Quantcast

Anthem doesn't want to pay for anesthesia during cataract surgery?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
D

deleted162650

With modern cataract technique, I think topical alone + PO valium is totally reasonable. It's minimally more invasive than LASIK nowadays. Our involvement is largely vestigial, left over from the time of retrobulbar blocks and strapping racquet balls to patients faces.



Although now I've gone and ruined that cataract gravy train we've all be riding. :rolleyes:
 
  • Like
Reactions: 9 users

anbuitachi

Full Member
10+ Year Member
Joined
Oct 26, 2008
Messages
6,310
Reaction score
3,126
With modern cataract technique, I think topical alone + PO valium is totally reasonable. It's minimally more invasive than LASIK nowadays. Our involvement is largely vestigial, left over from the time of retrobulbar blocks and strapping racquet balls to patients faces.



Although now I've gone and ruined that cataract gravy train we've all be riding. :rolleyes:

I've done a total of 0 cataracts in residency. I don't even know how to do them
 
  • Like
Reactions: 1 user

Urzuz

Full Member
10+ Year Member
Joined
Aug 24, 2011
Messages
720
Reaction score
1,554
I've done a total of 0 cataracts in residency. I don't even know how to do them

Little do you know, you've been practicing every time you have a day off from residency.

Sit there and watch TV on the big screen. It's riveting.
 
  • Like
Reactions: 6 users

Southpaw

Full Member
Lifetime Donor
15+ Year Member
Joined
Aug 12, 2004
Messages
2,626
Reaction score
4,850
In my experience there’s never been a gravy train, and the anthem thing is a total non-issue. I’ve done my fair share of anesthesia for cataracts between residency and being an attending, and can probably count on one hand the number that are non-Medicare.

That said, if ophtho wants to do them w topical and Valium, fine by me. Most of us can find something better to do with our lives than get paid Medicare rates for hand-holding anesthesia.
 
  • Like
Reactions: 5 users

nimbus

Member
15+ Year Member
Joined
Jan 14, 2006
Messages
9,233
Reaction score
14,087
In my experience there’s never been a gravy train, and the anthem thing is a total non-issue. I’ve done my fair share of anesthesia for cataracts between residency and being an attending, and can probably count on one hand the number that are non-Medicare.

That said, if ophtho wants to do them w topical and Valium, fine by me. Most of us can find something better to do with our lives than get paid Medicare rates for hand-holding anesthesia.


It’s not ophtho. They like us there. But we won’t be there if we don’t get paid.
 
  • Like
Reactions: 1 user

btbam

Full Member
10+ Year Member
Joined
Jan 16, 2011
Messages
530
Reaction score
337
I've done a total of 0 cataracts in residency. I don't even know how to do them

2 of Versed, 30mg Prop for the retrobulbar block, try to stay awake.
 
  • Like
Reactions: 1 user

coffeebythelake

I'm not a word-mincer
Lifetime Donor
15+ Year Member
Joined
Apr 9, 2006
Messages
4,006
Reaction score
4,555
Exactly, I'm not a fan especially of the truckloads of preops of sick ass patients getting nothing more than 1 or 2 of versed and a small bolus of propofol or alfenta. Our skills can be used in better situations.
 
Members don't see this ad :)
D

deleted162650

None of our guys block cataracts anymore. Straight drops.
 
  • Like
Reactions: 1 user

nimbus

Member
15+ Year Member
Joined
Jan 14, 2006
Messages
9,233
Reaction score
14,087
I work with a 2 retina guys who talk their patients through the block. No propofol necessary.
 
  • Like
Reactions: 1 user

DrOwnage

Attending
10+ Year Member
Joined
Oct 12, 2011
Messages
472
Reaction score
746
You only give 30 mg prop for a retrobulbar? Damn dude at least give something for analgesia. That's basically like giving someone a back massage then stabbing them in the eye. We do an prop:alfentanil:lido mixture that works pretty well.
 

dannyboy1

Full Member
10+ Year Member
Joined
Aug 11, 2008
Messages
1,158
Reaction score
1,506
can’t say I disagree. Topical works just fine. I usually give 25 mcg of fentanyl so I can say I did “sedation”. ( I know, you don’t have to give anything to bill for MAC but whatever, it makes me feel better). Being present at a cataract makes about as much sense as being present at an adult dental filling.
 
