One of the nation’s largest health insurance companies has created new bureaucratic hurdles for patients that could prevent many from receiving cataract surgery – part of a trend of insurance companies creating new “prior authorization” requirements that create hurdles for patients and physicians, reduce availability of health care services, and increase insurance company profits at the expense of patient care.

As of July 1, 2021, Aetna is requiring all cataract surgeries to be “pre-certified.” Aetna claims the practice will “help members avoid unnecessary surgery.” The reality is that this bureaucratic roadblock is not some kind of patient protection measure. It is an effort to deny care and pad the insurance company’s bottom line.

It has become common practice for health insurance companies to create new obstacles for patients, in hopes of not having to provide essential health care to those who need it. The reason for these types of obstacles is simple: Fewer surgeries performed translates to larger insurance company profits.

Like other insurance companies, Aetna has enjoyed record profits through the COVID-19 pandemic. The company, which was acquired by CVS Health in 2018, saw its operating income increase from $1.06 billion in 2019 to $3.07 billion in 2020.

The California Medical Association (CMA) continues to fight for medical decisions to be made by trained medical professionals, instead of lay entities more concerned with the corporate bottom line than the quality of patient care. This is why CMA is fighting to strengthen the prohibition on the corporate practice of medicine, and why we are supporting legislation at the state and federal levels that would streamline and standardize prior authorization requirements.

In California, CMA is sponsoring SB 250 by Senator Richard Pan, M.D. SB 250 would require state regulators to streamline the prior authorization system to ensure patients have access to critical care. One successful approach taken in other states is an audit-based system where prospective prior authorization is waived for clinicians deemed high-performing. Texas, for example, recently passed legislation  that prevents insurers from imposing prior authorization requirements on providers who have historically high approval rates.

CMA is also supporting federal legislation—HR 3173, the “Improving Seniors’ Timely Access to Care Act” authored by California Congressman Ami Bera, M.D.—that seeks to standardize and streamline prior authorization processes for routinely-approved items and services performed under Medicare Advantage programs, among other improvements.

Prior authorization requirements can be challenging for patients, creating  barriers to care and increasing administrative burdens for physicians who must spend time and resources to get approvals as insurance companies design and administer increasingly complex prior authorization systems.

The time delays and administrative burdens also continue to undermine health care outcomes. Most startlingly, in a 2020 American Medical Association survey, 30% of physicians reported that prior authorization led to a serious adverse event for a patient in their care such as hospitalization, medical intervention to prevent permanent impairment, or even disability or death. 

CMA strongly supports  SB 250 and HR 3173, both of which would place patient needs first by simplifying and streamlining the prior authorization processes.