Health insurer Anthem has decided that anesthesiologists are no longer ‘medically necessary’ to eye cataract surgeries, according to the new clinical guidelines.
Instead, it suggests that eye surgeons should somehow simultaneously monitor their patients’ anesthesia and vital signs while operating on open eyes – which they view through a microscope.
Ophthalmologists are not trained to monitor and administer deep anesthesia in the performing a delicate operation that requires both hands and their full attention.
Experts warn that Anthem’s guidance could begin a slippery slope, raising concerns that insurers might deem more crucial parts of procedures ‘unnecessary’ in order to cut costs.
Insurer Anthem’s new guidelines suggest that eye surgeons administer and monitor anesthesia themselves while operating on open eyes that they view through microscopes
‘Ophthalmologists cannot administer anesthesia, monitor a patient and do cataract surgery at the same time. It is not physically possible,’ says Dr David Glasser, spokesperson for the American Academy of Ophthalmologists (AAO).
‘The presence of anesthesia personnel in and throughout the procedure is one of the key ingredients contributing to the excellent safety record of cataract surgeries,’ says Dr Glasser.
Cataract surgeries are extremely common, and about 3.6 million are performed each year in the US, a number that is only set to grow as the baby boomer generation ages and needs to correct the age-related eye condition.
AAO’s guidelines advise that, while not all cataract surgeries will require monitored anesthesia, when this is necessary, an anesthesiologist or nurse anesthetist should be present.
Between 20 and 25 percent of patients ‘do fine’ without deeper anesthesia that requires supervision from a specialist, says.
But Anthem ‘took that data and extrapolated it to conclude that a majority [of cataract surgeries] could be done without anesthesiologists,’ Dr Glasser says.
The deeper the level of sedation a patient might need, the more supervision is required, and that determination needs to be made on a case-by-case basis, Dr Glasser says.
Anesthesia is particularly dangerous to older patients, putting them at elevated risks of heart attack, stroke and pneumonia.
Considering that eye cataracts are an age-related condition that affects more than half of all Americans over 65, the same population that is likely to undergo cataract surgery is also more vulnerable to the risks of anesthesia.
If we don’t convince them that it’s not a good argument, it’s possible that they may expand that to other procedures
Dr David Glasser, spokesperson for the American Academy of Ophthalmologists
‘The risk is that if a patient goes to deep or has trouble breathing, has a cardiac reaction or gets to nauseous from the anesthetic, the opthalmologist may not be aware,’ Dr Glasser says.
‘An ophthalmologist is 100 percent concentrated on surgery…and their entire field of view is concentrated on the eye. It’s a very small space where just a few millimeters makes a big difference,’ he adds.
If Anthem – which covers 73 million people with its affiliates – or other insurers refused to cover the cost of anesthesiologists for cataract surgery, most ophthalmologists would stop using the services.
Instead, patients would probably just have to pay out of pocket.
An average cataract surgery – in one eye – costs about $3,497 out of pocket, according to allaboutvision.com.
Anesthesiologists make an average of $178 an hour, though Dr Glasser says he has heard estimates for a their services for cataract procedures in the $400 range.
Even so, these surgeries typically take about 20 minutes, and anesthesia personnel account for only about 10 percent of their total costs.
With government-subsidized Medicare, anesthesia would be covered, but patients would be responsible for 20 percent an anesthesiologist’s fees, according to allaboutvision.com.
‘My guess is that [Anthem’s] interest in cataract surgery is related to volume. They are very common and could become more common as baby boomers age,’ Dr Glasser says.
Anthem’s new guidelines are based on a worryingly small proportion of cases where anesthesiologists were not needed and ‘if we don’t convince them that it’s not a good argument, it’s possible that they may expand that to other procedures,’ Dr Glasser says.