Aetna should stop overruling state doctors
I am not qualified to be an insurance executive. I have no experience underwriting coverage policies, I’ve never adjudicated a claim and I hold no license granting me the right to “practice” insurance.
What I do know is ophthalmology. It took 12 years of training and education to earn a license to practice medicine and perform surgery on the eye. I also know my patients. I know their medical histories, their lifestyles and their personal and professional needs, all of which I have followed over time, observing how changing vision impacts their ability to perform the things they need to do and the things they love to do —— Do they drive? Do they need to use a computer for work? Are there complications or risk factors to consider?
This expertise informs my discussions with patients about when it is time to remove a cataract. A lot more goes into this decision than whether the patient can read the big “E” on an eye chart, and some cataract surgeries are actual emergencies that can’t wait for “approval” from an insurer.
An insurance executive should not be the one to decide whether or when it is necessary to remove a cataract. Yet this is precisely what Aetna — the country’s third-largest insurer — has allowed by instituting a new requirement that it preapprove all cataract surgeries beginning July 1. With short notice, no verifiable data, and virtually no input from stakeholders in the medical community, Aetna has delayed thousands of needed surgeries and caused chaos for patients here in Connecticut and across the country.
Approximately 4 million Americans undergo cataract surgery every year with an overall success rate of 99.5 percent. Cataract surgery is vital to restoring patients’ vision and independence, allowing them to perform daily activities without fear of injuring themselves or having to rely on family members for assistance. Delaying cataract surgery, as Aetna has done, can lead to adverse outcomes for patients. Cataracts reduce patients’ quality of life, interfere with their work, and put them at increased risk for falls and car accidents.
Aetna’s irresponsible policy has had an immediate, negative ripple effect across patients and providers. Some physicians were told approval could take up to two weeks, others were told to cancel all surgeries, and some were told approval would be instant (though Aetna’s online portal was not operational when the policy went into effect). While the insurance giant dithered, thousands of Americans were forced to cancel or delay their procedures, a frustrating and potentially dangerous setback. In July alone, anywhere from 10,000 to 20,000 Aetna members had their cataract surgery unnecessarily delayed by the policy, according to estimates from the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery. Tellingly, no other major medical insurer believes such a prior authorization policy necessary for cataract surgery.
Aetna’s actions are the latest and most egregious example of insurers practicing medicine without a license — to the detriment of patient care. According to the most recent American Medical Association survey, 90 percent of physicians said prior authorization has a negative impact on patients’ clinical outcomes, while the average physician spends 16 business hours each week filling out prior authorization paperwork. These policies directly threaten the physician-patient relationship by allowing insurers to override clinical judgment and delay medically necessary care.
Nothing could be more corrosive to the trust that underpins the relationship between a patient and doctor than an outside agency casting doubt on their carefully thought-out decision making. Furthermore, these policies place significant administrative burden on providers and take precious time away from patient care. When I first began the practice of ophthalmology, I was able to manage my practice with just one employee. By the time I threw in the towel and gave up my solo practice for a group practice, I needed six full-time employees to handle all the administrative work, including a substantial degree of prior authorization that predates this new requirement by Aetna.
Enough is enough — it’s time to put guardrails around prior authorization. As a first step towards reforming this practice, Congress should pass the Improving Seniors’ Timely Access to Care Act (H.R. 3173), a bipartisan bill to increase transparency, streamline approvals and hold insurance companies accountable for denying and delaying care. Though the legislation is specific to Medicare Advantage plans, it represents a major milestone for patient access to physician-prescribed care.
By reforming this costly and frustrating practice, Congress can help ensure that insurers like Aetna are not overriding physicians’ clinical decisions and causing unnecessary disruptions to care. I encourage all our congressional representatives to support the passage of H.R. 3173 and Sens. Blumenthal and Murphy to support similar legislation in the U.S. Senate. I also urge Aetna to immediately reverse course with its dangerous prior authorization policy.
These policies directly threaten the physician-patient relationship by allowing insurers to override clinical judgment and delay medically necessary care.