ADVISORY ALERT FROM THE AMERICAN COLLEGE OF GASTROENTEROLOGY
To: State Insurance Commissioners
From: The American College of Gastroenterology
Daniel Pambianco, MD, FACG, President American College of Gastroenterology
Dayna Early, MD, FACG, Chair, ACG Board of Governors
Sita Chokhavatia, MD, MACG, Vice Cahir, ACG Board of Governors
Re: UnitedHealthcare’s Prior Authorization Announcement Impacts Access to GI Patient Care
On behalf of the American College of Gastroenterology (ACG), we are notifying you of a recent prior authorization rule initiated by UnitedHealthcare (UHC) which may significantly impact patient care in your states. UHC recently announced prior authorization changes for common gastrointestinal (GI) procedures and services beginning June 1, 2023. 1 Our members will be required to obtain prior authorization for the following services: upper endoscopy or esophagogastroduodenoscopy (EGD), capsule endoscopy, diagnostic colonoscopy, and surveillance colonoscopy.
As part of your role to protect consumers and help ensure fair, competitive, and healthy insurance markets, we urge you to conduct a review of these upcoming rules to better assess patient safety and the data supporting this decision.
UHC has cited clinical literature and “data on over-utilization,” as mentioned in their FAQs document. 2. ACG has met with UHC on this recent policy announcement, and to date, UHC has not provided any literature or studies on over-utilization for these procedures. It is imperative that the clinical data drive any coverage policy. Prior authorization is harming patient care, our members’ practices, and remains a key factor in physician-burnout. We urge you to conduct a review and hold hearings on this matter.
A national cross-sectional survey comprised of respondents from board-certified/board-eligible gastroenterology physician and advanced practice provider ACG members (ACG survey) 3 illuminates the problems of prior authorization and the adverse impact on patient care. More than 50% of ACG members surveyed reported that prior authorization led to a serious adverse event in patients.
In the same survey, respondents were asked to consider situations during the previous 7 days in which they gave up on a prior authorization and chose an alternative treatment. The alternative treatments were less effective, more costly to patients, less tolerable, and/or supported by a lower level of clinical evidence. Furthermore, more than 90% reported a high burden associated with prior authorization in their practices. Additionally, 59.5% reported hiring staff to work exclusively on prior authorizations. The burden was “high” or “very high” among practices with (95.7%) or without (89.1%) dedicated staff to process prior authorizations. These survey results emphasize the burden gastroenterologists face because of prior authorization, while increasing costs for patients and resulting in worse outcomes. It is practicing medicine without a medical license.
In March 2023, the American Medical Association (AMA) recently published data with similar findings. 4
According to the AMA survey:
- Almost half of physicians (46%) reported prior authorization policies led to urgent or emergency care for patients.
- More than four in five physicians (86%) reported that prior authorization requirements led to higher overall utilization of health care resources, resulting in unnecessary waste rather than cost-savings. More specifically, about two-thirds of physicians reported resources were diverted to ineffective initial treatments (64%) or additional office visits (62%) due to prior authorization policies.
- The health insurance industry maintains prior authorization criteria reflect evidence-based medicine, but physician experiences call into question the clinical validity of insurer-created criteria that lack transparency. Only 15% of physicians reported that prior authorization criteria were often based on clinical evidence.
A 2021 AMA survey 5 also found that 34% of physicians reported that prior authorization led to a serious adverse event, such as hospitalization, disability, or even death, for a patient in their care. Comparing the two surveys, serious adverse events due to prior authorization are on the rise. Other findings include:
- 93% reported care delays while waiting for health insurers to authorize necessary care.
- 82% said patients abandon treatment due to authorization struggles with health insurers.
- 51% of physicians who care for patients in the workforce reported that prior authorization had interfered with a patient’s job responsibilities.
