Doctors worry about accidents as seniors face delays getting routine cataract surgeries

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. "AU 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 for 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 Fafano 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."