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Ophthalmologists push against insurer on anesthesia policy

Dr. Arnold Prywes, at his Dix Hills home

Dr. Arnold Prywes, at his Dix Hills home in a Newsday file photo from 2017, is among those questioning the change in policy. Credit: Newsday / J. Conrad Williams Jr.

Eye surgeons are pushing back against a new policy by a major health insurer that would eliminate coverage for anesthesiology specialists during routine cataract operations, forcing ophthalmologists to both perform the procedure and sedate patients and monitor their vital signs.

The rule, to be implemented by Anthem Inc., the umbrella company for Empire BlueCross BlueShield in New York, is stoking the ire of eye surgeons on Long Island and beyond. As written, it declares anesthesiologists and nurse anesthetists unnecessary during most cataract operations.

Anthem asserts that ophthalmologists can perform double duty without jeopardizing patient safety. Cataract surgery involves removing the eye’s natural lens that has become clouded by the disease, then implanting a clear artificial one in its place.

In a statement emailed to Newsday, Anthem said its decision is based on providing patients with “high quality, affordable healthcare, including safe and effective medical technologies.”

The statement said the policy was developed by a panel of medical experts.

While the policy has not yet been fully implemented, ophthalmologists, nurse anesthetists and major medical societies are strongly opposed and want Anthem to rescind the rule before it’s enacted.

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The policy was quietly published on Anthem’s website late last year and has been amended in recent weeks.

Eye surgeons contend that such a fundamental change to how cataract surgery is performed sends the wrong message to patients. The procedure reverses vision loss from a condition long known as the leading cause of blindness. Ophthalmologists cannot work as dentists do, providing anesthesia and performing the procedure, medical experts say.

When being prepared for cataract surgery, patients are sedated but conscious. Under the new Anthem guideline, ophthalmologists would administer the sedating agent. Anthem has not yet announced when it will launch the guideline nationwide.

Eye surgeons say the change could harm patients. They also worry that a move by an insurer as dominant as Anthem might trigger other health care companies to follow suit.

“Ophthalmologists are not trained in anesthesiology and when we are doing surgery we are entirely focused on the eye,” said Dr. Richard Braunstein, interim chairman of ophthalmology for the Northwell Health network on Long Island.

“There is a unanimous voice in ophthalmology that this is not the right thing to do for the patient,” Braunstein said.

Standard practice during cataract surgery has been to have an anesthesiologist or nurse anesthetist administer the sedating medication and then remain in the operating room to re-administer anesthesia as needed. Ophthalmologists say it’s impossible to know when a patient may unexpectedly have a heart rhythm disturbance, respiratory problem or an anesthesia complication.

“I think in large part much of the safety that we associate with cataract surgery is the security of having an anesthesiologist to appropriately anesthetize the patient and monitor the patient to keep them safe during surgery,” Braunstein said.

Average costs for anesthesia services in a cataract operation are about $194.66 for an independent certified registered nurse anesthetist or an estimated $400.76 for a physician anesthesiologist performing the same procedure, according to a nationwide cost comparison study conducted for the American Association of Nurse Anesthetists in 2016.

The American Academy of Ophthalmology, the American Society of Anesthesiologists and the American Association of Nurse Anesthetists have gone on record against Anthem’s rule; so have the New York State Ophthalmological Society and the Medical Society of the State of New York.

Medicare, the government health insurer for people 65 and older, covers full anesthesiology care, according to the Centers for Medicare and Medicaid Services.

About 2 million cataract surgeries are performed annually in the United States, mostly involving patients 65 and older, according to the American Academy of Ophthalmology. Cataracts are the world’s leading cause of blindness.

“If you are looking through an operating microscope, working on someone’s eye, you really can’t do that and monitor how well the patient is doing under anesthesia,” said Dr. Arnold Prywes, a past president of the New York State Ophthalmological Society, who practices in Lake Success and Bethpage.

Anthem’s policy is reminiscent of a similar one advanced — but rescinded — by Aetna Inc., about a decade ago that would have denied coverage of anesthesiology services during a colonoscopy. Physicians and consumer groups protested the rule, doctors said.

Dr. Charles Rothberg, a Patchogue ophthalmologist and president of the Medical Society of the State of New York, said he’s most concerned when a rule is changed and eye surgeons have not been consulted.

“I perform cataract surgery and anesthesia [care] is part of a safe experience,” Rothberg said.

He estimates that a cataract operation can take anywhere from 20 minutes to 30 minutes, but the amount of time depends on each individual, Rothberg said, noting that in the operating room with him when he performs the surgery is not only a professional in anesthesiology, but also a technician and two nurses.

Anthem said that full anesthesia care is to be covered for patients who are under age 18; individuals who are unable to lie flat, such as people with severe back pain or congestive heart failure, and people who are unable to cooperate or communicate, particularly patients with dementia or movement disorders.

Dr. Amjad Hammad, president of the New York State Ophthalmological Society, said there is no evidence in medical literature that supports Anthem’s attempt to downsize health professionals in operating rooms.

“The literature does not support the concept that monitored anesthesia care is unnecessary for routine cataract surgery,” Hammad said. “The highest standard of care and the level of sedation most commonly used includes the presence of a certified registered nurse anesthetist or an anesthesiologist.”

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