These statistics highlight how critical it is to ensure that patients receive timely care and do not suddenly lose access to care. Yet, according to a March 2022 Medical Group Management Association (MGMA) survey, 98% of respondents said that problems of prior authorization have stayed the same or have gotten worse. 6
Patient Care Example: Surveillance Colonoscopy
UHC’s new prior authorization announcement impacts “surveillance colonoscopy.” A “surveillance” or follow-up colonoscopy is performed to detect cancer and/or remove precancerous lesions in a patient who is currently asymptomatic but has a personal history of colorectal cancer or polyps. Colorectal cancer remains the second leading cause of cancer deaths in the U.S. among men and women combined. Screening and surveillance are powerful tools in the fight against colorectal cancer. Based on UHC’s new rules regarding prior authorization, patients who are due for a surveillance colonoscopy will require prior authorization, which may delay their care and could result in worse outcomes for the patient. The U.S. Multi-Society Task Force (USMSTF) on Colorectal Cancer recommends that asymptomatic individuals undergoing screening colonoscopy require repeat colonoscopy exams to evaluate for new polyps at specific intervals based on the findings of their screening exam, ranging from 1 year to 10 years. While the intervals of repeat exams differ, the principle is the same: to detect and remove polyps in asymptomatic individuals. 7 Hence, this falls in the category of a screening—but at a different interval (and is now subject to prior authorization under UHC’s new requirements). 8 According to the USMTF guidelines, undergoing one or two follow-up examinations reduces the risk of colorectal cancer incidences by 43%–48%. For patients having an advanced adenoma, one follow-up colonoscopy has a significant impact on reducing the risk of colorectal cancer. The risk fell to the range found within the general population if patients with an advanced adenoma had at least 1 follow-up colonoscopy. This risk was more than 4 times higher in patients without the follow-up colonoscopy. 9 It is important to note that these patients started out as average-risk patients and now are part of the screening continuum of care. ACG recently updated its guidelines on colorectal cancer screening, noting that recent studies highlight a rising incidence of colorectal cancer in individuals younger than age 50. Incidence rates have doubled in ages 20 to 49. 10 Now, persons born around 1990 are estimated to have twice the risk of colon cancer in the U.S. and four times the risk of rectal cancer compared to those born around 1950. 11
Prior authorization continues to strain gastroenterology practices and limit ACG members’ ability to provide timely care to their patients. The U.S. is experiencing one of the greatest crises in the healthcare workforce today, with prior authorization cited as a significant source of provider burnout. Given these patient safety concerns with prior authorization, we urge you to conduct a review and hold hearings on the impact UHC prior authorization changes for GI procedures and services will have on patient care and access.
1 New requirements for gastroenterology services: https://www.uhcprovider.com/en/resource-
2 Prior authorization for gastroenterology services - UnitedHealthcare
3 Shah, Eric D. MD, MBA, FACG; Amann, Stephen T. MD; Hobley, James MD; Islam, Sameer MD, MBA; Taunk, Raja MD; Wilson, Louis MD. 2021 National Survey on Prior Authorization Burden and Its Impact on Gastroenterology Practice. The American Journal of Gastroenterology 117(5):pgs. 802-805, May 2022. | DOI: 10.14309/ajg.0000000000001728.
4 2022 AMA prior authorization (PA): physician survey https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
5 2021 AMA prior authorization (PA) physician survey, available at https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
6 Virtually all medical groups say payer prior authorization requirements aren’t improving (March 2, 2022), available at https://www.mgma.com/data/data-stories/virtually-all-medical-groups-say-payer-prior-autho
7 Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer:
8 Of note: The guidelines clearly exclude individuals with symptoms, undergoing colonoscopy for an indication deemed necessary for diagnosis and management of a medical condition.
9 USMST Guidelines: https://journals.lww.com/ajg/Fulltext/2020/03000/Recommendations_for_Follow_Up_After_Colonoscopy.19.aspx
10 ACG Clinical Guidelines: Colorectal Cancer Screening 2021:
11 ACG Clinical Guidelines: Colorectal Cancer Screening 2021: