February 05, 2018
Area(s) of Interest: Commercial Payors Payor Issues and Reimbursement
A policy change made by health insurer Anthem, Inc. could result in increased risk for many patients – up to and including blindness – if not immediately rescinded, according to physicians’ groups.
The California Academy of Eye Physicians and Surgeons (CAEPS) and the California Society of Anesthesiologists (CSA) have sent letters to Anthem Inc. requesting that they immediately rescind a new policy that deems Monitored Anesthesia Care (MAC) “not medically necessary” during “routine” cataract surgery – a move seen as endangering patients. These were followed up with complaints to the California Department of Managed Health Care (DMHC) and the California Department of Insurance by the California Medical Association (CMA), and supported by the other groups.
“The surgery 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,” wrote Craig H. Kliger, M.D., an ophthalmologist, and CAEPS Executive Vice President in a letter to Anthem. “Sedation is frequently vital to allow the patient to relax and avoid movement that could be catastrophic, thus minimizing risk.”
“The policies around cataract surgery are vital to patient safety,” said David H. Aizuss, M.D., an ophthalmologist and President-Elect of the CMA. "Anthem's newest policy change falls below the standard of care, and it follows a disturbing pattern of putting patients at risk to make a profit."
Anthem appears to cherry-pick statements in the “Anesthesia” section of an American Academy of Ophthalmology (AAO) Preferred Practice Pattern on the issue to justify its move. “Unfortunately, we believe Anthem is misinterpreting that document, and that proper interpretation would lead to the opposite conclusion,” wrote Dr. Kliger in the letter, meaning that sedation and concurrent appropriate monitoring should instead be considered necessary for the safety of the patient.
“If Anthem restricts payment for MAC services, thousands of patients either will have to pay for the service themselves or will have to undergo surgery under suboptimal conditions. This guideline seems especially harsh toward fragile elderly patients, many of whom have other coexisting illnesses that complicate the use of sedation,” wrote Karen S. Sibert, M.D., FASA, a physician anesthesiologist and CSA President, in CSA’s letter to the insurer.
Although Anthem amended the policy on February 1st to clarify that it did not intend to exclude “moderate sedation” from coverage, such sedation would have to be managed by the surgeon, which the AAO document explicitly says should not happen for cataract surgery because the procedure is very precise work, making it risky to divide time between the two tasks. Therefore, a qualified anesthesia provider would be both required and requested in all situations when sedation is anticipated to be needed (the vast majority of current cataract surgery cases), making the activity “monitored anesthesia care,” which the policy still excludes except under extreme exceptions.
“Anthem's predatory practices and policies are increasing in intensity, frequency and with complete disregard for their impact on California's health care delivery system," said Theodore Mazer, M.D., President of the CMA. “We urge the DMHC and the Department of Insurance to intervene when insurers functionally block access to services that are widely viewed as the standard of care."
The full content of the policy, letters, and complaints can be found by using the following links:
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The California Medical Association represents the state’s physicians with more than 43,000 members in all modes of practice and specialties. CMA is dedicated to the health of all patients in California. For more information, please follow CMA on Facebook, Twitter, LinkedIn and Instagram.
The California Academy of Eye Physicians and Surgeons is the only statewide organization representing California ophthalmologists and their patients. CAEPS' activities include public education about important eye health care concerns, legislative advocacy, interaction with third party payers about reimbursement and coverage issues, and continuing medical education for ophthalmologists and their staffs. For more information, please visit www.caeps.org.
The California Society of Anesthesiologists is a physician organization dedicated to promoting the highest standards of the profession of anesthesiology, to fostering excellence through continuing medical education, and to serving as an advocate for anesthesiologists and their patients. For more information, please visit www.csahq.org.