Aetna creates new barrier to care for the elderly, underscoring need for prior authorization reform
August 10, 2021
One of the country’s largest health insurance companies has created new bureaucratic hurdles for patients that could prevent many patients from having cataract surgery – part of a trend by insurance companies to create new “prior authorization” requirements that create barriers for patients and physicians, reduce the availability of health care services and increase insurance company profits at the expense of patient care.
As of July 1, 2021, Aetna requires that all cataract surgeries be “pre-certified”. Aetna says 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 inflate the bottom line of the insurance company.
It has become common for health insurance companies to create new barriers for patients, in the hope that they will not have to provide essential health care to those in need. The reason for these types of obstacles is simple: fewer surgeries performed translates into greater profits for insurance companies.
Like other insurance companies, Aetna has made record profits thanks to the COVID-19 pandemic. The company, which was acquired by CVS Health in 2018, saw operating income drop 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 qualified healthcare professionals, instead of lay entities more concerned with business results than the quality of patient care. This is why the CMA is fighting to strengthen the ban on the practice of medicine in the workplace and why we support legislation at the state and federal level that would streamline and standardize prior authorization requirements.
In California, the CMA is sponsoring Senator Richard Pan, MD’s SB 250 The SB 250 would require state regulators to streamline the prior authorization system to ensure patients have access to intensive care. One successful approach taken in other states is an audit-based system where prospective prior authorization is waived for clinicians deemed to be high performing. Texas, for example, recently passed legislation that prevents insurers from imposing pre-authorization requirements on providers with historically high approval rates.
The CMA also supports federal legislation — HR 3173, the “Improving Seniors’ Timely Access to Care Act” drafted by California Congressman Ami Bera, MD — which aims to standardize and streamline pre-clearance processes for consistently approved items and services performed under Medicare Advantage. programs, among other improvements.
Prior authorization requirements can be difficult for patients, creating barriers to care and increasing administrative burdens for physicians who must spend time and resources to obtain approvals as insurance companies design and administer systems. increasingly complex prior authorization.
Delays and administrative burdens also continue to undermine health care outcomes. Even more surprisingly, in a 2020 American Medical Association survey, 30% of physicians said that prior authorization resulted in a serious adverse event for a patient they were caring for, such as hospitalization, surgery. medical treatment to prevent permanent impairment or even disability or death.
The CMA strongly supports the SB 250 and HR 3173 standards, both of which would put the needs of patients first by simplifying and streamlining the pre-authorization processes.
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