'Prior authorization' requirements disrupting patient care

For the last 30 years, I've dedicated my life to caring for patients in my community in the western suburbs of Chicago. I've known most of my patients for decades. We're a team. We decide together when it's time for surgery.

But health care insurers would like to replace my medical expertise and relationships with an algorithm. Through a process called prior authorization, insurance companies are taking control of medical decisions from doctors and putting them in hands of administrators who delay and disrupt and sometimes deny medically necessary care.

The situation has gotten so bad that Gov. Pritzker this month signed a new law that attempts to rein in insurance companies by reforming prior authorization. That's great news for Illinoisans, but this is a national problem. Every American deserves to be protected from prior authorization abuse.

Take, for example, Aetna, the nation's third largest insurer. Beginning July 1, Aetna now requires prior authorization for all cataract surgeries, across all its members and plans. As a result, our practice had to cancel many cataract surgeries while we spend days or even weeks shuffling paperwork back and forth with Aetna. It's a headache for my practice, but it is my patients who suffer the most.

Cataracts impair vision. They interfere with the ability to perform basic daily activities such as working, driving and reading. Study after study shows cataract surgery not only improves quality of life but also cuts the risk of falls and car accidents and reduces cognitive decline among older adults. Cataracts don't get better with time, they only get worse, making it more difficult for patients to see and more likely that they'll fall or get in a car accident.

Aetna is not saving money by delaying cataract surgery, because eventually all cataracts must be removed. It's the only way to restore sight.

Why has Aetna 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 the 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 healthcare insurer believes necessary.

What we do know is that Aetna's new policy has already delayed cataract surgery for approximately 10,000 to 20,000 patients in July alone. Ophthalmologists report that when they appeal denials of care, Aetna puts them through a "peer-to-peer" review that is often led by doctors who don't specialize in ophthalmology.

The original intent of prior authorization was to save money by providing extra scrutiny to high-cost procedures that may not be medically necessary. But over time, prior authorization policies have expanded to include common procedures and surgeries. The folly of this logic is evident in our lived experience, because after all the delays and hassle, most of these surgeries are approved anyway.

A 2018 study by the American Academy of Ophthalmology found that half of ophthalmologists said their prior authorization requests were approved from between 75 percent to more than 90 percent of the time. A 2020 survey conducted by the American Medical Association found that 90 percent of physicians said that prior authorization policies have a negative impact on patient outcomes.

Prior authorization is also a huge financial burden for physicians. A recent AMA survey found that the average physician spends two whole business days completing prior authorization requests, taking valuable time and resources away from patient care. At my own practice, we have had to hire three dedicated staff members just to manage prior authorization tasks for medicines and procedures.

Patients and physicians deserve a faster, more transparent process so that care is not unnecessarily disrupted. I urge Aetna to reverse its prior authorization policy for all cataract surgeries and Congress to pass the Improving Seniors' Timely Access to Care Act (H.R. 3173). The bipartisan bill will help hold insurers accountable for causing dangerous disruptions to patient care and streamline patients' approvals so that physicians can focus more on patients than on paperwork.

I urge Congress to follow Illinois' lead and pass H.R. 3173 to protect all Americans from abusive prior authorization policies.

• Ruth D. Williams, M.D., is president of Wheaton Eye Clinic, one of the largest ophthalmology clinics in the Midwest. She specializes in the diagnosis and management of glaucoma.