Real-world data shows why new legislation introduced last week is needed to protect patients from unreasonable Medicare Advantage plan requirements
SAN FRANCISCO – The majority of ophthalmologists in a new survey said that a cost-management tool required by health insurance companies is delaying or disrupting the sight-saving care they give their patients. The tool is called prior authorization. Insurance companies use it to control costs by reducing medically unnecessary tests and procedures. Instead of accomplishing this goal, many health plans, including Medicare Advantage plans, have used prior authorization indiscriminately, creating treatment delays that may endanger patient health.
As this new study shows, these delays are needless. Half of the ophthalmologists responding to the study said their authorization requests are approved from 75 percent to more that 90 percent of the time.
Here’s what else the survey of members of the American Academy of Ophthalmology found:
- Nearly 90 percent of patient clinical outcomes are negatively impacted by prior authorization.
- More than 85 percent said burdens of prior authorization have increased significantly over the past five years with both private and public insurers.
- Due to the staff time required to process prior authorization requests, more than 53 percent of ophthalmologists said they have staff members who work exclusively on prior authorizations.
- For patients whose treatment requires prior authorization, 43 percent always experience a delay in care, and 44.8 percent often experience a delay in care.
- The average prior authorization request takes two to seven days to process once all the required documents are submitted.
For two years, the Academy has worked with seven other medical societies to get Congress to address Medicare Advantage plans’ abusive use of prior authorization. Last week, a bipartisan group of legislators in the House responded and introduced the Improving Seniors' Timely Access to Care Act of 2019. It would set standards for electronic requests for prior authorization that would make the process simpler and more efficient. The legislation is sponsored by Reps. Suzan Delbene, D-Wash., Mike Kelly, R-Pa., Roger Marshall, MD, R-Kan., and Ami Bera, MD, D-Calif.
For patients like Patricia Anderson of Tampa, Fla., relief from prior authorization is more than a welcome development. It’s assistance in her fight to keep her vision.
Anderson, 55, has a late-stage form of diabetic eye disease called proliferative diabetic retinopathy. It happens when the retina starts growing new blood vessels that bleed. If left untreated, it causes blindness. And that’s in her good eye. She is blind in her other eye, the result of trauma suffered years ago.
When she has to leave an appointment with her ophthalmologist without treatment – a treatment she’s had many times before – to wait for Medicare Advantage approval, it frustrates and angers her.
“They’re playing with my life,” Anderson said. “It doesn’t make sense to me. I’m trying to save the only eye that I have left. I don’t want to go blind. I know it’s more than just me. (Prior authorization) is affecting a lot of people.”
She typically must wait two weeks to get approval for treatment. But this month, she had to wait three weeks because she had to cancel her appointment due to a family emergency. She was lucky. She didn’t seem to lose vision during the wait. But the anxiety over her condition and the hassle of rescheduling was unnecessary and burdensome. People with her condition can deteriorate over a two- to three-week period.
Over the next few months, the Academy will work to secure congressional cosponsors and a companion bill in the Senate. Our hope is that Congress will act on this legislation after its August recess.
*The survey was sent to a randomly selected sample of 4,001 ophthalmologists from the Academy’s member database; 406 ophthalmologists completed the 27-question web-based survey.
About the American Academy of Ophthalmology
The American Academy of Ophthalmology is the world’s largest association of eye physicians and surgeons. A global community of 32,000 medical doctors, we protect sight and empower lives by setting the standards for ophthalmic education and advocating for our patients and the public. We innovate to advance our profession and to ensure the delivery of the highest-quality eye care. Our EyeSmart® program provides the public with the most trusted information about eye health. For more information, visit aao.org.