Two weeks ago, I saw my 39-year-old patient with long-standing ulcerative colitis in clinic for new onset bleeding per rectum. She mentioned needing to attend an upcoming conference, and was eager to get to the source of the problem and start treatment right away. Given her new symptoms, we decided on an urgent colonoscopy the following week, so we could diagnose the underlying cause and begin treatment.
Prior to this episode, her ulcerative colitis had been in remission, and given her increased risk of colon cancer from long-standing disease, she has been undergoing surveillance colonoscopy to look for dysplasia or cancer every 2 years. Her last surveillance colonoscopy was 1 year ago.
Reading about the recent news from UnitedHealthcare to require prior authorization for diagnostic and surveillance colonoscopies got me thinking about how this scenario would play out after the implementation of their new policy. For my patient, both the diagnostic colonoscopy ordered urgently in a clinic visit and her routine surveillance colonoscopy would require prior authorization. At the very least, it would require my office, and likely me, answering questions and engaging in a back and forth with her insurance company. At the very least, this adds delays to care, and far worse, if not diagnosed in a timely manner, her ulcerative colitis flare could require hospitalization and escalated therapy.
In my career, I wear three hats that provide a unique vantage point through which I view the question of prior authorization for colonoscopy.
First, I am a clinician and must put my patients first and foremost. Second, I am a clinical researcher on the evidence-based medicine that we can adopt into guidelines. I was a co-author on the 2021 U.S. multi-society task force guideline document where we proposed lengthening the surveillance colonoscopy intervals after low-risk adenomas from "5 to 10 years" to "7 to 10 years." We found moderate evidence for our recommendation, but also nuanced it with the discussion of individualized decision making based on patient factors and noted that high quality evidence was lacking (usually multicenter randomized clinical trials are required). There are multiple such RCTs underway in the U.S. and Europe, but they will take time to complete. In the meantime, we must use clinical judgement in interpreting the follow up intervals for repeat colonoscopy.
Prior authorization policies -- such as the one set forth by UnitedHealthcare -- where that clinical judgment is constantly challenged and needs defending, erode the patient-physician experience. Another untoward consequence is that physicians may delay timely endoscopy and colonoscopy, fearing a time and effort drag on prior authorization back and forth. Ultimately, this may worsen clinical outcomes, such as missing timely colonoscopy after a high-risk adenoma or high-grade dysplasia.
My third hat is practicing population health. I realize the need for some guidance and standardization in clinical care, and reducing variability at either end. In my medical institution, I have collaborated with our clinical informatics team to create clinical support tools, such as flags in the chart indicating a need for follow-up colonoscopy based on the highest risk lesion found. We base these flags on the current guidelines, and the purpose is to reduce both overuse and underuse of colonoscopy. These chart flags do not dictate care but act as a reminder for the clinician to address the need by evaluating the patient's health condition and their preferences, and engage in shared decision making. I know most healthcare systems have clinical support tools, and patients are good stewards of their health. Neither the clinician nor the patient want unnecessary procedures. At the same time, neither party wants to miss a procedure that they deem necessary. So, putting up barriers like prior authorization for procedures may do nothing except create unnecessary bureaucracy and potential delays in care.
When it comes to procedures for symptoms, it is unclear how or who in UnitedHealthcare will be making decisions about whether the procedure is indicated. We do have general guidance for procedure indications, but most of it comes down to clinical judgement, which may not be reflected in the information reviewed by UnitedHealthcare. Without having the benefit of the patient in front of them, it is unclear how their decision making would be anymore sound than that of the clinician. The move by United also invites other insurance carriers to follow in their footsteps; very soon, our practices could become nothing but triage hubs, where we collect information and let administrative managers decide what we should do, based not on patient factors but on dollar amounts. If this policy were to creep into other areas of care, more and more clinical autonomy and judgement would be kicked to the curb.
I am also concerned about how physician burnout comes into play with this new policy. Having been through a global pandemic, we are in an unprecedented era of physician stress, where the everyday clinical practice burden feels like death by a thousand paper cuts. Putting up yet another burdensome policy, without evidence that it improves patient care or reduces overall cost of care, is highly irresponsible, if not downright dangerous.
Potential solutions would be for UnitedHealthcare to rescind this policy for now and engage in a dialogue with clinicians and member societies, and review concerns on both sides. With optimal and timely care of the patient in mind, I'm sure we can reach common ground.
For starters, they should evaluate diagnostic versus surveillance procedures separately. For a diagnostic procedure, they should at least consider removing the prior authorization requirement for procedures with urgent indications, such as bleeding per rectum (my patient). Other examples of urgent indications include iron deficiency anemia, dysphagia, unintentional weight loss, and melena, to name a few. For a surveillance procedure, this might include developing an evidence-based framework for providing feedback to clinicians for procedures that may not be due or supporting use of the current quality indicators for colonoscopy (e.g. adhering to guideline recommended intervals for follow up colonoscopy in at least 85% of procedures). Many practices already track this, and may be able to submit reports for their physicians.
The bottom line is that we all want the same thing: patient-centric care, good clinical outcomes, and reducing low value care. So, let's clean the slate and start afresh.
Aasma Shaukat, MD, MPH, is the Robert M. and Mary H. Glickman Professor of Medicine and Gastroenterology and the director of outcomes research in the Division of Gastroenterology & Hepatology at NYU Langone in New York City. She is a practicing gastroenterologist and researcher in colon cancer screening and quality indicators of colonoscopy.