  • Like
Reactions: 1 users

Hawaiian Bruin

Breaking Good
15+ Year Member
Joined
Mar 13, 2003
Messages
2,182
Reaction score
1,207
You only give 30 mg prop for a retrobulbar? Damn dude at least give something for analgesia. That's basically like giving someone a back massage then stabbing them in the eye. We do an prop:alfentanil:lido mixture that works pretty well.
Ah yes, the old "6:2:2" method.
 
D

deleted171991

You only give 30 mg prop for a retrobulbar? Damn dude at least give something for analgesia. That's basically like giving someone a back massage then stabbing them in the eye. We do an prop:alfentanil:lido mixture that works pretty well.
Solo alfenta is more than enough.
 

btbam

Full Member
10+ Year Member
Joined
Jan 16, 2011
Messages
530
Reaction score
337
I work with a 2 retina guys who talk their patients through the block. No propofol necessary.

"Ok ma'am just hold steady while I bring this big ass needle right towards your eye.."
 
  • Like
Reactions: 1 user
D

deleted59964

pretty standard here for us to do either sub tenon or peribulbar block. some of us give some sedation, some do not.

if they have a cataract they don’t see the needle coming
 
  • Like
Reactions: 2 users

facted

Full Member
10+ Year Member
Joined
Dec 15, 2008
Messages
1,018
Reaction score
559
"Ok ma'am just hold steady while I bring this big ass needle right towards your eye.."
Three guys we work with give po benzo preop, then eye drops. Of my last 100 patients or so, I gave one of them 1mg midaz, and that was for a longer corneal transplant.

They do just fine just without blocks and extra sedation.
 
  • Like
Reactions: 1 user
Members don't see this ad :)

Urzuz

Full Member
10+ Year Member
Joined
Aug 24, 2011
Messages
720
Reaction score
1,554
The comfort of the patient is directly related to how slick the ophthalmologist is doing the block. We have eye docs that range from super gentle (i.e.: wouldn't wake a sleeping baby) to caveman status.

As an aside, I'm shocked to hear that so many of your guys' eye docs are still doing retrobulbar blocks for straightforward cataracts...
 

anbuitachi

Full Member
10+ Year Member
Joined
Oct 26, 2008
Messages
6,310
Reaction score
3,126
The comfort of the patient is directly related to how slick the ophthalmologist is doing the block. We have eye docs that range from super gentle (i.e.: wouldn't wake a sleeping baby) to caveman status.

As an aside, I'm shocked to hear that so many of your guys' eye docs are still doing retrobulbar blocks for straightforward cataracts...

What block do you do?
 
D

deleted59964

As an aside, I'm shocked to hear that so many of your guys' eye docs are still doing retrobulbar blocks for straightforward cataracts...

Pretty sure they’re actually peribulbar not retrobulbar
 
  • Like
Reactions: 1 user

Psai

This space for lease
Removed
5+ Year Member
Joined
Jan 2, 2014
Messages
11,384
Reaction score
23,987
It’s a tiny needle and they’re very gentle.

Every needle looks huge when it's going into your eye. Knock me out please.
 
  • Like
Reactions: 3 users

Hawaiian Bruin

Breaking Good
15+ Year Member
Joined
Mar 13, 2003
Messages
2,182
Reaction score
1,207
I wonder if this move is maybe intended to force ophthos to switch to topical anesthesia.

Blocks for cataracts is horse and buggy stuff, man.
 
  • Like
Reactions: 3 users

Ezekiel2517

Anesthesiologist
15+ Year Member
Joined
Jan 21, 2005
Messages
1,137
Reaction score
1,894
I wonder if this move is maybe intended to force ophthos to switch to topical anesthesia.

