Photo illustration by Jeff Boyer / Times Union. Getty Images
by Brandon Johnson
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 phone line — 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’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 phone line — 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.
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.
I spent hours on the phone that day, with no resolution. That night, I went to bed 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 they 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 of this year. They’ve used this policy not only to deny my surgery, but also to delay or deny surgery for thousands of ophthalmology patients with cataracts.
Aetna says this is necessary because it “helps (its) members avoid unnecessary surgery.” 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 health costs down. But patients and physicians deserve a faster, more transparent process so that care is not unnecessarily disrupted. I urge Aetna to reverse its aggressive prior authorization policy. Congress should also act by passing the bipartisan Improving Seniors’ Timely Access to Care Act (H.R. 3173) . The bill will help hold insurers accountable for causing dangerous disruptions to patient care and streamline approvals so that physicians can focus more on patients than paperwork.
I don’t want to live in a world in which my health and that of my patients is in the hands of an insurance administrator, instead of a doctor. Do you?
Dr. Brandon Johnson is an ophthalmologist in New York City and founder of New York Retina Center (www.nyretinacenter.com). He’s also a clinical instructor for the Department of Ophthalmology at NYU Grossman School of Medicine.