Q&A: Prior authorization policy for cataract surgery results in costly delays to care
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In July 2021, Aetna implemented a policy stating that all cataract surgery procedures require prior authorization.
This resulted in delayed and canceled procedures while COVID-19-related delays were still wreaking havoc. Alice T. Epitropoulos, MD, discussed with Healio/OSN the implications of these restrictions and how they can be detrimental to patients.
Healio/OSN: Can you please detail the process of acquiring prior authorization?
Epitropoulos: Aetna is the third-largest health insurance company, and it issued a new prior authorization policy for cataract surgery, which more or less overrides a physician’s recommendation for treatment. This has created concerning and sometimes dangerous delays in providing care to our patients.
Aetna announced a sweeping mandate requiring prior authorization for nearly all cataract surgeries, which started in July 2021. This is regardless of the status or condition of the patient. Its software programs, which have been touted as making the process easier to submit paperwork, had functionality issues at the outset, triggering a lot of stress on the administrative end. Cataract surgeries that had been scheduled for July had to be postponed or canceled. This has caused a tremendous amount of upheaval, not only for patients and their families, but also for doctors’ offices frantically trying to expedite the process for approval.
If you are able to enter patient information into the software program, there is a questionnaire. Here is where Aetna starts its own medical decision-making. If the patient sees 20/50 or worse, it does not ask any further questions and basically lets you know within 72 hours; typically, these patients are approved for surgery. If the patient, however, sees 20/40 or better, the process becomes detailed and specific. Aetna requires a lot of information, and it can require up to 2 weeks to process and respond to that request. Then we go into an appeals process, which delays surgery. This has been a regular occurrence.
We are already short-staffed with the pandemic and have a backlog of patients who have not been able to have surgery due to the pandemic, so this has added a lot of stress to every office, not just our office.
Healio/OSN: What happens when insurance companies put up these barriers?
Epitropoulos: If we take the medical decision-making away from patients, physicians and surgeons and give it to nonmedical insurance representatives, that can create dangerous delays in providing care. Denying patients this sight-restoring procedure may put them at increased risk for getting in a motor vehicle accident due to disabling glare at nighttime; there has been documentation in peer-reviewed literature that the risk for getting in a car accident is 2.5 times higher in patients who have cataracts compared with those who do not. There is also an increased risk for falling due to reduced depth perception.
Healio/OSN: What are some of the wider implications of these types of barriers?
Epitropoulos: I would like to share an example from my colleague who is currently treating a 60-year-old woman who has poor eyesight due to cataracts and glaucoma. The surgeon has recommended treating both of these conditions in one operation. The patient was scheduled for surgery in August, and Aetna approved her glaucoma surgery, but the insurance representative did not think her cataracts were bad enough yet, so her cataract surgery was denied. This insurance agent never saw or talked with this patient. So, this patient who sees 20/30 during the day is no longer able to drive at night and, in fact, is considered legally blind at night with oncoming headlights, but this factor is not being considered by Aetna.
As an ophthalmologist who has gone through 15 years of training, I have serious concerns with how Aetna is determining medical necessity, as it is not following internationally recognized standards. This ultimately compromises the patient-doctor relationship and the decision-making process.
One of the absurdities of this policy is that Aetna claims that its rationale for this sweeping prior authorization mandate for cataract surgery is to cut back on what it feels is unnecessary surgeries and therefore cutting back on expenses in the health care system. Ironically, by performing both cataract and glaucoma surgery at once, not only is it the best and safest option for the patient and for their quality of life, but it is also less costly for the health care system than doing each procedure separately. In fact, surgeons make about half by doing two procedures at once. If Aetna’s objective is to cut back on costs, it is shooting itself in the foot with examples like this.
Healio/OSN: What do these barriers mean for the future of ocular surgery in the U.S. in the cataract space and beyond?
Epitropoulos: Cataract surgery is one of the most effective and most common procedures performed in the U.S., with a 99.5% success rate with approximately 4 million surgeries performed every year. This transformative surgery helps patients restore their vision and resume their activities and quality of life. This is not a kick-the-can-down-the-road treatment. Cataracts do not go away and worsen over time. We offer surgery when a cataract reduces activities of daily living, including the ability to safely drive at night . Sometimes, cataracts are the gateway surgery to the more serious conditions such as glaucoma or retinal problems that require cataract surgery first before addressing the other conditions. In the example I shared, the patient’s vision has deteriorated since August. Aetna is looking at an algorithm, while doctors are looking at their patients as human beings.
Healio/OSN: Is there anything that can be done to reduce the burden of these barriers?
Epitropoulos: In regard to Medicare Advantage patients, Congress has sent letters to CMS asking for an update on previous actions it took in the prior authorization policies. In December 2020, CMS issued a proposed rule to modernize prior authorization and reduce the burden on health care providers. More recently, CMS issued a memo to the Medicare Advantage plans that strongly encouraged waiving or relaxing prior authorization requirements due to COVID. There can be some regulatory actions by CMS to address prior authorization, but only for federally funded plans. Ultimately, Aetna needs to reverse this policy, and Congress needs to act with legislation. Our patients need better protections against this type of insurance abuse, which has gone on way too long.
Healio/OSN: Do these barriers add stress to the administrative environment of your practice?
Epitropoulos: This policy adds burden and stress along with allocation of resources that is completely unnecessary. Most eye care practitioners are practicing back to normal but are faced with a backlog of patients, reduced staff and scheduling changes. Our staff spends hundreds of hours trying to file appeals with these insurance companies that are making things even more challenging. Over the past few months, Aetna has added more questions and has made it more difficult to obtain a prior authorization. We have followed every rule that Aetna has added, which has made the process that much more difficult and time consuming, and Aetna does not inform us of any changes. It does not have any rationale or explanation as to how it can decide cataract surgery is not medically necessary for patients who can see better than 20/40 without any other considerations or determinations found on the exam. It is putting profits before patients.
Healio/OSN: Do you have anything else to add?
Epitropoulos: There is no scenario in which medical decision-making should be grasped from the purview of medically trained physicians and put into the hands of individuals who are not medically trained or, if they are, not medically trained in the specialty of the case they are reviewing, which is happening too frequently. These review panels are often non-health care workers within the company. They have never examined patients, and they are not educated in how cataracts can bother patients. They are looking at charts and reports, but they are not looking at people. We need practical, commonsense guardrails in place. Congress needs to pass the Improving Seniors’ Timely Access to Care Act, which stresses the need to continue to pass legislation to stop these actions by insurers to put profit before patients.
Reference:
- Owsley C, et al. J Gerontol A Biol Sci Med Sci. 1999;doi:10.1093/gerona/54.4.m203.
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