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  • The Delay is the Point: An Ophthalmologist Navigates Abusive Health Insurer. Barely

    By Brandon Johnson, MD
    Published Mar. 04, 2022

    I’ve often done battle with insurance companies to get my patients the health care they need. I’ve also been the patient at the end of the phoneline – for hours – with no idea if help is on the way. Health insurance practices are no longer just unbelievably and pointlessly complicated, they’ve become abusive and dangerous. 

    I’m sharing my story to sympathize with the millions of Americans who may not have the medical understanding or resources to navigate a system that has so clearly been re-designed to confuse, delay, and ultimately deny healthcare. I’m an ophthalmologist and I run my own practice in New York City. I should be among the more capable in navigating this process and clearly my best efforts were not good enough.

    I was diagnosed with scoliosis as a child. Scoliosis is a degenerative disease that causes the spine to curve. It can lead to chronic back pain, neurological problems, and even trouble breathing later in life. By the time I reached my 20s, the curvature of my spine advanced to well over 70 degrees and I developed chronic, severe back pain. I underwent successful spinal fusion surgery to relieve the pain. Fast forward 20 years, I’m now 39, and another segment of my spine has degenerated, again causing severe pain. I managed the pain on my own for about a year, until three months ago, when I developed the worst back pain that I’ve ever experienced, pain that has now progressed to my neck.  

    I went to two orthopedic surgeons at the number one hospital in America for orthopedic surgery, the Hospital for Special Surgery. They both reviewed my medical record, examined me, imaged my spine, and came to the same conclusion: I would need another spinal fusion surgery. Three days before my scheduled surgery, I got a call from my surgeon’s office to inform me that my insurance carrier, Aetna, had denied the prior authorization request for my surgery. I was given a reference number, an appeal number, and a phone number to call. 

    Over the next 12 hours, I would spend 4.6 frustrating hours on the phone with no resolution.  I went to bed that night worrying that my health insurance may not cover a procedure that offered me hope of returning to a normal life.

    All that time on the phone did bring clarity to one issue. The physician who denied my surgery, overturning the diagnosis of two orthopedic surgeons, was not a surgeon, but a family medicine physician employed by Aetna.

    When prior authorization – the process that requires physicians to get advance approval from health plans before it will agree to cover a medical service or a medication – began to take hold about 20 years ago, it was intended to focus on expensive new drugs and diagnostic tests. But over the years, the practice has expanded to common procedures and surgeries, ensnarling physicians and patients in red tape. This process is arduous. I’ve had to hire a full-time employee just to handle prior authorizations for my patients.

    Aetna, the nation’s third largest insurer, decided to expand prior authorization for a range of surgeries, beginning July 1. They’ve used this policy not only to deny my surgery, but also surgery for ophthalmology patients. Aetna now requires prior authorization for all cataract surgeries.

    Aetna says this is necessary because it “helps [its] members avoid unnecessary surgery.” Think about it. What is unnecessary about restoring a patient’s vision? It’s not like ophthalmologists are requesting an MRI for a patient with a headache. Cataracts only get worse with time, and they can only be treated with surgery. While these patients wait for an Aetna administrator to decide that their vision is sufficiently deteriorated to justify surgery, they face an increased risk of falling or getting into a car accident.

    I’m not against efforts to keep healthcare costs down. But patients and physicians deserve a faster, more transparent process so that care is not unnecessarily disrupted. That’s why the American Academy of Ophthalmology is asking Congress to pass the Improving Seniors’ Timely Access to Care Act (H.R. 3173). The bipartisan bill will help hold insurers accountable for causing dangerous disruptions to patient care and streamline patients’ approvals so that physicians can focus more on patients than paperwork.

    I believe my health and that of my patients should be in the hands of a physician, not an insurance administrator.