By now, you’ve heard about the ill-advised new Aetna policy that, effective July 1, mandates prior authorization for all cataract surgeries. The insurer has been under attack by the AAO and ASCRS as the organizations try to get a reason as to why, especially since no other major insurance carrier has felt the need to enact such a policy. Aetna has only replied that the chance of it deeming a cataract surgery unnecessary is probably less than 5%. This was a last-minute announcement for a policy that Aetna seems unwilling to discuss or delay by even a month to help practices prepare. The AAO has estimated that 10,000 to 20,000 patients covered by Aetna will have their surgeries delayed in the first month alone (www.aao.org/newsroom/news-releases/detail/aetna-urged-to-reverse-policy-on-cataract-surgery ).
EYE DISEASE DOESN’T STOP FOR VIRUSES
Thinking about these delays, my mind wandered back to the spring of 2020. During the early days of the pandemic, when all eyes were on the surging infections and subsequent hospitalizations and deaths, severe lockdowns were implemented. And they impacted most all of us in ophthalmology.
Here in Tennessee, eye care of all stripes was deemed an “essential service,” but as cases began to rise here, we made our own decision to shut down — sort of. While we closed all the optometric offices, we kept our main two offices open to continue to see our postops and critical-need patients. That still amounted to about 20-30 people a day.
But two and a half weeks into it, we realized we had to open back up fully. We felt that more people would likely be harmed by missed eye care than the risk of COVID. We are still seeing patients who needed retinal injections but went blind because they isolated at home and refused to come out, even for sight-saving care.
ALL ABOUT THE BENJAMINS?
Back to Aetna. I think we all know that a patient who has a significant cataract needs to have surgery in an expeditious manner. People with cataracts have car wrecks, falls resulting in hip fractures and all manner of other incidents. Sure, some of the patients we see have milder cataracts and just can’t see a golf ball that well. But, at least here in rural Tennessee, most of the patients I schedule for cataract surgery are a menace on the road! So why this policy?
My guess is some actuary realized that even a month’s delay in cataract surgery will produce more revenue for the company and in turn for the stockholders. Face it: at typical cataract surgery age, people’s clocks are winding down. Any delay can lead to death or even a serious illness that will indefinitely postpone a surgery that the insurer now doesn’t need to reimburse. Some patients will put it off due to the frustration of having to delay scheduling surgery.
Are some cataract surgeries performed unnecessarily? Certainly. I’ve seen multiple cases of one eye operated upon by another surgeon and the patient subsequently came to me for consultation about surgery on the other eye. Prior records indicated a moderate or severe cataract in the unoperated eye, where my exam revealed 20/20 vision and little or no cataract. And yes, in many practices where the norm is still that the optometrist makes the decision for and scheduling of cataract surgery and the surgeon just shows up to operate, often performing an “eye exam” right before the patient is wheeled to the OR.
But would this Aetna policy reduce unnecessary surgeries? The minority — hopefully the very tiny minority — of surgeons who operate unnecessarily are probably pretty good at poor refractions and shoddy exam documentation, so it’s likely a chart review by a nurse won’t detect any issues. Thus, I’m guessing the purpose of Aetna’s delay is just about money. What do you think? Whatever the motivation, though, these delays, much like those we experienced due to COVID, will do more harm than good. OM
