem with these critical endoscopic services, the country’s GI societies are open to reviewing the data and collaborating on a solution. However, UHC remains unwilling to come to the table and transparently discuss its plans or to listen to the gastroenterology community’s concerns.
Ironically, AGA data shows many medically necessary endoscopic services are actually underutilized, particularly in communities of color. UHC’s policy moves will likely worsen the issue of underutilization, discouraging patients from getting the procedures needed to begin treatment.
Ultimately, UHC’s requirements to provide non-clinical data will massively increase physician burdens and drive a wedge in doctor-patient relationships. From the limited available information, we gather that the enacted process of “advance notification” does not adhere to any data entry standards for the thousands of physician offices with vastly different electronic medical record software programs. Experts in healthcare delivery and implementation have voiced concerns about how actionable that data may be, but again, gastroenterologists were not asked to lend our expertise.
There is still time for UHC to pull the reins on advance notification and prior authorization. UHC should work with our community, not against it, so we can collectively define the problem and improve access and patient care together. As the health of our population has worsened over the pandemic, aligning around a common goal of effective, accessible care is paramount.
Dr. Barbara Jung is the president of the American Gastroenterological Association and is a gastroenterologist in Seattle.
