Q&A: AGA snubs UHC’s choice to ‘forgo transparency’ in Gold Card program for GI endoscopy
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As the launch of UnitedHealthcare’s Gold Card program approaches, the AGA continues to urge the insurer to reconsider implementation of a program that could affect various gastrointestinal procedures and “threaten patient health.”
According to UnitedHealthcare, its Gold Card program, which recognizes qualified practices that have “consistently demonstrated adherence to evidence-based guidelines,” will begin Oct. 1, 2024. Qualified practices will not have to submit prior authorization requests, but instead will be “required to complete a simple advance notification for Gold Card services, which will confirm member eligibility and coverage for the service(s) requested.”
In a statement, the AGA said the process sounds like a “familiar strategy” to implement prior authorization.
“A Gold Card program that requires participation in an advance notification program, which is another form for prior authorization, is a disingenuous attempt to avoid the stigma that prior authorization now has because of the abusive practices by insurers,” Maria T. Abreu, MD, AGAF, AGA president and director of the Crohn’s and Colitis Center at University of Miami Miller School of Medicine, told Healio. “This is prior authorization by any other name.”
In an interview with Healio, Abreu discussed the potential impact of UHC’s Gold Card program, as well as the AGA’s continued efforts to get the answers they seek and change the course of the insurer’s plan.
Healio: Why do you think UHC is trying to package the Gold Card program as something different than prior authorization?
Abreu: UHC has not released any details about the Gold Card program beyond what was included in the initial announcement.
This Gold Card process will still add an additional burden to physicians and their practices. In addition, we believe only a small number of practices that consistently meet a high level of initial prior authorization approvals will be eligible and that likely won’t include IBD specialists because we often have to go through multiple levels of denials before needed care is finally approved.
UHC has provided no data that physicians are overusing endoscopic procedures. If that is the rationale for this extra administrative burden, then UHC should put forth data that shows evidence of overuse and identify those physicians. The AGA has repeatedly asked for such data to corroborate UHC claims that prior authorization is necessary, but the nation’s largest insurer fails to produce any scientific justification for such a policy.
As it stands now, a gastroenterologist who only treats IBD patients, as I do, has little chance of avoiding UHC prior authorization since every patient with IBD is unique and will not fall neatly into their outline.
Healio: How is patient health affected when overreaching prior authorization policies are implemented?
Abreu: We already know what it is like to get prior authorization for medications. The insurance company makes opaque the magic algorithm they have set to allow approval for a medication. The prior authorization process often involves doctors taking time away from seeing patients to explain their treatment decisions to someone who does not know the patient and typically isn’t even a gastroenterologist.
In reviewing what UHC shared last year, the insurer provides an 18-page commercial colonoscopy outline, a 20-page esophagogastroduodenoscopy guideline and 10 pages on capsule endoscopy. The parameters for IBD, for example, say a colonoscopy 6 months after Crohn’s disease surgery is approved.
Ok — so then what? What if a patient has increased symptoms? Now treatment for a patient with IBD and increased symptoms is going to be delayed while the doctor’s office gets prior authorization, certain to be followed by more delays to receive prior authorization for medications or medication adjustments.
I expect that many IBD patients will end up hospitalized for colonoscopies, which only drives up cost all the way around. The impact on patients, in addition to their health status, includes the loss of productivity at work due to days missed. For family and friends committed to providing transportation or post-procedure needs, it’s time and schedule management which for many people is no small thing.
I am confident that many payers will follow UHC and undermine medical decision-making between physician and patient, as well as unnecessarily increase administrative costs to the health care system and independent doctors’ offices.
Healio: What do you think will happen when the Gold Card program becomes effective?
Abreu: There will be chaos while offices figure out the process, hire more people to fax and enter data, and necessary procedures are delayed. As always, it will be patients with minimal health literacy who may fall through the cracks and postpone procedures due to the arduous and lengthy process they have to endure before gaining approval — if they do — and receiving necessary care.
Healio: Does the AGA plan to campaign against it?
Abreu: The AGA led a successful campaign last year to delay the implementation of this program and worked with patient groups who also protested prior authorization policies impacting their care.
This change may eventually affect every adult with commercial insurance since other insurers will surely follow UHC’s lead and implement their own programs. Thus, AGA will continue its advocacy efforts to educate patients, providers and policymakers that prior authorization policies accompanied by zero rationale or relevant data are unacceptable and continue to threaten patient health and undermine physician medical decision-making.
The AGA is working with our congressional champions to provide much-needed oversight of UHC, an insurer that chooses to forgo transparency with beneficiaries or physicians about this program. This so-called Gold Card will ultimately impact patient health and legislators are concerned that patients are not getting the care they are paying for through their monthly premiums.
Healio: How can AGA members help?
Abreu: AGA will call upon our physician members to voice their concerns to UHC when we are informed of the details it says it will release on Sept. 1.
AGA is also working with patient groups such as Crohn’s & Colitis Foundation, Let My Doctors Decide and others to help patients learn how to advocate for their care and speak up against policies that threaten their health, such as this latest prior authorization proposal by UHC.
References:
- Here we go again: UHC announces “gold card” program, AGA demands details.
- https://gastro.org/news/here-we-go-again-uhc-announces-gold-card-program-aga-demands-details/. Published Aug. 9, 2024. Accessed Aug. 21, 2024.
- UnitedHealthcare Gold Card Program. https://www.uhcprovider.com/content/dam/provider/docs/public/policies/protocols/UHC-Gold-Card-Program-Protocol.pdf. Accessed Aug. 21, 2024.
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