Opinion

Aetna Is Attempting to Practice Medicine and It Could Endanger People’s Vision

Cataract surgery is one of the most effective and common procedures performed in all of medicine, with some 4 million American choosing to have cataract surgery each year and an overall success rate of 97 percent or higher. Cataract surgery is transformative, allowing people to see again — and recover their lives. Study after study shows cataract surgery improves quality of life, cuts the risk of falls and car accidents and reduces cognitive decline among older adults.

But Aetna has put this successful, long-established procedure through a new algorithm known only to the insurer and determined that some 5 percent of these surgeries are unnecessary; a mere cosmetic choice. To “help (its) members avoid unnecessary surgery,” Aetna in July started a sweeping new policy requiring pre-approval for all cataract surgeries. The new policy applies equally among its members — 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.

Why has Aetna — the country’s third-largest provider of health insurance – chosen to make it more difficult for each and every one of its beneficiaries to obtain this sight-restoring surgery? The American Academy of Ophthalmology and 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 health care insurer believes is necessary. Aetna said in a statement that up to 20 percent of surgery could be unnecessary, while offering no evidence to support its claim.

About 25 million Americans have cataracts, but not all of them need surgery immediately. Ophthalmologists determine when surgery is necessary based on guidelines developed by the AAO, with input from ASCRS. These guidelines are grounded in an exhaustive search of peer-reviewed literature and backed by a panel of leading experts in cataract surgery. They serve as the gold standard for U.S. ophthalmologists, as well as for ophthalmologists across the globe. In short, we know cataract surgery. On what algorithm is Aetna’s policy based? We don’t know.

We do know that precertification policies, also known as prior authorization, are intended to save the insurance companies money. But prior authorization ultimately ends up costing the health care system. It costs time and money for both physicians and insurance companies, while it builds a wall between patients and access to needed care.

And it’s not even clear that insurance companies save money in the long run because after all the delays and hassle, most of these surgeries are approved anyway.

  • The AAO conducted a 2018 survey in which half of the ophthalmologists responding said their prior authorization requests across all ophthalmic procedures are approved from 75 percent to more that 90 percent of the time.
  • A 2018 U.S. Department of Health and Human Services’ Office of the Inspector General audit found that 75 percent of all requests Medicare Advantage plans denied at the outset were ultimately approved.
  • 2020 physician survey by the American Medical Association showed that 94 percent of physicians reported delays in care due to prior authorization requirements and 90 percent said the practice has a negative impact on clinical outcomes.

America’s ophthalmologists are calling on Aetna to reverse its prior authorization policy immediately. Americans with cataracts – and other diseases on which Aetna this month imposed prior authorization requirements – cannot wait for Aetna to approve the care their physicians have prescribed.

If Aetna won’t act, Congress must. Fortunately, bipartisan legislation has been introduced at the federal level that would put reasonable parameters around insurers’ use of prior authorization. The Improving Seniors’ Timely Access to Care Act of 2021(H.R. 3173) would enhance transparency in the prior authorization process, streamline approval and ensure decisions are based on evidence-based guidelines – not subjective, concealed criteria. Although the bill applies only to Medicare Advantage plans, it represents a significant first step toward reforming an industry practice that has needlessly wreaked havoc on the U.S. health care system. It would also send a message to insurers that we, as a society, won’t stand for a system does not deliver cost-effective and timely care to people in need.

 

Tamara R. Fountain, MD, is president of the American Academy of Ophthalmology.  

Richard S. Hoffman, MD, is president of the American Society of Cataract and Refractive Surgery. 

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