ATLANTA — Peggy Mitchell, 71, was having trouble driving at night, so she knew she could not wait any longer to have the cataract clouding her right eye removed.
The lively Alpharetta resident had scheduled her surgery for Nov. 22, before Thanksgiving, and arranged for a friend to drive her to the surgery and back home. She had already had a cataract on her left eye removed the prior year without a hitch.
But her carefully laid plans ground to a halt at the last minute when her Medicare Advantage insurer, Aetna, denied approval for the routine, vision-saving surgery most older adults need at some point.
Mitchell and her doctor appealed the denial but did not receive a response in time, forcing Mitchell to postpone the procedure for more than a month, until after Christmas. Mitchell’s ophthalmologist, Dr. Susanne Hewitt of North Fulton Eye Center, came into the office during her holiday vacation to perform the surgery for Mitchell and others.
What’s unusual about this situation is that Aetna Medicare Advantage requires prior approvals for cataract surgery only in Georgia and Florida — not in any other states. Aetna Medicare Advantage plans covered 132,414 Georgians in 2022, according to the Kaiser Family Foundation (KFF).
Humana instituted a similar policy — only in Georgia — last fall. Humana Medicare Advantage plans covered 264,010 Georgians last year, according to KFF.
In contrast to the insurers’ Georgia policies requiring approvals, traditional Medicare — not run by insurance companies — does not require prior authorizations for most procedures, including cataract surgery.
Ophthalmologists and patients say Aetna and Humana’s policies delay care, put Georgia seniors at risk, and create burdensome administrative requirements, only for the surgeries to be approved in the end.
“What happened in that one month would be my question,” Mitchell said. “All that frustration and denial. … I can’t tell you how it felt.”
As a self-described “healthy senior,” Mitchell had rarely used her Aetna health insurance and always paid her monthly premium. She was so certain her surgery would be approved that she started taking the expensive eyedrops needed to prepare. That proved a waste when Aetna did not approve her surgery for the originally scheduled date.
“I don’t know why me,” Mitchell told Capitol Beat.
The answer to Mitchell’s question appears to lie in the contractual relationship between Aetna and iCare Health Solutions.
Back in 2021, Aetna began requiring prior authorizations for cataract surgery across the country. But after an outcry from ophthalmologists, Aetna reversed the policy last year — except in Georgia and Florida.
“Aetna has been engaged in a 10-year relationship with iCare Health Solutions to manage ophthalmology and optometry services in Florida,” Aetna spokeswoman Kimberly Eafano said. “Almost two years ago, Aetna expanded this arrangement to include the state of Georgia, where iCare also has a community presence.”
Humana instituted a similar policy for its Medicare Advantage enrollees — only in Georgia — last fall. Humana said the unique Georgia policy is due to its relationship with iCare.
iCare did not comment, despite multiple requests.
Georgia doctors are worried the delays put patient safety at risk.
“Any type of delay — even a few weeks or a couple of months — that’s usually a safety issue,” said Hewitt, Mitchell’s ophthalmologist.
Many patients put off seeking treatment for cataracts because surgery, even a routine one like cataract removal, can be scary.
“I have patients that say they can’t see to drive on the road,” Hewitt said. “[They] follow the car in front of them. If that car turns and they’re not turning that way, they’re really in trouble because they can’t follow them anymore.
“If you have a patient who comes in as having a stated problem, and it’s backed up by the examination, then we should act on that. We shouldn’t be telling them no, just for the sake of saying no.”
Dr. Chandler Berg, an Albany-era ophthalmologist and president of the Georgia Society of Ophthalmology, echoed Hewitt’s concerns.
“Aetna’s policies have not improved and continue to limit patient access to surgical care,” Berg said. “I encourage patients with Aetna to switch to a different Medicare plan.”
The problem has drawn the attention of the state’s congressional delegation.
“These policies put Georgia [Medicare Advantage] patients at greater risk of falls and accidents as their vision continues to deteriorate while they wait for surgery,” the state’s Democratic representatives, led by Atlanta’s Rep. David Scott, wrote to the Centers for Medicare and Medicaid Services (CMS), the federal health-care regulator, last December.
“Georgia [Medicare Advantage] beneficiaries have faithfully paid premiums every month,’’ they wrote. “They deserve the same access to sight-restoring surgery that Aetna and Humana … beneficiaries have in other states.”
Five Republican representatives, led by Rep. Buddy Carter of Savannah, wrote a similar letter.
“Aetna’s and Humana’s prior authorization policies create obstacles to this common surgery for both patients and their physicians,” the GOP congressmen wrote.
But neither Carter nor Scott has received a response from CMS, their spokespeople said.
“CMS is committed to ensuring that people with Medicare Advantage have timely access to medically necessary care,” a CMS spokesperson said in response to a query about the Georgia situation.
A proposed regulatory change that could take effect in 2024 would require Medicare Advantage plans to ensure that “people with Medicare Advantage receive the same access to medically necessary care they would receive in traditional Medicare.”
Meanwhile, the problems in Georgia continue. Gwen Brightman, a 67-year-old Aetna Medicare Advantage customer from Newnan, was forced to delay her surgery from Feb. 9 to Feb. 23 because the company did not provide her with timely approval. Even the delayed surgery was approved at the last minute, said Brightman, who has a full-time job.
“I spent approximately two hours on the phone desperately trying to make the deadline and didn’t get the approval until the late afternoon [the day before],” she said. “This caused me extreme and unnecessary stress. Between the strain on my eye and the never-ending requests and requirements, I was a wreck. No one else should have to experience this nonsense.”