Protect patients from abusive health-insurance practices
It’s not news that most people don’t love their health insurance provider. The industry ranks third worst in customer satisfaction.
But here’s what is new. Insurance company practices are no longer just exasperating and pointlessly complicated, they’ve become abusive and dangerous.
Take, for example, a practice called prior authorization. It’s a process that requires physicians to get advance approval from health plans before it will agree to cover a medical service or a medication. When prior authorization began to take hold about 20 years ago, it was intended to focus on expensive new drugs and diagnostic tests. But over the years, the practice has expanded to common procedures and surgeries.
This practice reached its nadir last summer when Aetna, the nation’s third-largest insurer, decided to apply prior authorization to all cataract surgeries, regardless of the person’s age or their medical condition.
There’s nothing experimental about cataract surgery. It’s one of the most common procedures performed in all of medicine, with some 4 million American choosing to have cataract surgery each year. It’s astonishingly effective, with an overall success rate of 99 percent. Most importantly, it’s transformative for our patients, it allows them 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.
All this, and it’s a relatively inexpensive surgery (Medicare allows a charge of $500 to $700 dollars for the average cataract surgery).
Since Aetna started this policy, tens of thousands of medically necessary cataract surgeries have been canceled, forcing patients to wait weeks or in some cases months for approval. Some people whose vision has reduced to the point that they no longer feel they can safely drive at night have had their request for surgery denied because Aetna believes they just haven’t lost enough vision yet.
It’s been an extraordinarily frustrating experience for our patients. They pay their insurance premiums month after month, and when they need sight-saving surgery, Aetna refuses to pay for it. For physicians, it has been an incredibly wasteful and time-consuming experience. As we work through a backlog of surgeries due to COVID19, we must dedicate more resources to fight for approval for surgeries we know our patients need.
But this issue goes beyond Aetna’s inexplicable new policy on cataract surgery. The health insurance system has so clearly been re-designed to confuse, delay, and ultimately deny healthcare, that a national response is necessary.
According to the American Medical Association, doctors like me spend an average of 16 hours each week fighting with insurance companies to secure prior authorization for our patients’ procedures. Despite our medical training and clinical expertise, insurance representatives who do not examine our patients overrule our professional opinions, resulting in serious harm to some patients.
Fortunately, Congress is working to rein in prior authorization abuse. The Improving Seniors’ Timely Access to Care Act of 2021 (H.R.3173 / S. 3018) is designed to cut red tape, speed up approvals, and prevent unnecessary disruptions to care by streamlining the prior authorization process under Medicare Advantage. If passed, the legislation would establish an electronic prior authorization process, create a national standard for clinical documents needed, allow patients to receive real-time decisions for routinely approved services, and encourage Medicare Advantage plans to adopt policies that adhere to evidencebased guidelines. These guardrails represent a major step towards ensuring transparency and patients’ access to care.
Since being introduced, the bill has earned strong bipartisan support with 252 co-sponsors in the House — including 13 from Florida alone. I urge our entire congressional delegation, including Senators Marco Rubio and Rick Scott, to support the commonsense legislation. Finally, I implore Aetna to reverse its dangerous prior authorization policy so Florida’s seniors can get the cataract surgery they need—when they need it.