The Eyes Have It by Pat Conrad MD

How many of you have had, or plan to have, cataracts?  (pssst – raise your hands, everyone).  And as we know, it takes a specialist to remove the little buggers.  Apparently they can be nuclear, cortical, or posterior capsular, or other variants that I’ve never heard of because I didn’t do that weekend CME where they train primary care docs to take them out.  But ophthalmologists spend years studying these and the various ways of dealing with them, thank goodness, which can be a sight-saving proposition.

Cataracts are indeed ubiquitous with age, which I guess ends up costing a lot of money to treat, because Big Insurance player Anthem has found a nifty new way to make their removal more affordable   Now ophthalmologists won’t need to elbow their way around the anesthesiologist in the OR – they can just handle it all themselves.

When I’m not sure about the topic, I like to consult an expert, so I called an ophthalmologist who’s been taking out cataracts for about half a century.  I asked what he thought about Anthem’s latest cost-saving move.  “It’s bullshit”, was his reply.  It seems that ophthalmologists would rather not place sharp edges against moving targets, at least not the squishy little marbles we use to see with.  So anesthesiologists used to place patients under general anesthesia for the extractions.  As medicines and techniques evolved, the gas-passers developed conscious sedation routines now administered by nurse-anesthetists called Modified Anesthetic Care (MAC) which is much shorter in duration, with (I presume) less chance of systemic toxicity complications.  The patient is “out” for only minutes, while the surgeon is able to inject select spots to paralyze and numb the eyeball, before cutting and sewing on it under a microscope (again, I missed that weekend CME, but how hard could it be?).  The ophthalmologist I spoke with said that some of his number are now just performing a local block and more geometrically direct approach which has a higher post-operative infection rate, which he also described as “bullshit.”  I threw a softball devil’s advocate query:  “But once the conscious sedation is over and the blocks injected, why do you need the anesthetist in the room?”  You guessed the answer, didn’t you?  Because this surgery is generally done in an elderly population that has more that its share of co-morbidities, respiratory depression and arrhythmias, and it’s best for someone appropriately trained to keep an eye on the O2 sat, vitals, and rhythm monitor while the surgeon is staring through a microscope and his fingers manipulate sutures finer than a human hair.  And because a vagal response and serious bradycardia might occur, but jamming in some IV atropine might not be the best immediate response during eye surgery.  My consultant agreed that Anthem’s latest gimmick is simply sub-standard care and a danger to patients, just to pad the bottom line next FY.  It is just wrong.

 I’m guessing the Anthem actuaries have probably already forecast a complication/adverse outcome rate, including the likely number of lawsuits and average settlement payouts over the next decade.  I’ll bet someone with no medical training beyond watching “Greys Anatomy” has figured out cost curves and acceptable loss rates, and decided Anthem will lose less profit by skimping on anesthetists and taking an occasional hit.  So what if a few ophthalmologists get put on the NPDB, or a few patients lose some eyesight or spend a night in the ICU?  As the old saying goes, you can’t make an omelet…

 I hear some of you in the back row starting to clamor for a Bernie Sanders Medicare-for-All plan as a solution to this corporate corruption.  But before we go there, consider that wait-times for this elective surgery are lengthening in Britain, and increasing numbers of patients are simply going blind waiting for the fix.

(Want to be reminded of some of our controversial, entertaining and motivational articles?  Just sign up here. We don’t give your email out and we don’t spam you.)