Insurer tactics to delay care pushes health equity further away

OPINION – Long plagued by racism and discrimination, communities of color lag on many healthcare measures. Eliminating disparities requires increasing access to care and improving outcomes. Unfortunately, some insurance companies are erecting extraordinary barriers that will actually delay necessary treatment for patients — and exacerbate inequities.

Case in point: UnitedHealthcare (UHC) just rolled out a nebulous new Advance Notification Program for all commercial plans that will require doctors to gather data at a granular level to order most gastrointestinal (GI) colonoscopy and endoscopy procedures for their patients — an arduous process that will be used to create a “Gold Card” prior authorization program in early 2024.

Prior authorization, a process through which insurance companies can overrule doctors’ expertise and deny coverage for medically necessary care, will seriously disrupt patients’ ability to receive life-saving colonoscopies and endoscopies that can detect pre-cancers and cancers in the esophagus, stomach, small intestines, and colon.

UHC’s new policy makes clear that the insurer does not have any data whatsoever to suggest that colonoscopies or endoscopies are overutilized — its initial rationale for prior authorization. Moreover, the insurance company has not released specific details about how this advance notification program will work, but if prior authorization does indeed come to pass, it will likely have devastating consequences for millions of Americans, delaying care, jeopardizing lives, worsening health equity, and disproportionately harming communities of color who already receive less care than their White counterparts. Gastroenterologists fear this will impact several types of diagnostic colonoscopies used to diagnose colorectal cancer, and surveillance colonoscopies, which are critical in monitoring several chronic diseases like inflammatory bowel disease.

California’s’ lawmakers are taking notice. On July 11, the Assembly Health Committee advanced SB598, legislation designed to streamline care for patients by exempting doctors with a high approval rate from going through the rigamarole of prior authorization. This bill is a step in the right direction—but in the meantime, insurance companies like UHC must put people over profits and immediately rescind this potentially disastrous policy.

Some insurance companies are erecting extraordinary barriers that will actually delay necessary treatment for patients — and exacerbate inequities.

Enforcing intrusive and unnecessary prior authorization requirements for time-sensitive procedures means that patients with severe pain, vomiting, and bloody stool will have to wait to find out if they have cancer, Crohn’s disease, or other serious conditions. This is true even if they have a family history of disease. Unfortunately, any delay in treatment, by definition, prolongs patients’ pain and anxiety. And, even worse—since some forms of gastrointestinal cancers progress quite rapidly, it is not a stretch to say that these prior authorization requirements could cost lives.

That is especially true for communities of color, which suffer higher burdens of colorectal cancer and which, due to a range of existing social determinants of health, also face significant access barriers to the procedures necessary to diagnose and monitor disease development. According to the American Cancer Society (ACS), colorectal cancer is the second-most common cause of cancer death in the country, with incidence and mortality rates highest among American Indian, Alaska Native, and non-Hispanic Black individuals. The racial disparities in incidence and mortality rates for colorectal cancer are largely driven by differences in risk factors and access to care, including screening and cancer treatment.

Despite facing an increased risk of colorectal cancer, studies show Black and indigenous adults in the United States complete colonoscopies at lower rates than other patient demographics, a problem that worsens as household income drops. In fact, people with the lowest socioeconomic status are over 40% more likely to be diagnosed with colorectal cancer than those with the highest socioeconomic status due to both differences in the prevalence of risk factors, like smoking and obesity, as well low participation in colonoscopy. Disturbingly, other studies have found that, despite colorectal cancer screenings being proven to decrease mortality rates, healthcare disparities persist in Black and indigenous community.

At a time when stakeholders throughout the healthcare ecosystem should be working to increase awareness of and expand access to potentially life-saving endoscopies and colonoscopies, UHC’s abrupt policy shift will do just the opposite. Instead of addressing healthcare inequities, the ill-defined Gold Card program’s prior authorization requirements will intensify them.

It is not too late to do the right thing. If UHC truly wants to contribute to the health of its beneficiaries and advance healthcare equity, it needs to ensure critical GI procedures are more—not less— accessible for millions of Americans, particularly patients of color.

Dr. Fola May, MD, PhD, a practicing Gastroenterologist in Los Angeles, is the DEI editor of the American Gastroenterological Association’s (AGA) journal, Clinical Gastroenterology and Hepatology.

July 31, 2023 An earlier version of this story referred to SB 58. The correct bill number is SB 598. The piece has been corrected.