Patricia Anderson of Tampa is worried her insurance company may someday cost her vision. Anderson, 56, has a late-stage form of a 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 her ophthalmologist, Scott Friedman, M.D., detects a worsening in her condition, he needs to treat her immediately with a sight-saving medication or she risks permanent vision loss.
Unfortunately, if she wants her insurance plan to pick up most of the costs, prior authorization approval is required, which can take up to two or three weeks. This delay in treatment could cause a significant deterioration in her eye condition and causes extreme anxiety.
“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.”
Anderson is not alone.
It’s happening to people across the country and across all medical specialties: People who need treatment to save their sight; people who need urgent spinal surgery to prevent irreversible damage; people with rheumatoid arthritis unable to walk due to swollen joints, heart patients with new chest pain who need a stress test provided in physicians’ offices; all of them, waiting for an insurance carrier to approve a treatment their physician prescribed.
The American Academy of Ophthalmology (AAO) conducted a survey showing that these delays are needless because most of the authorization requests are approved anyway. Half of the ophthalmologists responding to the study said their authorization requests are approved from 75% to more than 90% of the time.
(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.)
The coronavirus has laid bare myriad inefficiencies in the U.S. health care system. But this is one crisis we can fix.
The Florida Society of Ophthalmology (FSO), along with the AAO and several other medical societies, are urging Gov. Ron DeSantis and State Commissioner David Altmaier to suspend prior authorization requirements and another onerous roadblock called step therapy for both COVID-19 and non-COVID-19-related services until normalcy in the health care delivery system is restored.
The FSO is also urging Florida’s U.S. representatives to support Improving Seniors’ Timely Access to Care Act. This bill 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, M.D., R-Kan., and Ami Bera, M.D., D-Calif.
In this pandemic, these policies have reached levels of comic absurdity as there’s no one to pick up the phone when physicians call seeking treatment approval because the insurance company shuttered its office due to the pandemic. Or, when practices, operating with skeleton staffs, have no one available to remain on hold with a carrier for up to four hours to obtain approval.
For people like Anderson, relief from prior authorization would do more than eliminate bureaucratic red tape, it would assist her in her fight to keep her vision.
Darby D. Miller, M.D. MPH, is president of the Florida Society of Ophthalmology and an assistant professor of Ophthalmology at the Mayo Clinic.