Blocks for cataracts is horse and buggy stuff, man.
There are certain cases and patients where a block is preferred over topical by the surgeon and actually helps them perform the procedure . Many times when the ophtho sees the patient in their office, they know whether it's better to book them for a block vs topical
 
Members don't see this ad :)
D

deleted697535

most of us can find something better to do with our lives than get paid Medicare rates for hand-holding anesthesia.

I did a list one day where my borderline senile consultant wanted to literally hand hold the patient under the drapes. The nurse did the same.
It took them 10 mins to figure out they were hand holding each other under the drapes and not the patient's!!
 
  • Like
Reactions: 7 users

nimbus

Member
15+ Year Member
Joined
Jan 14, 2006
Messages
9,233
Reaction score
14,087
There are certain cases and patients where a block is preferred over topical by the surgeon and actually helps them perform the procedure . Many times when the ophtho sees the patient in their office, they know whether it's better to book them for a block vs topical


For these cases you could justify medical necessity and the insurance company will pay.
 

nimbus

Member
15+ Year Member
Joined
Jan 14, 2006
Messages
9,233
Reaction score
14,087
Every needle looks huge when it's going into your eye. Knock me out please.


He instructs the patient to look up and injects below so the patient doesn’t see the needle;)

It’s really no different than the blocks we do preop. Many times which I do without sedation.
 
D

deleted59964

As an aside, I'm shocked to hear that so many of your guys' eye docs are still doing retrobulbar blocks for straightforward cataracts...

We do the blocks.
they're very safe blocks, take about 1 minute and give excellent akinesis.
the consultant (attending) ophthalmologists don't need it, the trainees do
 

Psai

This space for lease
Removed
5+ Year Member
Joined
Jan 2, 2014
Messages
11,384
Reaction score
23,987
I did a list one day where my borderline senile consultant wanted to literally hand hold the patient under the drapes. The nurse did the same.
It took them 10 mins to figure out they were hand holding each other under the drapes and not the patient's!!

They were probably also playing footsie under the table
 
  • Like
Reactions: 1 user

BLADEMDA

Full Member
Lifetime Donor
15+ Year Member
Joined
Apr 22, 2007
Messages
20,939
Reaction score
7,187
Here is my take on this ruling by Anthem:

1. Like in most things there are good and bad Optho surgeons. The good ones work at surgicenters and do topical for their cases 99% of the time. They take about 10-15 min to do the case. For them, this ruling doesn't cause much of a concern.

2. The bad Optho surgeons work at hospitals. They have not improved their techniques since 1990 or earlier. They need Retrobulbar blocks because they lack the skill necessary to do the case under topical. So, they transfer the "risk" of the case to the poor, dumb-ass Anesthesiologist who gets paid NOTHING for doing the block. The Optho surgeon being limited in skill demands these blocks for almost every case. When a complication occurs he/she blames the block and not their poor surgical skill.
I've seen these "surgeons" take 90 minutes or more to do a cataract.

3. The "slick" Optho surgeon can do his own block without sedation (or with minimal sedation) from time to time as needed (should be less than 10% of cases).

Overall, this ruling is a blessing to the hospital based Anesthesiologist and the patients. Now, those who can't cut the mustard must retire (as they should) or send the patient to a better Optho surgeon.

It is high time the ASA comes out against Anesthesiologists doing RBBs for these cases as Medicare pays us nothing and this is the responsibility of the Optho surgeon.
 
  • Like
Reactions: 3 users

BLADEMDA

Full Member
Lifetime Donor
15+ Year Member
Joined
Apr 22, 2007
Messages
20,939
Reaction score
7,187
Retrobulbar Anesthesia

RBA was the “gold standard” for eye blocks from the beginning of the 20th century until the formalization of PBA and STA in the 1990s. RBA is achieved by injecting a small volume of local anesthetic agent (3–5 ml) inside the muscular cone. The main hazard of RBA is the risk of injury to the globe, the rectus muscles, or one of the many vulnerable elements located in the muscular cone. Near the apex, these structures are packed in a very small volume and are fixed by the tendon of Zinn, which prevents them from moving away from the needle. Currently, RBA is used less frequently because of these potential complications.

