Aetna’s prior authorization policy harms California patients

It took 13 years of training and education for me to earn a license to practice medicine and perform surgery on the eye. For more than 30 years since, I’ve been attempting to provide the best there is in ophthalmic medical and surgical care to my community in Encino and West Hills. But health care insurers would like to replace my deep experience with an algorithm. Through a process called prior authorization, insurance companies take control of medical decisions from doctors and puts them in hands of administrators who delay and disrupt, and sometimes deny medically necessary care.

When prior authorization policies began to take hold about 20 years ago, it was intended to focus on specific new drugs and diagnostic tests. But over the years, the practice has expanded to common procedures and surgeries, ensnarling physicians and patients in red tape.

The latest example of prior authorization gone too far comes from Aetna, the nation’s third largest insurer. Beginning July 1, Aetna now requires prior authorization for all cataract surgeries, across all its members and plans. The new policy applies equally, from children born with cataracts, to adults whose cataracts interfere with their ability to drive, to people in need of emergency cataract surgery before vision-threatening retinal conditions can be treated. The fallout has been swift and chaotic. Seniors whose cataracts make it impossible to drive at night are being denied surgery. People losing their vision to other eye diseases, such as glaucoma, have to wait for approval for their combined cataract and glaucoma surgery.

About 4 million Americans undergo cataract surgery every year, a number that will grow as our population ages. Cataracts reduce our patients’ quality of life because they impair their ability to carry out basic activities. We don’t remove cataracts merely out of patient convenience; cataracts put people at risk of harm. Study after study shows cataract surgery not only improves quality of life, but also cuts the risk of falls and car accidents and reduces cognitive decline among older adults.

The only way to treat cataracts is through surgery. An ophthalmologist decides when it’s time for surgery after a careful examination and in consultation with the patient. Why has Aetna decided that an algorithm can better determine when it’s time for surgery? The American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery have tried to get a clear answer, but Aetna provided no reason for creating a policy that no other large healthcare insurer believes necessary.

What we do know is the policy has already delayed cataract surgery for approximately 10,000 to 20,000 patients in July alone. Ophthalmologists report that when they appeal denials of care, Aetna puts them through a “peer-to-peer” review that is often led by doctors who don’t specialize in ophthalmology.

Here in California and across the country, ophthalmologists are going to great lengths to secure approval from Aetna for cataract surgery, while the backlog caused by prior authorization and delayed elective care during the Covid-19 pandemic only grows. In my own practice, this requires three full-time employees to schedule the surgery, verify insurance plans, confirm appointments and coordinate the patients’ care with their primary care physicians and ensure covid testing requirements have been met and authorization for ambulatory surgery centers are in place.

Enough is enough. Patients cannot afford these dangerous disruptions to their care. The nation’s ophthalmologists call on Aetna to immediately reverse course on its prior authorization policy for all cataract surgeries. We also urge Congress to take action and institute long-overdue reforms to the prior authorization process by passing the Improving Seniors’ Timely Access to Care Act (H.R. 3173). If passed, the bipartisan bill would help hold insurance companies accountable for delays in authorizing healthcare services, streamline approvals, and inject much-needed transparency into the prior authorization process. Though it would only apply to Medicare Advantage plans, the bill will help protect patient access and remove major burdens on already-overstretched physicians.

I urge California’s Congressional delegation, including Senators Padilla and Feinstein, to put patients first by supporting H.R. 3173. California’s patients cannot afford to wait for their healthcare.

Photo: Piotrekswat, Getty Images

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