Biggest U.S. Health Insurer Tightens Rules on Hysterectomy Coverage

I thought this was interesting so I wanted to share it with our readers and providers.

By JENNIFER LEVITZ and JON KAMP in Feb 27 Wall Street Journal

UnitedHealth to require doctors to get authorization before performing most types of procedure; decision marks another blow to laparoscopic power morcellator, which can spread hidden cancer

Many hospitals have stopped using the morcellator, a surgical device that was found to spread hidden cancer in some women undergoing hysterectomies.

The nation’s largest health insurer is imposing tighter controls on its coverage for hysterectomies after more than a year of debate over a medical device that was found to spread hidden cancer in some women undergoing the procedure.

As of April, UnitedHealth Group Inc. will require doctors to obtain authorization from the insurer before performing most types of hysterectomies, according to a bulletin sent to physicians and hospitals.

The decision marks another blow to the tool known as a laparoscopic power morcellator, which cuts up and removes tissue through small incisions in the abdomen. Until recently, morcellators were being used in thousands of laparoscopic hysterectomies every year to remove benign growths known as fibroids. Fibroids can be hard to distinguish from a dangerous form of cancer, uterine sarcoma, which can’t be reliably detected before surgery.

Morcellators, which typically use a fast-spinning blade, can spread the malignancy and worsen the outcome, the U.S. Food and Drug Administration has said.

Only vaginal hysterectomies performed on an outpatient basis won’t require prior approval. The method, in which the uterus is removed through the vagina and no morcellator is used, has long been considered the least invasive and cheapest option yet is used in only 15% to 20% of cases, according to federal data and studies. The technique hasn’t been emphasized enough in medical training, many doctors say.

The move by UnitedHealth, which covers 40 million health-insurance customers in the U.S., could trigger broad changes in clinical practice, many in the field said. Roughly 500,000 hysterectomies are performed a year, making it one of the most common surgeries for American women.

The FDA began examining morcellators in December 2013 after aWall Street Journal article about a high-profile cancer case that had emerged in Boston. In November, the agency warned morcellators shouldn’t be used on the vast majority of women.

According to a letter from UnitedHealth to doctors reviewed by the Journal, the insurer will base hysterectomy approvals on a new medical policy statement that cites the FDA’s warning and medical evidence in favor of vaginal surgery.

Sam Ho, chief medical officer for UnitedHealth’s insurance business, said the company was already reviewing guidelines favoring vaginal surgery put out several years ago by the main gynecology society and also factored in the morcellation debate when writing the pre-authorization policy.

“We needed to do more on behalf of our members to ensure that they would get the safest and most effective method” of hysterectomy, Dr. Ho said.

He said the policy decision would apply nationwide to all of the insurer’s commercial customers. The policy doesn’t include hysterectomies involved in cancer treatment.

Requiring prior authorizations for medical care is increasingly common for UnitedHealth and other insurers. The approach gained popularity in the 1990s as a cost-cutting tool, waned in popularity and is now seeing a resurgence as insurers are strained by an ever-growing array of options and technology, said Linda Hull, a principal at Mercer, a consulting unit of Marsh & McLennan Cos.

An article published last year in the American Journal of Obstetrics & Gynecology, citing the experience at a Philadelphia hospital, concluded that vaginal hysterectomies were by far the least costly minimally invasive option. Average hospital costs for these procedures were $7,903, compared with $11,558 for a total laparoscopic hysterectomy and $13,429 for a robotic-assisted hysterectomy. The cost of open abdominal surgery, which isn’t considered minimally invasive and usually requires a hospital stay, wasn’t included in the analysis.

Still, prior authorization had been uncommon for hysterectomies. Among the major commercial insurers, only Anthem Inc. requires them. A spokeswoman said the company started the practice last year over concerns that doctors weren’t fully considering alternatives to hysterectomies to treat fibroids.

Cigna Corp. and Aetna Inc. said they don’t require the extra step. “We believe this is best left up to the physician and patient based on clinical circumstances,” an Aetna spokeswoman said.

The FDA’s action in November significantly curtailed use of the morcellator, gynecologists said. Many hospitals have banned the devices, and former top manufacturer Johnson & Johnson left the market last year. But the FDA chose to leave morcellators on the market, leaving a narrow window for their use.

Requiring prior authorization will likely steer doctors more toward vaginal surgery, although much will depend on how UnitedHealth implements the policy, gynecologists said. It can take days or weeks to clear a typical prior authorization request, and the process can drag on for a month if the insurer requires the doctor speak with an internal medical expert, Ms. Hull said.

Mike Norgard, a gynecologist in Fergus Falls, Minn., who accepts UnitedHealth in his practice, still uses the power morcellator but said the added bureaucracy would probably lead him to do more vaginal surgeries than he currently performs. “I don’t really want them telling me what type of hysterectomy I should be doing,” he said.

Gynecological societies also bristled. “These decisions are best made between a physician and a patient, not a third party administrative decision-maker,” the American College of Obstetricians and Gynecologists, the field’s main medical society, said. ACOG endorses vaginal surgery as the best option when possible, which UnitedHealth noted in its new policy.

Although medical evidence shows vaginal hysterectomies are less invasive and associated with quicker recoveries, lower costs and better cosmetic results, the technique has been far less popular than open abdominal surgery, which also doesn’t use a morcellator, and laparoscopic surgery, which is often performed with robotic assistance.

Catherine Matthews, a University of North Carolina gynecologic surgeon and board member for the American Urogynecologic Society who trains doctors world-wide in hysterectomy techniques, said she had reservations about an insurer guiding doctors toward one method. But she said gynecologists often leave residencies with insufficient instruction on vaginal procedures, and the move could improve training.

“It’s a huge deal,” Dr. 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.”

Not all patients are candidates for vaginal surgery, gynecologists said. A woman with a uterus that is too large could be ruled out, and patients with distorted anatomy from prior surgeries might be encouraged to have an abdominal procedure, said Isaac Schiff, the chief of obstetrics and gynecology at Massachusetts General Hospital.

The technique, however, has also suffered from limited training for residents, doctors doing too few cases to maintain their expertise, and heavy device-industry marketing of high-tech tools, said a study published in Obstetrics & Gynecology in September.

As a result, not all doctors have the technical skills to do vaginal hysterectomies, gynecologists said.

“We’ve developed a generation of surgeons who don’t know how to do vaginal surgery, quite frankly,” said Neil Finkler, the chief medical officer at Florida Hospital Orlando.

The Accreditation Council for Graduate Medical Education, an organization that accredits residency programs, said the group’s key training official was traveling and unavailable to comment. In an interview in August, the official said vaginal hysterectomy training is continually reassessed.