Regional Anesthesia and Eye Surgery | Anesthesiology | ASA Publications
 
Joined
Nov 20, 2017
Messages
265
Reaction score
326
Completely agree with above. When topical is given plus 1mg versed. We are unnecessary. Just paper work monkeys.

If they are doing peribulbar or retrobulbar blocks I understand being involved. Just don't know why these still need to be done, but, hey, I work in academics.

That said, 85% of our eye cases are topical only and I still have to do a pre op evaluation, MAC attestation, and post op. Just unnecessary IMO.

Sent from my XT1710-02 using Tapatalk
 

diamondgold

New Member
Joined
Jan 5, 2018
Messages
3
Reaction score
0
This must be a concern for ophtho guys not us! Who really wants to fight on behalf of ophthalmologists? If they can handle severe bradycardia that happens once a while then good luck to them!
 
D

deleted59964

Retrobulbar Anesthesia

RBA was the “gold standard” for eye blocks from the beginning of the 20th century until the formalization of PBA and STA in the 1990s. RBA is achieved by injecting a small volume of local anesthetic agent (3–5 ml) inside the muscular cone. The main hazard of RBA is the risk of injury to the globe, the rectus muscles, or one of the many vulnerable elements located in the muscular cone. Near the apex, these structures are packed in a very small volume and are fixed by the tendon of Zinn, which prevents them from moving away from the needle. Currently, RBA is used less frequently because of these potential complications.

Regional Anesthesia and Eye Surgery | Anesthesiology | ASA Publications

No one should be doing retrobulbar blocks.
I feel like no one is listening ...

It’s topical, or sub tenon or peribulbar.

Both peribulbar and subtenon are MUCH safer than retrobulbar.

For what it’s worth I hate doing eye blocks, but it’s quite the gravy train in private practice here.
 

Ezekiel2517

Anesthesiologist
15+ Year Member
Joined
Jan 21, 2005
Messages
1,137
Reaction score
1,894
Sure, but cataracts aren’t one of them. Modern phacoemulsification technique makes blocks completely unnecessary.
Well then I guess you know more than the ophthos. Bc they tell me firsthand the blocks help with specific patients and with longer and more complex cases, even cataracts. It's actually quicker for them to do the case with topical but they choose to request a block for certain cases
 

Hoya11

Senior Member
15+ Year Member
Joined
Sep 4, 2004
Messages
1,230
Reaction score
995

IMO the bigger question is what do you do with the surgical centers that house these eye factories... ? Have no anesthesiologist anywhere on the premises? In a hospital you are available for a bail out in an unforeseen emergency, but now you are talking a CRNA (an eye center CRNA at that) and an eye surgeon as the only providers.. what if something terrible were to happen?

In a given day in a busy eye center (which I have unfortunately spent quite a few days at), if I do 40 cases, ill typically cancel 1 due to things like: new onset afib, extreme bradycardia to 30s, sugar in the 500s, etc... but I am ready to DEAL with those things.. im not just going to call an ambulance and delay appropriate care for these people in these tough situations.. there was even a code (yes it was 8 years ago) after a block that required intubation and resuscitation.

While I completely agree that we are not needed most of the time, if you are not in a hospital, doing high volume cataract surgery for people who are 80,90 with uncontrolled medical problems and an eye surgeon h and p, eventually something bad is going to happen.. As the owner of that lucrative center, I'm going to want to be able to say I did everything I could to prevent that person from dying/being harmed even if its once every 6 months or 1 year
 

nimbus

Member
15+ Year Member
Joined
Jan 14, 2006
Messages
9,233
Reaction score
14,087
Well then I guess you know more than the ophthos. Bc they tell me firsthand the blocks help with specific patients and with longer and more complex cases, even cataracts. It's actually quicker for them to do the case with topical but they choose to request a block for certain cases


Well many ophthos never need to block their cataracts and take 10min while others always block and routinely take an hour. I know which ones I’d let operate on my eyes.
 
  • Like
Reactions: 2 users
Top