Insurance company policy delays sight-restoring surgery, puts patients in jeopardy
New Aetna policy delays cataract surgeries by requiring prior authorization
Fairfax, Va. – July 1, 2021 – The ability to see has been described as a “gift,” and it has been cited as the most valued of the five senses.1 Due to aging, congenital conditions, or traumatic injury, cataracts can develop to threaten one’s ability to see. Cataract surgery, one of the world’s most common and clinically successful procedures, is a medically necessary, sight-restoring procedure that, if delayed, results in safety issues, negatively impacts quality of life, and ultimately leads to blindness.
Delaying this procedure is what a new insurance company policy, put into effect by Aetna today, July 1, is doing for patients. Despite opposition from the two largest ophthalmology societies in the U.S.—the American Society of Cataract and Refractive Surgery (ASCRS) and the American Academy of Ophthalmology (AAO)—and concerns shared from member ophthalmologists, Aetna is requiring prior authorization for all cataract surgery procedures.
“It is difficult to imagine that Aetna would willingly place its reputation and brand at such a high risk knowing there are studies in peer-review journals detailing increased incidents of injurious falls and automobile accidents as a result of delayed surgery. A prior authorization requirement will delay surgery, will put patients at higher risk, and will alienate patients and physicians,” said Steve Speares, ASCRS executive director.
In a meeting with ASCRS and AAO last week, Aetna failed to provide concrete reasoning on why this policy is being implemented, without examples or rationale for why all cases are being subject to precertification. The organizations raised transparency concerns and discussed concerns from ophthalmologists about the inconsistent instructions from Aetna staff and the inability to get prior authorization approval for cataract surgery. In the meeting, Aetna failed to address ASCRS concerns on the operational aspects of the program and offered no relief for the short implementation timeline, its inoperable portal, and the unhelpful general support line that has resulted in complete confusion for ophthalmologists and, as of today, cancelations of cataract surgeries for the beginning of July.
Cataract surgeries are usually scheduled several weeks in advance and, for the most part in the U.S., are performed on one eye at a time, meaning the patient needs to return for a second procedure on their other eye. Delaying these sight-restoring procedures, where the clouded natural lens is removed and replaced with a clear, vision-enhancing implant, can result in a host of issues:
- It can lead to further hardening of the lens, increasing the risk for cataract surgery complications or the need for more invasive surgical procedures.2
- It can be associated with physical safety concerns (increased risk of car crashes,3 increased risk of falls,4 etc.).
- It can reduce a patient’s quality of life.5
- It can result in permanent blindness or impaired visual function, especially in children where timeliness matters to the developing brain’s pathways.6
Patients who have received cataract surgery often describe how the procedure affected their lives.
“I have seen first-hand how fighting for patients to receive this sight-restoring surgery can change their lives,” said Hayley Boling, MBA, COE, member-at-large, American Society of Ophthalmic Administrators (ASOA) Board of Directors. “One patient who had given up his career driving due to poor vision was, after cataract surgery, able to earn a living and enjoy life again—all because he was given the gift of sight. Restricting and/or delaying access to care by implementing this blanket policy not only hurts medical practices like mine, tying up valuable resources, it hurts patients who depend on their vision every waking moment of every single day.”
In a year when cataract surgeries have already been significantly delayed due to the COVID-19 pandemic—ophthalmology was the surgical specialty hit hardest by the shutdown,7 which created an existing backlog of patients for ophthalmologists to serve8—further delays are being imposed by the prior authorization policy instituted by Aetna.
"Cataract surgery can restore vision and give the patient back their independence. I'm sad to have to cancel cases that were arranged months ago and delay patient care further because of Aetna's poorly reasoned, poorly executed, greedy new policy that puts their profits before our patients’ eyesight,” said Parag Parekh, MD, MPA, chair, ASCRS Government Relations Committee. “They have offered no logic behind their decision and refuse to work in any corporate manner to arrive at a reasonable solution."
“This policy creates an overly burdensome amount of unwarranted work for our teams and unnecessarily restricts access to this essential surgery for patients suffering from sight-threatening cataracts,” Ms. Boling said. “This mass application of preauthorization requirements sets a dangerous precedent for other insurance companies and creates a slippery slope for other medical services and specialties.”
ASCRS, along with AAO and ASOA, is calling on Aetna to rescind this policy and has asked members to voice opposition directly to Aetna regarding this policy.
“The best two people qualified to determine if cataract surgery is necessary are the patient and their ophthalmologist,” said Richard S. Hoffman, MD, ASCRS President. “Having an insurance company, such as Aetna, determine if a patient should have surgery does nothing to enhance patient care and adds the potential for delaying sight-restoring surgery and is at its worst rationing of care.”
For more, visit ASCRS’ webpage with resources for advocacy and more information about Aetna’s policy and its negative impact on patient care. ASCRS will continue to advocate for the needs of patients and their surgeons and is continuing to work to rescind Aetna’s policy.
7. Changes in Medicare Physician Spending During the COVID-19 Pandemic. Economic and Health Policy Research, American Medical Association, April 2021. PDF.
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