In its latest cost-saving policy, Anthem released clinical guidelines this month that will not require an anesthesiologist or nurse anesthetist to monitor anesthesia during cataract surgery.
Critics of the policy, including California doctors and surgeon groups, say the change will force patients to "pay for the service themselves or will have to undergo surgery under suboptimal conditions."
In response to the new policy, at least one practice is asking Anthem patients to pay $400 out-of-pocket upfront for anesthesia services before cataract surgery.
In its guidelines, Anthem said administration of monitored anesthesia care or general anesthesia for cataract surgery isn't considered medically necessary unless it involves a child, the physician expects a prolonged or complex surgery and a few other select situations.
Anthem pointed to research from 1999 and said there isn't just one approach to anesthesia for cataract surgery. Instead, the decision should be based on the individual patients and potential risks.
Physician groups oppose the change.
“If Anthem restricts payment for MAC [monitored anesthesia care] 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 CSA President Karen Sibert.
“With this policy change, Anthem has effectively decided that rather than allowing the treating physician, in discussion with his or her patient, to make the medical decision that is best for that patient, that it can unilaterally decide which patients can receive intravenous anesthesia during cataract surgery,” wrote CMS President Theodore Mazer and President-Elect David Aizuss.
Anthem offers Blue Cross plans in 14 states. The payer has been particularly aggressive in new cost-cutting policies over the past year.
Anthem also said it would no longer pay for emergency department (ED) visits that were later not deemed an emergency and not pay for imaging tests in hospitals. Anthem also decided to cut provider payments by 25% for separate evaluation and management services on the same day as a procedure or other service.
These moves are part of Anthem’s attempt to have patients get care at medically appropriate, but less expensive locations, such as outpatient centers and urgent care centers.
Anthem added some exceptions to its ED denial policy at the beginning of this year and has said the policy doesn't affect many claims. But that hasn't stopped providers from taking aim at the program. They say not reimbursing for ED visits could make patients delay needed care because they’re afraid the payer will say it’s not an emergency.
A handful of hospitals are taking Anthem to court over the ER program. Atlanta-based Piedmont Hospital said in its lawsuit the program is geared to “intentionally deteriorate coverage for policyholders.”
Provider organizations have whacked Anthem for its policies, but Lori McLaughlin, Anthem communications director, recently told Healthcare Dive that Anthem’s goal is to move services to a “clinically appropriate setting.” That will lead to lower healthcare costs for members and the healthcare industry overall, she said.
“Anthem’s primary concern is to provide access to quality, safe and affordable healthcare for our affiliated health plan members. We’re always looking at new approaches to ensure clinical quality and improve affordability and we are committed to reducing overall medical cost where possible when the safety of the member is not put at risk,” she said