Washington, DC – Today, patient advocates joined gastroenterologists on Capitol Hill to highlight some of the most frustrating, dangerous and abusive practices in all of health care: prior authorization and step therapy. At today’s American Gastroenterological Association (AGA) Advocacy Day Fly-in, advocates shared the real-world impacts of insurance barriers that delay and sometimes deny medically necessary care.
The group also expressed serious concerns about UnitedHealthcare’s (UHC) proposed “Gold Card” prior authorization policy for virtually all colonoscopies and endoscopies expected to go into effect in early 2024 for all its 27 million commercial beneficiaries.
On June 1, UHC unveiled a confusing and burdensome “advance notification” program for GI endoscopy and colonoscopy services. AGA contends this is a way for UHC to lay the groundwork for future prior authorization requirements next year through its “Gold Card” program, for which it has yet to release any meaningful details or rationale. If it looks anything like its proposed prior authorization program for GI services announced earlier this year and rolled back to advance notification after public outcry, it has the potential to compromise access to the care that helps millions of Americans receive accurate diagnoses and manage their diseases — including colorectal cancer, inflammatory bowel disease, , and other serious health challenges.
“Prior authorization has become increasingly utilized by insurers who provide no rationale or data to justify its implementation. This often results in serious health care access issues and adverse patient outcomes due to significant delays or outright denial of care. Instead of getting timely treatment, many patients have told us that the stress of fighting their own insurance company exacerbates their conditions. It’s unconscionable that patients are often put through an administrative obstacle course when they should be getting quickly approved for medically necessary care,” said Barbara H. Jung, MD, president of AGA.
Consider the stories of two patient advocates who shared their experiences with lawmakers today.
Kimberly Hooks of Georgia has lived with ulcerative colitis for 12 years. She was on steroids for the first eight years after her diagnosis due to her insurance company’s step therapy policy. Only after her doctor discovered her colon was on the verge of rupturing and immediately admitted her to the hospital in 2018 was she finally able to receive the biologic medications her doctor believed would most effectively manage her condition. Facing an elevated risk of colorectal cancer, her colon and rectum were removed in 2020 which required her to receive an ostomy. The ostomy has since been reversed and she now lives with a j-pouch. She has taken steps for preventative care and as a result, she must have an invasive endoscopic procedure done to examine her ileo-anal pouch. This procedure is called a pouchoscopy and it must be examined every two years. As a UHC beneficiary, should the insurer’s prior authorization policy go into effect as scheduled, she fears timely care will be significantly disrupted.
“It’s a blessing that I had a second chance on life, but I shouldn’t have to experience the extreme stress and the unnecessary run around that is prior authorization – just to access quality care,” said Hooks.
Another patient, Karen Mancera Azamar, a PhD student in Florida, discussed her struggles with insurance denials. “After my initial diagnosis and failure with a treatment for mild ulcerative colitis, my gastroenterologist recommended an antibody-based infusion treatment. For months, I fought with my insurance company to cover the treatment. Before I got a final denial from my health insurance seven months later, my disease got so bad that I fainted and had to go to the emergency room. I was in the intensive care unit for more than a week. A group of gastroenterologists at the hospital had to give me an antibody infusion before I showed any improvement. Now I have to apply for patient assistance directly from the pharmaceutical company to receive this medication,” Mancera Azamar said.
Prior authorization has become extremely prevalent in the U.S. health care system, and not just in GI care. The latest prior authorization survey from the American Medical Association (AMA) shows that one-third (33%) of doctors say the insurance barrier has led to a serious adverse event such as hospitalization, permanent disability, or death for a patient in their care. Nearly half (46%) of physicians report that prior authorization has led to immediate care and/or emergency room visits.
According to a 2023 survey of AGA’s membership, 95% of respondents say that prior authorization restrictions have impacted patient access to clinically appropriate treatments and patient clinical outcomes. Furthermore, 84% described that the burdens associated with prior authorization policies have increased “significantly” (60%) or “somewhat” (24%) over the last five years.
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About AGA
The American Gastroenterological Association is the trusted voice of the GI community. Founded in 1897, AGA has grown to more than 16,000 members from around the globe who are involved in all aspects of the science, practice, and advancement of gastroenterology. The AGA Institute administers the practice, research and educational programs of the organization. For more information, visit www.gastro.org.
AGA is collecting stories and data about how UHC’s GI advance notification policy is affecting patients and practices at www.gastro.org/StopUHC.
