In 2021, insurer Aetna implemented a policy requiring Medicare Advantage patients to receive prior authorization for cataract surgeries nationwide. After receiving pushback from physicians, patients and advocates, it withdrew the policy in 2022 in every state except for Florida and Georgia.
This has caused continued procedure denials in the two Southern states, and industry groups have expressed frustrations, claiming that Aetna will not disclose its reasons for keeping the policy in place in just two states.
"While Aetna refuses to disclose its reasons, physicians suspect that it’s because of the states’ large senior populations that Aetna can target to line their pockets with money," an ophthalmology group spokesperson told Becker's in an Oct. 2 email.
Ninita Brown, MD, PhD, a comprehensive ophthalmologist at Thomas Eye Group in Newnan, Ga., has been on the front lines of the industry's ongoing fights with Aetna over the past year.
Dr. Brown spoke with Becker's about how her practice, her Medicare Advantage patients and other practices within the state of Georgia are being impacted by Aetna's continuing prior authorization policies.
Question: How are Medicare Advantage patients being impacted in Florida and Georgia right now?
Dr. Brown: So in the ophthalmology space, they have created prior authorizations for cataract surgery, which we know is a highly effective surgery, standard of care, it's kind of the bread and butter of ophthalmology surgery. We're good at treating it, we're good at diagnosing it and it is creating an extra hurdle for the patients and for our team. In essence, patients usually end up getting the surgery, but there is a big delay in their care. It creates a disparity from regular Medicare patients. With our Medicare Advantage patients, we'll find out the Friday before they have surgery on Monday that even though they've taken their family out of work, prepared for surgery, they'll get denied or else we won't get paid for the surgery we do. So the insurer will find different clauses — everything from a patient needing anti-reflective glasses, which is not a solution for cataracts, to, for some patients, asking for archaic tests to check for things that we don't even have in our preferred practice patterns. The American Academy of Ophthalmology has been really diligent across the nation in fixing this for Aetna and Humana and a lot of the other Medicare Advantage programs, but it hasn't happened in Georgia or Florida. So it sucks for us. We are more or less still dealing with this.
Q: How is this worsening disparities between Medicare patients and Medicare Advantage patients?
NB: People choose these Medicare Advantage plans because they're cheaper. You already have people who are trying to find a cheaper option for their care because they may be on fixed income; they may have other challenges, so that's the first level. You are already self-selecting people who may have a smaller budget for their healthcare. On top of that, a lot of patients with cataracts don't drive, they specifically don't drive after being dilated, so they may have somebody with them. You have to find some type of social support. When we look at the social determinants of health, we can look at all the strikes people have against them and how this will create even more of a disparity between the people who are able to have the surgery and the people who aren't.
Q: Are you seeing a willingness from Aetna to work with ophthalmologists and ophthalmology interest groups?
NB: I have been on multiple calls with Aetna. We even got our state representatives involved. We've gotten the academy involved at every level. We talked to our state representatives and senators. We've been pushing at every level, state and federal, to have some type of reconciliation or change and we were on the phone with some of their physicians who review the cases and we've made a lot of headway with Humana, but Aetna, their representative more or less, promised over the phone that she would be more vested in this if they hadn't made a change, but that was months ago. I'm not really sure what the discussions are. I am on the front lines just trying to take care of my patients. I work in a very large group with staff, ancillary staff, but if you're with a small group and have to do backflips to get patients what they need, it can drain your resources. There's a doctor that's a single practitioner in Atlanta and he's been sending me all of his Medicare Advantage patients because he can't do all the paperwork and buy all the equipment that's requested.
Q: Why do you think Aetna is focused on these two states when it has withdrawn prior authorization requirements everywhere else?
NB: In terms of the south and Florida, we have a large volume of cataract surgeries down here. It's a different market than across the nation. Advocacy is something that is learned, and a lot of times in a lot of communities, relationships with insurance companies and all the different levels of government can be daunting. People are conservative, they follow the rules and do what they are supposed to do. It's a different tradition in the South. We do our best as physicians to try to get patients the best care that they need. At this point it's really a shame because these people are elderly, they've contributed to the system and they are suffering because of made up hurdles. I feel like I'm supposed to be the advocate and I have the flexibility of being at a large practice so I wouldn't be targeted compared to solo practitioners. We have been doing this for a year, if not more. I make myself available and I'm really trying to do everything I can or something that is blatantly wrong. If it was right, they would've kept it going across the nation. It makes absolutely no sense for these requirements to exist in a place where you have so many patients that are older and are challenged in getting access to care. We don't have a lot of cataract specialists, we don't have as many physicians in the South, we have fewer training programs, we're a different world than other parts of the nation. I just feel bad for patients who have done what they are supposed to do. And we are supposed to treat them in the way that is the standard of care.