Question Raised: Is Monitored Anesthesia Care Always Needed?
A suggestion from one of the nation's largest for-profit managed healthcare companies concerning the use of anesthesia providers during cataract procedures has drawn the attention of Memphis-area healthcare professionals.
Anthem, Inc., part of the Blue Cross and Blue Shield Association - formerly WellPoint Health Networks - updated its cataract surgery guideline in February saying "administration of monitored anesthesia care or general anesthesia for cataract surgery is considered not medically necessary." The policy lists five exceptions - children less than 18 years of age, patients unable to cooperate (eg dementia), patients who are unable to lie flat, patients who have reactions to anesthesia and anticipation of a complex surgery.
Typically performed on an outpatient basis, cataract surgery begins with an incision in the eye with a laser, ultrasound probe or blade. The ophthalmologist uses a microscope to remove the protein deposits and insert a new artificial lens for improved vision. Patients are usually conscious, but receive a numbing shot to keep the eye comfortable. Often, anesthesia providers give a systemic medication to relax the patient, who must remain perfectly still during the procedure.
"We are putting you [the patient] in a twilight state, not normally under general anesthesia," says Subba Gollamudi, MD, ophthalmologist at Eye Specialty Group in Memphis. He adds that psychologically, a lot of patients have anxiety about the procedure, which is understandable since a blade or laser is making an incision in the eye.
The National Eye Institute says that more than half of all Americans either have a cataract or have had cataract surgery by the time they are 80 years old.
Nationally, Anthem has come under fire for this new guideline, which is not currently impacting Memphis patients as Anthem has no market presence in Tennessee. However, area ophthalmologists and anesthesiologists are concerned that the guideline could be used by Blue Cross Blue Shield or other insurers.
"Monitored anesthesia care" or "MAC" as Anthem calls it in its updated guideline, is generally provided by a certified registered nurse anesthetists (CRNA) or anesthesiologists before, during and after the cataract surgery. Anthem cites a 1999 study by Rosenfeld and colleagues in which 1006 participants where tracked for intervention by the anesthesia professional during surgery. The results concluded that 376 patients required intervention, and the number of those needing more than one type of intervention were 548.
Examples of intervention from anesthesia professionals range from hand-holding, to more serious needs such as treatment for cardiac arrhythmias or hypertension. Furthermore, a pre-surgery EKG did not predict intervention by an anesthesia professional, nor did a review of underlying medical conditions, meaning it is very challenging to know in advance of cataract surgery which patients might need additional care during the operation.
The American Society of Anesthesiologists Statement on Anesthetic Care During Interventional Pain Procedures of Adults (2016) quoted by Anthem in their guideline states that physicians must weigh the benefit of anesthesia during procedures with the potential risk factors. Additionally, "for most patients who require supplemental sedation, the physician performing the interventional pain procedure(s) can provide moderate (conscious) sedation as part of the procedure. For a limited number of patients, a second provider may be required to manage moderate or deep sedation..." according to the updated guidelines.
Anthem concludes that "there is no one definitive approach to anesthesia for cataract surgery" but as mentioned above, the policy states MAC is not medically necessary (unless a patient falls into one of the five exception criteria).
Nationally, Anthem has come under fire for this new guideline, which is not currently impacting Memphis patients as Anthem has no market presence in Tennessee. However, area ophthalmologists and anesthesiologists are concerned that the guideline could be used by Blue Cross Blue Shield or other insurers.
Eric Callan, CRNA, DNAP, CEO LifeLinc Corporation says that the new policy takes the ophthalmologist away from the surgery, which is performed through a microscope, to check vital signs, resulting in poor patient care. "Even though it's light sedation, different people react differently to medication so it's just not prudent to have someone unmonitored," says Callan. Gollamudi, who works closely with Callan, describes the surgery in this way: "Anesthesia professionals are monitoring everything else while I take care of the eyeball."
The majority of patients undergoing cataract surgery are over 65, so they are insured by Medicare, which covers anesthesia care during the procedure. However, Gollamudi adds that the surgery has improved so much that younger patients with mild-to-moderate cloudy vision are opting to undergo cataract surgery because they see such improvement with minimal downtime. Under Anthem's change, these younger patients would likely not qualify for MAC during surgery.
Kourtney Houser, MD, Assistant Professor of ophthalmology at the University of Tennessee Health Science Center's Hamilton Eye Institute said the surgery is on average 10 to 20 minutes long, but "it's a high intensity procedure that requires the patient to be very still and cooperate. Most patients don't know how they're going to react to manipulation of the eye [before surgery]." She also adds that many patients have other health conditions like high blood pressure or are on dialysis, while others feel claustrophobic, complicating the surgery and anesthesia care.
"We understand healthcare is ratcheting down on costs across the market," says Callan, "but jeopardizing patient safety is not an area that should be skimped on."
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University of Tennessee Health Science Center