Insurer’s new policy limits access to cataract surgery

“I’ve fallen, and I can’t get up!” proclaims an elderly woman in a 1980’s commercial for LifeCall, a home system that summoned emergency care, but became the subject of derision and perhaps a bit of schadenfreude over time, spawning parodies.

Of course,  it might seem funny until it’s you or a loved one, perhaps the victim of a fall due to poor eyesight. Now imagine that poor eyesight might have benefited from cataract surgery your insurer decided you didn’t need.

That hypothetical is now a reality for those with coverage from the major insurer Aetna, which as of July 1 requires all cataract surgeries to be “precertified,” as a May publication quaintly-titled “Hello there” reminds participating eye surgeons.

Precertification, also called “prior authorization” (PA), is an increasingly utilized tool in the health insurance industry.

That missive also asserts — without evidence or reasoning –  that the process “helps [its] members avoid unnecessary surgery.”

Ignoring the hubris involved in that assertion, one can imagine how an insurer’s bean counters might view a surgery that nearly everyone eventually needs as a target for savings.

Indeed, roughly 2 million surgeries are performed nationally each year (around 250,000 in California), and that number is almost certain to increase as baby boomers join the ranks of those over 65.

Precertification, also called “prior authorization” (PA), is an increasingly utilized tool the health insurance industry seems to believe – as indicated in a slide deck outlining its position – will “reduce misuse and waste” (euphemisms for “savings”). It apparently does this by sparing beneficiaries from being the subjects of pesky “unnecessary” procedures and other services.

In short, they appear to have concluded certain treatments are being performed inappropriately in such numbers to justify making providers jump through hoops to provide them. It would be one thing if this really had the potential to do what these companies hope.

“When somebody says it’s not about the money, it’s about the money.” — H.L. Mencken

However, my experience as the executive of a society representing California’s ophthalmologists (and a Board-Certified ophthalmologist myself) is that PA only creates frustrating paperwork that is unhelpful to perhaps anyone except – and this is key – shareholders who benefit from potentially delaying payment long enough for an insurer’s quarterly earnings report to look that much better.

H.L. Mencken purportedly said, “When somebody says it’s not about the money, it’s about the money.” Hard to believe this is any different.

In fact, another example from my specialty – intraocular injection for wet macular degeneration (a rapidly blinding retinal condition in the elderly) that requires relatively expensive drugs (some $1500-2000 per dose) – is already the subject of aggressive PA.

Published data is scarce, but since it is my job to monitor such things, ophthalmologists report nearly 100% of these are approved (some on the second go-round after correcting paperwork errors), making obtaining “permission” solely an exercise in futility and – yes – potential delay that may negatively impact visual outcomes.

Requiring advance “confirmation” of something that should be obvious seems solely a delaying tactic.

Of course, such high rates of approval seem commonsense if you consider what rational person would allow a needle to be stuck in their eye on a monthly basis indefinitely (and assume the associated risk of infection that might result in the loss of the eye) if it weren’t “medically necessary?”

Cataract surgery will almost certainly prove no different. Aetna itself anticipates less than 5 percent non-approvals) given the standard to perform it is pretty clear-cut “Visual function that no longer meets the patient’s needs,” according to the American Academy of Ophthalmology (pg. 18), which almost invariably requires documenting a specific inability to perform a significant “activity of daily living” to defend intervention.

So, requiring advance “confirmation” of something that should be obvious seems solely a delaying tactic.

And resulting delays may not be benign, given the inability to see well can cause falls that – as the woman in the LifeCall commercial might agree – can lead to serious injuries including hip fractures associated with significant morbidity almost certainly requiring far more expensive care than any savings from PA.

Truth be told, if insurers had to reimburse providers for the added work of each successful PA – say, at $30 each – the requests would almost certainly vanish.

As of this writing, I am aware of numerous cancellations of these surgeries as an unprepared Aetna attempts to implement a process about which it has provided little to no real training and direction.

Put simply, patients and their surgeons are being left in the dark about whether payment for the procedures will be forthcoming, an untenable situation when expensive facilities and related supplies are involved.

The California Departments of Managed Care and Insurance should take a hard look at this type of health insurer behavior, which appears to be spiraling out of control and – at least in the cases described – is functionally penalizing 100 percent of providers to address what might be a small handful of potential abuses.

California may want to consider legislation similar to an innovative law just passed in Texas (House Bill 3459) that prevents insurers from imposing PA requirements on providers who have historically high approval rates, which would avoid functionally penalizing 100 percent of providers to address what might be a small handful of potential problems. Congress can also help by passing federal legislation: H.R. 3173, the “Improving Seniors’ Timely Access to Care Act,” that seeks to standardize and streamline PA processes for routinely-approved items and services performed under Medicare Advantage programs, among other improvements.

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Editor’s Note: Dr. Craig H. Kliger has more than 30 years of experience working in health policy. He is the Executive Vice President of the California Academy of Eye Physicians and Surgeons.