Anthem insurance wants your eye surgeon to also be your anesthesiologist

Anthem insurance wants your eye surgeon to also be your anesthesiologist
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Your insurance company wants your eye surgeon to also be your anesthesiologist so it can save a few dollars. This is great for the shareholders. However, it is very bad medicine.

Insurance giant Anthem announced this month in a clinical guideline that it is not medically necessary to have an anesthesia doctor or a nurse anesthetist available for eye cataract surgery.

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They want the eye surgeon to perform surgery, administer medications, and even monitor the patient’s medical status throughout surgery.

 

There is no substantial medical evidence to support this as being standard of care in the United States. There is no definitive anesthesia approach for eye surgery. However, ophthalmologists are trained surgeons; they are not trained in the complexities of anesthesia.

This is intentionally manipulative behavior on behalf of the insurance company to reduce cost. If the insurance company won’t pay for anesthesia coverage in routine cases, it simply won’t be done.

Control of our medical care has been ceded to insurance companies. And, patients are the ones who could get hurt in the process.

Cataract surgery is a relatively straightforward procedure. It lasts less than half an hour. It’s an outpatient procedure; patients go home the same day.

Patients are generally not “put to sleep” with a breathing tube, but rather they are kept in a state of either moderate sedation or monitored anesthesia care (MAC). The patient should be comfortable, and it is generally best they don’t make their eye ball a moving target.

The problem with Anthem’s concept is what happens when something goes wrong?

Not having anesthesia trained personnel in the room takes away the ability to provide monitored anesthesia care.  

There is no ability to completely monitor sedation levels; there is no ability to convert to deeper levels of anesthesia if the need arises, and the ability to resuscitate the patient is limited.

Do you really want your eye surgeon to have to look up and monitor your blood pressure, heart rate and oxygen saturation while trying to operate on your eye through the microscope?

The ophthalmic surgeon is concentrating on the procedure and just simply should not be distracted by having to manage a patient’s medical issues that may come up during surgery.

None of this matters. Insurance companies are now calling the shots.

We have seen this before. Our academic paper in a leading neurosurgical journal illustrates how insurance companies are intentionally delaying approval for high-price neurosurgical spine procedures. Insurance companies will not approve certain surgeries without a prior approval by an insurance company employee. And, they take their time. This a simple way to reduce costs by delaying or not approving planned, non-emergency (elective) surgery for patients who need it.

It’s intentional obfuscation.

The problem is that doctors are just not active enough in the political process. Activity "politically' requires massive donations. And, physicians cannot counteract the big healthcare industries.

In the last election year, groups representing health professionals spent only $85,061,148 of the total $514,224,628 spent in healthcare lobbying. Less than a quarter of physicians in the United States are members of the American Medical Association.

Data being presented at the upcoming American Association of Neurological Surgeons Annual Meeting illustrates that the donation rate of an active neurosurgeon to their neurosurgery specific political action committee was six percent. For ophthalmologists, donation participation rates through the political arm of the American Academy of Ophthalmology was around eight percent.

Insurance companies have a much more unified approach: make money for their shareholders. Insurance companies gave $168,137,953 in the year leading up to the passage of the Affordable Care Act. In the same year, the American Medical Association donated only about 12% of that total,$20,720,000. The American Academy of Ophthalmology was only able to put forth $1,607,691 towards the effort.

Who is your congressman going to listen to?

Now, is this specific idea from an insurance company completely without merit? Maybe or maybe not.

It needs to be better studied and integrated into physician training. In developing their clinical guideline, Anthem cites only one scientifically peer-reviewed publication, and it’s from 1999.

Physicians, especially surgeons, are not blind to the momentum of cost-saving medicine, but this needs to be driven by science not by an insurance company. For example, it certainly saves insurance companies money to have distinct spinal procedures performed on an outpatient basis where patients go home the same day rather than an inpatient basis where they spend a day or two in the hospital. This is reasonable. As such, spine surgeons have studied this and reproduced this as safe and reliable in certain patients. It’s now be integrated into practice patterns.

Also, through the Anthem model, it seems at least mildly intuitive that ophthalmologists would eventually need more training in advanced anesthesia. Ophthalmology training programs do not yet offer an intensive anesthesia curriculum.

On the other hand, oral maxillofacial surgeons will at times provide deeper anesthesia and monitor patients during things like wisdom tooth extractions. The difference is that their respective training programs have prepped their physician-dentists for this experience. Oral surgery training programs must offer at least five consecutive months of anesthesia tutelage in their curriculum.

Literally, almost everyone over the age of 65 will eventually develop a cataract. This problem is not an abstract “if” but a definitive “when.” There are four generations of physicians in our family, and we would never want a family member to have outpatient surgery without proper anesthesia coverage.

Would you?

We, as patients, ask our physicians all the time about new medications and new treatments. Perhaps, we should also be asking our physicians about stepping into the political arena.

Peter Menger M.D. is an ophthalmologist with 34 years of experience. Richard Menger M.D. is a chief resident in neurosurgery and a 2016 graduate of the Harvard Kennedy School; he is a member of the AEI Enterprise Club.