On June 1st, UnitedHealthcare, the nation’s largest health insurer by membership, will implement a prior authorization policy for surveillance and diagnostic colonoscopies. The new coverage policy entails that any UnitedHealthcare enrollee seeking surveillance and diagnostic colonoscopies to detect cancer will first require pre-approval from the insurer.
This policy does not apply to screening colonoscopy, which is the routine procedure generally conducted once every ten years to examine the large intestine for ulcers, polyps, and cancer in low-risk members of the general population between the ages of 45 and 74.
What makes the new policy regarding surveillance and diagnostic colonoscopy particularly controversial is that it goes against the grain of what experts in the field – gastroenterologists, but also health economists – would consider a rational pathway. Erecting barriers to access for those who are at risk and therefore more likely to develop colorectal cancer doesn’t make sense.
Specifically, surveillance colonoscopy is indicated for individuals who have a personal history of cancer or colorectal polyps, or conditions that predispose them to colorectal cancer. And, diagnostic colonoscopy is used for individuals with symptoms of cancer, or for those who’ve either had a positive stool test or had polyps detected on routine screening colonoscopies.
A UnitedHealthcare spokesperson defends the policy as follows: “Multiple clinical studies have shown significant overutilization or unnecessary use of non-screening gastroenterology endoscopy procedures which may expose our members to unnecessary medical risks and additional out of pocket costs.”
Though there may be questions surrounding the cost-effectiveness of screening asymptomatic, low-risk individuals for certain cancers, there’s no doubt that at-risk individuals for colorectal cancer should be screened and that it’s cost-effective to do so. Indeed, surveillance and diagnostic colonoscopies for high-risk individuals have been part and parcel of clinical practice guidelines for quite some time. Moreover, surveillance colonoscopy is cost-effective for patients who are at high risk for developing colorectal cancer.
Notably, prior to this year, Medicare had a somewhat analogous coverage policy, which was heavily criticized and subsequently reversed. Previously, Medicare would pay for, say, a Cologuard test, used to periodically screen adults 45 years of age and older who are at average risk for colorectal cancer by detecting certain DNA markers and blood in the stool. But if the test result was positive Medicare wouldn’t necessarily pay for a follow-up colonoscopy.
Recently enacted policy changes require Medicare and most commercial insurers to pay for colonoscopy after a positive Cologuard test without out-of-pocket costs to the patient. This change took effect starting January 1, 2023. The update to expand Medicare coverage policies for colorectal cancer screening explicitly aligns with recent United States Preventive Services Task Force and professional medical society recommendations. This includes expanding Medicare coverage for certain colorectal cancer screening tests by reducing the minimum age payment and coverage limitation from 50 to 45 years. Second, it expands the regulatory definition of colorectal cancer screening tests to include what is deemed “complete colorectal cancer screening,” in which a follow-up colonoscopy after a Medicare-covered stool-based colorectal cancer diagnostic test returns a positive result.
Prior authorization
UnitedHealthcare’s new protocol won’t eliminate reimbursement of surveillance and diagnostic colonoscopies. Prior authorization isn’t the same thing as exclusion from coverage.
If used judiciously, prior authorization is intended to be a check on overutilization of technologies and services in the healthcare system. Insurers such as UnitedHealthcare say that by requiring physicians to demonstrate that an intervention is medically necessary before they agree to cover it, they can prevent overuse of technologies and medical services that patients may not actually need. Alternatively, insurers can nudge doctors towards the use of other less costly alternatives.
But this presumes the alternatives work as well or better than the intervention placed under prior authorization protocol. And in the case of surveillance and diagnostic colonoscopies for at-risk individuals that presumption is far from self-evident. Moreover, prior authorization tends to be a fairly blunt instrument that doesn’t work well as a cost containment measure. To illustrate, upon appeal, of 35 million prior authorization requests to Medicare Advantage Plans in 2021 82% were overturned.
In the end, prior authorization in instances like the one in question in this article isn’t conducive to better practice of medicine or a more cost-effective way of doing colorectal cancer testing. In fact, by creating more paperwork and confusion, it’s likely to cause a backlash in which healthcare providers and patients are strongly dissatisfied. In turn, this could lead to a reversal in policy, just as we saw with Medicare.
For more latest Health News Click Here