The health insurance giant UnitedHealthcare will soon require physicians to obtain prior authorization for hysterectomies, except vaginal hysterectomies conducted on an outpatient basis.
But the policy, which takes effect April 6, is being criticized by some physicians for interfering with the physician-patient relationship.
In a recent coverage update, UnitedHealthcare cited a committee opinion from the American Congress of Obstetricians and Gynecologists stating that vaginal hysterectomies are the preferred method because of evidence demonstrating that they are associated with better outcomes and fewer complications than are laparoscopic or abdominal hysterectomies.
The coverage policy will affect abdominal, laparoscopic, and laparoscopy-assisted vaginal hysterectomies, as well as vaginal hysterectomies not performed on an outpatient basis.
But ACOG officials themselves questioned the move. In a statement, they acknowledged that vaginal hysterectomy, when possible, produces the best outcomes for patients. “However, many factors are considered when making decisions about the ideal route of hysterectomy for each individual patient,” ACOG wrote. “These decisions are best made between a physician and a patient, not a third party administrative decision-maker.”
Officials at the AAGL, or the American Association of Gynecologic Laparoscopists, said they were still reviewing the change and declined to comment on it.
And physicians in practice are asking whether the decision is wise considering that an increasing number of ob.gyns. are becoming more proficient in performing laparoscopic procedures.
“The number of vaginal hysterectomies that residents do during their training has decreased substantially, whereas the number of laparoscopic cases increased,” Dr. Catherine A. Matthews, division chief of urogynecology and reconstructive pelvic surgery at the University of North Carolina, Chapel Hill, said in an interview. “It is an art that is slowly dying. I think it’s very fair to say more residents are more comfortable with the laparoscopic approach than with the vaginal approach.”
Dr. Isaac Schiff, chief of the department of obstetrics and gynecology at Massachusetts General Hospital in Boston, agreed.
“The problem may be that some doctors may not quite have the skills for vaginal hysterectomy that they have for laparoscopic hysterectomy,” he said in an interview. “They may feel more comfortable doing it laparoscopically than vaginally, and now they are being forced to do it vaginally.”
It is patients’ individual needs that may be getting lost in the debate, though, Dr. Matthews said.
With more surgeons performing laparoscopic procedures, “patients may have been steered [toward] having one mode of hysterectomy over another, based on an individual surgeon’s competence and bias, but it may not actually have been the best thing for any one individual patient,” she said.
The UnitedHealthcare coverage decision may actually promote a procedure that is typically better for patients, Dr. Matthews added, but unless physicians have the necessary training and comfort with it, a shift toward more vaginal hysterectomies won’t necessarily lead to better outcomes.
“If you get a bunch of laparoscopic surgeons trying to do vaginal hysterectomy, the morbidity may well increase, so it may not remain the least morbid intervention,” Dr. Matthews said.
In the future, changes in payment models could also push physicians toward vaginal hysterectomies, Dr. Matthews said. If more insurers adopt systems that offer a single rate of payments for all hysterectomies, regardless of the type of procedure, vaginal hysterectomies could become the preferred method since they are less costly to perform, she said.