UnitedHealth Group, the nation’s biggest player in the health insurance market, recently announced a policy change to narrow the rules on hysterectomy coverage.
Even though the insurer’s plan to impose tighter restrictions on the use of the morcellator has garnered the most attention – many hospitals ceased using the laparoscopic surgical device after the FDA reported in April 2014 the fast-spinning blade can actually spread uterine sarcoma in some women undergoing hysterectomies – the squeeze is also being felt on the performance of hysterectomies in general.
UnitedHealth (NYSE: UNH), the insurer of 40 million patients based in Minneapolis, Minn., now requires specific authorization before most types of hysterectomies are performed. Only vaginal hysterectomies – the least invasive and inexpensive option – done on an outpatient basis are exempt. The policy doesn’t affect hysterectomies performed in cancer treatment. Approximately half a million hysterectomies are performed annually in the United States.
Before UnitedHealth announced its policy decision, Anthem was the only major commercial insurer requiring pre-authorization for hysterectomies. Cigna and Aetna haven’t indicated they will follow suit. An Aetna spokesperson said the decision is “best left up to the physician and patient based on clinical circumstances,” a position also adopted by the American College of Obstetricians and Gynecologists (ACOG).
Days after UnitedHealth’s announcement, ACOG members buzzed about the issue at an ACOG national leadership conference.
“It’s been good fodder for discussion, though we’re taking it very seriously,” said Ravi Johar, MD, an OB/GYN from St. Louis, Mo., past president of the St. Louis Metropolitan Medical Society. “For UnitedHealth to reverse course, no one knows exactly what it means.”
Johar, council chair of the Missouri State Medical Association, said OB/GYNs are certainly accustomed to the pre-certification process.
“We’ll do what we’ve always done,” he said. “We’ll discuss with patients all of the options and go from there. The decision is between the patient and physician. My job is to provide the best medical care possible. How that affects them financially is a big impact, but it’s not my area of expertise.”
UnitedHealth is a good weathervane in the post Affordable Care Act era, with its combination of market power, community support, and access to exceptional data, said Jay Wolfson, DrPH, JD, Distinguished Professor of Public Health, Medicine and Pharmacy at the University of South Florida (USF) Morsani College of Medicine.
“In this case in particular, it’s important to recognize that UnitedHealth, over the past couple of years, has been the most aggressive of the health insurers in tightening up their markets,” he said. “They began eliminating a lot of physicians and hospitals from their panels in many communities.”
For example, said Wolfson, cancer and children’s hospitals were removed from UnitedHealth’s list of risk providers, based on the argument of cost being significantly higher at those healthcare facilities than others.
“Procedures in hospitals like MD Anderson, Sloan Kettering and Moffitt may cost 50 percent more than non-specialty, community facilities,” he said. “That’s to be expected because they’re teaching hospitals.”
Wolfson also pointed out that UnitedHealth acquired Optum, a healthcare technology firm established in 2010, which he considers one of the “best staffed analytic division of third parties.”
“Optum focuses on quality, outcome and cost-effective analyses of United’s (and other available) databases” said Wolfson. “Their research translates into what, to whom and how much United will pay.”
That influence has infiltrated the healthcare industry in many ways. In January 2013, while outsourcing work with Optum before bringing the firm in-house, UnitedHealth Group’s Center for Health Reform and Modernization proposed the use of predictive modeling software, particularly in Medicare and Medicaid programs, as tools for care management and information security as a possible solution to both healthcare fraud and preventable hospitalizations.
“As part of the ACA, they’ll continue to drill down and drive down costs and utilization and attempt to be as directive as they can to their patients, physicians, hospitals … to optimize cost, utilization and safety while also reducing liability,” said Wolfson.
Some hospital systems are adopting a tough stance against UnitedHealth’s culling process and policy changes they view as unfavorable.
“Three years ago, BayCare (Health System, Tampa Bay's dominant non-profit hospital chain), went up against UnitedHealth over reimbursement issues,” noted Wolfson. “Unlike most standoffs, there was no last minute negotiation and 450,000 members in Tampa Bay had to change hospitals and physicians because BayCare stood its ground against this healthcare delivery powerhouse.”
Wolfson also sees a trend of separate policy issues, in part led by UnitedHealth, that are shaking up the medical device manufacturing industry and the pharmaceutical sector.
“Until recently, pharmaceutical companies have had a tremendous influence in medical schools and communities concerning what medications physicians prescribe,” he said. “Now some medical schools across the country like ours have gone ‘drug-free’ and no longer allow pharmaceutical reps to teach in our classrooms or offer ‘educational’ program lunches.”
The same cycle holds true for manufacturers of medical devices, Wolfson said.
“The device manufacturing industry has also heavily affected medical practice,” he said. “Their significant influence is waning.”
In response to UnitedHealth’s policy change on hysterectomies, medical schools will place a stronger emphasis on technical skills to perform vaginal hysterectomies.
“We’ve developed a generation of surgeons who don’t know how to do vaginal surgery, quite frankly,” said Neil Finkler, MD, an OB/GYN in Orlando and CMO at Florida Hospital Orlando.
“So many physicians stopped using vaginal hysterectomies and it’s not being taught very much,” Wolfson added. “Our younger medical students don’t have the skills. It’s easier to use a device, which generates more revenue and becomes a standard. Most clinicians interviewed say it’s safer, less complications, but it’s not done because it’s just not being done. That’ll change.”
