On Sept. 1, UnitedHealthcare introduced a new national initiative called the gold card program, which is set to go into effect on Oct. 1. According to the insurance company’s website, the program “will reward contracted provider groups who consistently adhere to evidence-based care guidelines.”

The website further states that qualifying practices will not have to “submit requests for prior authorization” for specific services that “would otherwise require authorization,” with gold card status providers needing only “to complete a simple advance notification for Gold Star services.”

But what the company seems to be describing as a reward for best practices could be interpreted as quite the opposite, said Andrew Albert, MD, MPH, a gastroenterologist at Chicago Gastro. “This appears to be penalization for not practicing within guidelines that are based on corporate pressures rather than evidence-based data.”

Many Unanswered Questions

UHC published a list of services that will be eligible for the gold card program. At this point, no endoscopy services are included. They also noted that providers can view their program status in the UHC provider portal. But experts told Gastroenterology & Endoscopy News that it’s unclear what guidelines the company is using to make decisions about what services to include and what providers are eligible.

The lack of detail provided by UHC leaves a lot of questions unanswered, Dr. Albert said. “Who is making those clinical decisions on their side? If a practice loses its ‘gold card’ status, do they lose their ability to participate with UnitedHealthcare patients? Is there a set of guidelines they could share that rule in or rule out gold card eligibility?”

Maria T. Abreu, MD, the director of the Crohn’s and Colitis Center at the University of Miami Health System and president of the American Gastroenterological Association, also underscored the lack of clarity about the program. “How do they roll out a gold card program if they haven’t already gathered the data to support it? What data are they using to decide who gets a gold card?”

Dr. Abreu expressed concern that “if there’s something called a ‘gold card,’ it will be given to a select few. The majority, who take care of the majority of patients, won’t be included.”

Advance Notification Process for GI Procedures

When UHC launched its advance notification for non-screening GI procedures last June, the company stated that it would use the data received through advance notification to make decisions about gold card eligibility (Gastroenterology & Endoscopy News 2023;74[7]:1,36-37). But this would seem contingent on GI practice participation in the company’s advance notification process, said Prateek Sharma, MD, a professor of medicine at the University of Kansas School of Medicine, in Kansas City, and the president of the American Society for Gastrointestinal Endoscopy. “ASGE does not know how many practices participated; therefore, we cannot anticipate how many GI practices will be eligible for UHC’s gold card program.”

Dr. Sharma added that “UHC says it is using a two-year look-back period for this round of gold card eligibility, starting with April 1, 2022. Because UHC has not included any endoscopy codes on the list of gold card–eligible services, we assume it is because UHC is relying on its advance notification process for endoscopy codes, which began June 1, 2023, to determine whether endoscopy services will be among the gold card–eligible services in the future. But, honestly, it is hard to know how UHC arrived at its list of eligible services.”

UHC will require a prior authorization approval rate of 92% or higher for two consecutive years as its gold card program eligibility requirements, Dr. Sharma said, adding that it’s unclear how the company identified 92% as its minimum approval rate and the significance of that number.

‘Little Room for … Medical Judgment’

Regardless, “that threshold leaves very little room for physicians to exercise medical judgment that is in the best interest of their patients but conflicts with care guidelines if they want to be rewarded with a gold card and possibly some relief from administrative burden,” Dr. Sharma said.

Dr. Abreu, too, is concerned about what it means to reward adherence to guidelines in a field so dependent on physician experience and clinical judgment in the management of often very complex patients. “This may work for practices that do primarily screening colonoscopy in patients 45 and older with no risk factors, but most people have some variant that keeps them from falling into a neat bucket. Also, we have so many guidelines on different things; some are old, some are new. Realistically, I don’t know how you parse through all that data,” she said.

In discussions with UHC last year, as the company was preparing to launch its pre-authorization policy (scrapped in the 11th hour and replaced by advance notification), leaders of the GI societies attempted to find a workable agreement, said Daniel Pambianco, MD, a managing partner of Gastro Health in Charlottesville, Va., and recent past president of the American College of Gastroenterology.

Lack of Transparency

“We asked why they wanted to implement that policy, and they said there were gastroenterologists overutilizing services. We asked to see the data on this, and at first, they seemed to be willing to share that information,” Dr. Pambianco said. But the company backtracked and stated they could not share that data.

“Another point we brought up is that if they’re concerned about overutilization, they should be concerned about underutilization, too. For example, in Barrett’s esophagus, if we knew it was being underutilized, we could increase surveillance and save lives with early detection.

“Their sidestepping [of] these issues leads us to the conclusion that this is all about saving money. It has nothing to do with quality,” Dr. Pambianco said.

Although Dr. Abreu said she suspects that very large practices may have the resources for the increase in administrative burden that will accompany this shift in policy, she thinks smaller practices will be particularly vulnerable. “In our Crohn’s and Colitis Center, patients are often referred to me because their doctors don’t have the staff and the bandwidth to fight with insurers about drugs that need to be approved. In our healthcare system we already spend 30% of healthcare dollars on administrative costs. It’s an endless fight.”

—Monica J. Smith

Drs. Albert and Sharma are members of the Gastroenterology & Endoscopy News editorial board.