The simmering dispute about the overuse of hysterectomy has triggered a major debate over the role of insurers in determining when the procedure should be performed.
Long criticized as one of the nation's most over-performed surgeries, hysterectomies could be avoided from 30% to 50% of the time, according to many studies. Now, some health insurers are trying to determine the appropriateness of the 1 million hysterectomies performed each year in North America.
In recent months, Blue Cross/Blue Shield in Illinois, Maine, Tennessee and California have adopted stricter coverage guidelines that are designed to reduce the number of hysterectomies. In some cases, insurers are requiring that physicians try other treatments before performing a hysterectomy.
Other health-care providers, such as Aetna Life & Casualty, have established programs to review whether they deem the surgery justified in individual cases.
"Hysterectomy is one of the procedures . . . that insurance companies want to have more of a say in," says Bruce McLucas, a Santa Monica physician who specializes in a new procedure to remove the lining of the uterus without having to remove the entire organ. "There is pressure from within society (to reduce hysterectomies)."
Some physicians and consumers, however, are uncomfortable with the idea of insurance companies becoming involved with personal medical decisions.
"I find it quite insulting to me and my patients to have them that invasive," says Dr. Ruth Schwartz, a member of a physician task force that studied hysterectomies.
"I think in the effort to save money in health-care costs, there is some possibility that (insurers) will interfere with patients' rights. If you were bleeding heavily . . . does somebody have the right to say, 'No, you can't have a hysterectomy because it costs too much'? That bothers me."
The spotlight on hysterectomy is part of a larger insurance-industry trend of reviewing how medical decisions are made, experts say. Other common surgical procedures under scrutiny are prostatectomy, coronary bypass surgery and Cesarean section.
Insurers believe a review process will help them curb inappropriate medical procedures that waste money and don't benefit the patient, says Dr. Constance Winslow, Aetna research director in Hartford, Conn.
"The guidelines are not to reduce the rate of hysterectomy. They're to make sure that those people who are needing them are getting them," she says.
Hysterectomy involves the removal of the uterus, the pear-shaped organ that contains and nourishes an embryo. The procedure is commonly performed because of irregular or heavy bleeding caused by a hormone imbalance, benign fibroid tumors or endometriosis, a condition characterized by abnormal growth of uterine tissues outside the uterus.
The surgery also is common for a condition called prolapsed uterus, a relaxation of the pelvic structure that causes the uterus to drop, and for cancer of the endometrium or cervix.
The majority of hysterectomies, which usually cost at least $10,000, are necessary, medical experts say. But critics say some women undergo hysterectomies when alternative treatments, such as medication, could have been attempted first. (See related story.)
A recent study by doctors at Blue Cross/Blue Shield of Illinois found that about one-third of 5,884 hysterectomies were probably unnecessary. About 40% of the surgeries in the study were performed on women under age 40 for diseases that did not include cancer.
"We wanted to increase women's awareness on this issue," says Dr. Arnold L. Widen of Blue Cross/Blue Shield of Illinois. "We want women to ask their physicians questions (about) the alternatives . . . There is a whole host of different approaches that can be utilized nowadays short of hysterectomy."
Dr. Mark Chassin, senior vice president of Value Health Sciences, a Santa Monica-based health utilization research firm that gathers information to help insurers perform more efficiently has studied medical requirements for hysterectomy for the past year. He says many surgeries still take place for problems that can be treated with less drastic procedures.
Applying detailed criteria, his study concludes that 25% to 35% of hysterectomies are inappropriate.
For example, a hysterectomy might be performed for minimal bleeding for which the physician did not perform other diagnostic tests or try hormonal treatment, Chassin says.
A similar study in Boston also found that physicians have varying reasons for recommending hysterectomy. But that study found patients' wishes often play an important role in the decision, says Dr. Marlene Beggelman, president of Medical Intelligence, a private Boston company that assists health-care providers in reducing costs.
The study asked medical experts to compile extensive medical literature on hysterectomy and then meet to discuss various conditions, symptoms and patient circumstances that can lead to a hysterectomy.