Incidence of Surgeries Questioned : Health: Insurers contend too many hysterectomies are performed. They want more say in deciding who should have the surgery, an idea some dislike.

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.

“Who is right? This (process) allows physicians to find out where they have differences of opinion and try to find out what is the right thing to do,” Beggelman says.

“We’re really finding out what the important factors are that go into their decisions. It turns out that patient preference has enormous importance in decision-making about many procedures, including hysterectomy. Different people can have exactly the same symptoms and feel completely different about them.”

Such studies define cases where scientific evidence clearly points to the need for a hysterectomy. “But (physicians) don’t always understand or follow the clear scientific evidence,” she says.

Conversely, these studies also show that, in many cases, not enough evidence exists to say which kind of treatment would be best.

Physicians often lack scientific evidence to say that one treatment might be better or worse than another treatment, says Schwartz, a University of Rochester professor and a member of an American College of Obstetrics and Gynecology task force on hysterectomy.

“It’s complicated and it’s very individualized,” Schwartz says of a physician-patient decision to opt for a hysterectomy. “One of the problems we found is there isn’t the kind of hard data to say how people would do with alternative approaches to the problem.

“On the other hand, I’d like to be comfortable that doctors are not doing unnecessary procedures. But what is unnecessary?”

(Blue Cross/Blue Shield of Maine is conducting one of the first studies to compare hysterectomy to alternative, non-surgical treatments.)

For consumer health groups, the most important issue is the freedom to choose among various treatment options.

For instance, some women find their insurance carriers do not pay for alternative treatments to hysterectomy. Others say they cannot find physicians who will review the alternatives and assist them in making a choice. And, occasionally, a patient cannot find a doctor skilled in an alternative treatment who also accepts her insurance plan.

Deanne, 28, of Sylmar, endured four months of intense pain from uterine cysts waiting for her health maintenance organization to refer her to a specialist who might have been able to help her find an alternative to hysterectomy. When she felt could wait no longer, she found a physician who performed an alternative surgery to remove the cysts--even though her insurance didn’t cover it.

“I became so frustrated that I put the whole bill on credit cards,” she says.

Many women find avoiding a hysterectomy is often easier said then done, says Dr. Herbert A. Goldfarb, a pioneer in the use of gynecological laser surgery and author of a new book, “The No-Hysterectomy Option.”

“There are a number of strategies to avoid hysterectomy,” he says. “But physicians are not going through the steps because it takes time and work and training. Also, part of it is that insurance companies are unwilling to pay (for alternative treatments).”

Insurers vary in what they pay for, but newer or experimental procedures generally are not covered.

And, says Chassin, who works with numerous insurers: “I think that there are a number of reasons why the . . . alternatives are bypassed. Hysterectomy is in fact a simple solution. It’s definitive. You won’t have bleeding any more.”

Many more women would avoid hysterectomy if they knew of alternatives and if their insurance companies would pay for alternative treatments, says consumer health advocate Sidney Wolfe, MD, of the Washington-based Public Citizen Health Research Group.

“There have always been a wealth of alternatives for most of the problems that lead to hysterectomy. That has not been the major cause of the problem,” Wolfe says. “But women only know about alternatives if their doctors let them know.”

Wolfe also charges that hysterectomy rates won’t fall because the surgery is profitable for hospitals and physicians. He is even more critical of health insurers and doesn’t believe they will be able to reduce the number of hysterectomies performed.

Insurers “have known for years that hysterectomies are over-performed. Now we’re seeing these terse little press releases saying there is a problem. But I don’t think they are to be taken very seriously.”

However, McLucas, the Santa Monica physician, says hysterectomy rates will drop as new alternative procedures become firmly established.

For instance, use of a tool to perform endometrial ablation--removal of the uterine lining to stop heavy bleeding--was approved by the Food and Drug Administration only a year ago. Since then, he says, Blue Cross of Tennessee has gone from denying insurance coverage for the procedure to requiring that women about to have a hysterectomy for heavy bleeding obtain a second opinion to consider endometrial ablation as an alternative.

Ablation is easier on the patient and costs much less than a hysterectomy, McLucas says.

“Insurance companies have limited resources, and they would like to see those resources used as wisely as possible,” he says.