The Futility of Prior Authorization

  • by: Peter Pitts |
  • 08/25/2021
In a recent op-ed, ophthalmologist and Executive Vice President of the California Academy of Eye Physicians and Surgeons, Dr. Craig H. Kliger points out that Aetna now requires prior-authorization for all cataract surgeries. He is astounded. And rightfully so.

According to Aetna, prior-authorization, “helps [its] members avoid unnecessary surgery.” That’s healthcare shorthand for “We don’t want to pay for it.” H.L. Mencken said, “When somebody says it’s not about the money, it’s about the money.”  As Dr. Kilger comments, “Hard to believe this is any different.”

No other large medical insurer believes such a policy necessary.

Cataract surgery is the most effective and most common procedure performed in all of medicine with some 4 million Americans choosing to have cataract surgery each year and an overall success rate of 97 percent or higher. The impact feels almost biblical, as cataract surgery allows people to see again — and recover their lives. Study after study shows cataract surgery improves quality of life, cuts the risk of falls and car accidents, and reduces cognitive decline among older adults. 

Per Dr. Kilger, “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.” His article ran three weeks ago.

This issue may be new to ophthalmologists – but it is hardly new.

Prior authorization, also known as pre-authorization, pre-certification or prior notification, is an extra set of steps some insurance carriers require before determining whether they will pay for a medical service or prescription medication. The physician, or other medical provider, is required to obtain approval from the insurance carrier before the carrier will agree to cover the cost of the medical service or prescription medication. Step therapy, also referred to as “fail-first,” requires patients to “fail’ on one or more less costly medications before the health insurance carrier will agree to cover a more expensive medication, even if a physician thinks it is a better option for the patient.

Currently, prior authorization and fail-first protocols are primarily paper-based, and non-standardized. Each insurance carrier has its own set of requirements, which can vary among plans, even within the same carrier’s portfolio of coverage options. To meet prior authorization requirements physicians must complete a time-consuming series of faxes, phone calls, emails, input of data into insurance carrier web sites and, in some cases, letters.  

Two independent nationwide surveys, one by the American Medical Association (AMA) and the other from the American College of Rheumatology (ACR) shows broad physician dissatisfaction with the insidious practices of prior-authorization and step therapy – specifically the ways in which it impacts the ability of physicians to treat patients.

The AMA-conducted survey shows that physicians are running into roadblocks because of prior authorization, or the process of requiring health care professionals to obtain advance approval from health plans before a prescription medication or medical service is delivered to the patient. 

The 1,000 practicing physicians surveyed in December 2020—when new COVID-19 cases were soaring — reported that prior authorization was widespread.  Eighty-three percent of respondents indicated that prior authorizations for prescription medications and medical services have increased over the past five years. Along with this increased volume of requirements, most physicians reported a continued lack of transparency in prior authorization programs, with a majority of physicians stating that it is difficult to determine whether a prescription medication (68 percent) or medical service (58 percent) requires prior authorization. An overwhelming majority (87 percent) of physicians also reported that prior authorization interferes with continuity of care.

“You would think insurers would ease bureaucratic demands throughout a pandemic to ensure patients’ access to timely, medically necessary care. Sadly, you would be wrong,” said AMA President Susan R. Bailey, M.D. 

In parallel, the American College of Rheumatology reports that

* About 48% (47.94%) of patients receiving treatment for their rheumatic disease reported that their provider needed to obtain prior authorization for their prescription in the past year.

* About 47% (46.17%) of patients receiving treatment for their rheumatic disease reported that they were required to undergo step therapy, a process where patients are required to try therapies preferred by their insurance company before they can receive the therapy their doctor originally prescribed — even when doctors are not confident the insurer-preferred option will be effective.

The American Medical Association, the American College of Rheumatology and the American Acadamy of Ophthamology are calling on Congress to remedy the problem by passing The Improving Seniors’ Timely Access to Care Act (HR 3173). 

This bipartisan legislation would require Medicare Advantage (MA) plans to implement a streamlined electronic prior authorization process that complies with technical standards developed by the Department of Health and Human Services, in consultation with relevant stakeholders. In addition, the bill would require increased transparency for beneficiaries and providers, as well as enhance oversight by the Centers for Medicare & Medicaid Services on the processes used for prior authorization. Moreover, to ensure that routinely approved care and treatments are not subjected to unnecessary delays, the program would provide for real-time decisions by an MA plan with respect to certain prior authorization requests.  Importantly, the bill would also require MA plans to meet beneficiary protection standards, such as ensuring continuity of care when patients change plans. 

As for cataract surgery prior-authorization, Aetna has provided no reason and offered no evidence for pre-approval for all cataract surgeries. According to the American Academy of Ophthalmology (AAO), “Because Aetna published no updated policy documents and provided limited prior education, the new policy is already causing chaos at the doctor’s office. This at a time when ophthalmology practices are struggling to fit patients in as they work through a backlog of surgeries due to COVID-19 shutdowns.”

Per the AAO, “The policy has been implemented in such an inefficient manner that we estimate that 10,000 to 20,000 Aetna patients will have their cataract surgery unnecessarily delayed in the month of July alone. Just yesterday, a confused patient called their ophthalmologist in anger to blame him for cancelling surgery. One day before the effective date, and it’s already threatening to erode trust between patients and physicians. There must be a better way to solve this unstated issue Aetna wishes to fix; a way that helps consumers improve their health and simplify their health care experience. The nation’s ophthalmologists are committed to finding a solution that does not delay or deny our patients access to vision-restoring surgery.”

Sadly, prior authorization ends up raising healthcare costs. If doctors can only prescribe “less expensive," less effective treatments, folks will get sicker, be hospitalized more frequently, and require more expensive care. That demand will drive up overall healthcare costs and overwhelm doctors and hospitals with waves of new patients.

It’s time for change. It’s time for action. Lives are at stake.

Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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