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Anthem's guidelines for monitored anesthesia care draw condemnation
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New guidelines from the medical insurer Anthem that restrict the conditions that would merit medically necessary monitored anesthesia care with an anesthesiologist or nurse anesthetist present have drawn condemnation from many in the ophthalmology community.
The guidelines indicate that administration of monitored anesthesia care is not medically necessary for cataract surgery unless the patient is younger than 18 years, unable to cooperate or communicate, unable to lie flat, has failed or has contraindications to topical, local, regional or moderate sedation, or is undergoing prolonged or complex surgery.
The American Academy of Ophthalmology strongly disagrees with the policy and is lobbying Anthem to rescind it, according to David B. Glasser, MD, secretary for federal affairs and clinical spokesman for the AAO.
“The Academy feels strongly that this policy should not be implemented,” he told Healio.com/OSN. “The decision as to whether an anesthesiologist or nurse anesthetist be in the room during cataract surgery with sedation is best made by the ophthalmologist and the patient. That decision should place the patient’s well-being first and not financial considerations.”
Cataract surgery is most often performed in patients older than 60 years, according to the AAO, whereas Anthem’s guidelines do not consider that age demographic alone to necessitate monitored anesthesia. Yet, older age is accompanied by a greater chance of comorbidity.
“There have been good studies that have showcased the many times monitored anesthesia has been critical with an elderly sick population,” Randall J. Olson, MD, CEO, chair and professor of the John Moran Eye Center at the University of Utah School of Medicine, said in an email to Healio.com/OSN. “This would definitely be the case at our institution where many patients are very sick and do have other troubles during routine surgery.”
Audrey R. Talley Rostov, MD, agreed, saying many elderly patients with other medical problems need extra care and calling the new policy “an additional burden placed on the surgeon.”
“Although these procedures can be done safely with topical anesthesia, having a trained CRNA or anesthesiologist for monitored care can provide an additional element of safety for the patient,” she said in an email to Healio.com/OSN. “These new Anthem guidelines go against patient-centered care by decreasing patient safety and should be reversed.”
Olson called the new guidelines a “shortsighted” attempt to saving health care dollars.
“We should save, but there is often a fine line between saving and being penny smart and pound foolish,” he said. “With Anthem having started this policy, I expect that many will follow, and this could easily become standard of care. Yes, we’ll save some money, but what will be lost without monitoring and support is where I am very concerned.”
Having anesthesia personnel present in the operating room is one of the keys to successful cataract surgery and “an excellent safety record,” according to Glasser.
“An ophthalmologist cannot administer sedation and monitor the patient and do cataract surgery at the same time,” he said. “While a small but significant percentage of cases are managed safely without anesthesia personnel, the decision to proceed along that path needs to be made by the ophthalmologist and the patient, not the payer.”
In California, at least three physician groups — the California Academy of Eye Physicians and Surgeons (CAEPS), the California Medical Association (CMA) and the California Society of Anesthesiologists (CSA) — oppose the policy.
“The policies around cataract surgery are vital to patient safety,” David H. Aizuss, MD, president-elect of the CMA, said in a press release. “Anthem’s newest policy change falls below the standard of care, and it follows a disturbing pattern of putting patients at risk to make profit.”
The CAEPS and CSA both sent letters to Anthem requesting that it immediately rescind the policy change.
“The procedure is carried out in a tiny space about a third of the size of a thimble using a needle vibrating at ultrasonic speeds that can cause blindness if it contacts the wrong structures. Sedation is frequently vital to allow the patient to relax and avoid movement that could be catastrophic, thus minimizing risk,” Craig H. Kliger, MD, CAEPS executive vice president, wrote.
A response letter from Anthem to the CMA states that the policy has yet to take effect in California and that physicians will be given notice when it is to begin. The letter, signed by John Yao, MD, MPH, MBA, FACP, Anthem staff vice president, also states that the revised guidelines are consistent with the AAO’s Preferred Practice Pattern.
“Anthem agrees that there is no singular definitive approach to the use of anesthesia for cataract surgery from a clinical evidentiary basis,” the letter reads. “The guideline is designed so that consumers will have access to appropriate and medically necessary anesthesia during cataract surgery.”
The AAO, however, feels Anthem has misinterpreted the Preferred Practice Pattern in its new guidelines.
“That document clearly says that anesthesia personnel should be present when there is sedation significant enough to require intravenous access,” Glasser said. – by Rebecca L. Forand
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Disclosures: Glasser, Olson and Talley Rostov report no relevant financial disclosures.