Originally published by our sister publication Anesthesiology News

Almost as quickly as it came, Anthem Blue Cross Blue Shield’s proposed policy to limit reimbursement for anesthesia beyond a certain time limit has disappeared, leaving in its wake a trail of unanswered questions and broken trust.

On Nov. 1, the commercial insurer announced—in a now-retracted statement—that its insurance plans in Connecticut, New York and Missouri would no longer pay for anesthesia care for procedures exceeding an arbitrary time limit, regardless of the actual length of the procedure. The policy was set to take effect in February 2025. Anthem stated that the policy was based on metrics from the Centers for Medicare & Medicaid Services.

The proposal provoked a widespread outcry. The American Society of Anesthesiologists (ASA) released a statement on Nov. 14, calling for the policy to be reversed, characterizing it as an “egregious” and “cynical” cash grab. On Dec. 5, New York Gov. Kathy Hochul responded to the proposal, warning Anthem: “Don’t mess with the health and well-being of New Yorkers—not on my watch.” On the same day, Connecticut comptroller Sean Scanlon announced that his office had contacted Anthem and persuaded them to withdraw the proposal.

A few days later, on Dec. 10, Sens. Richard Blumenthal (D-Conn.) and Josh Hawley (R-Mo.)—who agree on very little else—wrote a letter to the CEO of Elevance Health, the parent company of Anthem, lambasting the policy as “draconian” (bit.ly/3BBpAHx). On Dec. 9, Rep. Ritchie Torres (D-N.Y.) introduced a bill in the U.S. House of Representatives that would ban insurance companies from setting such limits on anesthesia care (bit.ly/3DwWXM0).

The Anesthesia for All Act would “prohibit health insurers ... from imposing arbitrary time caps on reimbursement for anesthesia services and for other purposes.” If passed, the bill would direct the Department of Health and Human Services inspector general to conduct audits to ensure health insurance companies are complying with the law.

“We cannot trust insurers to do right by doctors and patients out of the kindness of their hearts. There is a need for legislation that prevents any insurer anywhere in America from micromanaging the length of anesthesia care in a medically necessary surgery. The purpose of medicine should be to prevent pain, rather than cause it through the denial of anesthesia,” Torres said in a statement.

How did this happen?

Anesthesiology professionals said insurance companies are becoming increasingly brazen in their pursuit of profits—and this time, they overreached.

“This is just one more insult in a long line of appalling behavior by commercial insurers just in the past year,” said ASA President Donald Arnold, MD, citing as examples Anthem’s decision to discontinue payments for qualifying circumstances, which went into effect on Nov. 1, and Blue Cross Blue Shield’s discontinuation of payments for physical status modifiers—which prompted Aetna to follow suit—effective June 1. “In this case, not only anesthesiologists but the general public, who clearly understand the essential role of anesthesiologists in providing care, and also state and federal elected and regulatory officials, realized how misguided this proposal was.”

In general, Arnold said, anesthesiology payments are typically based on the complexity of the procedure as well as the patient in each case, and the time it takes to provide safe and high-quality care. “We’ve seen commercial insurers in the past year refusing industry-standard payments for patient complexity—patients at extremes of age, patients undergoing emergency surgery, or patients who have more medical conditions that limit their overall health.”

Following ASA’s statement on Nov. 14, Arnold and other representatives of the organization joined a call with representatives from Anthem, at which the ASA raised the concerns of anesthesiology professionals and asked additional clarifying questions. Anthem agreed to a follow-up call for further discussion, but did not respond to attempts to schedule that call.

“There was a promise on both sides to meet again, but Anthem did not honor that promise,” he said.

Peter J. Papadakos, MD, a professor of anesthesiology and perioperative medicine, and the director of critical care medicine at the University of Rochester Medical Center, in New York, said the proposed policy would also have had a disproportionately negative effect on teaching hospitals, where procedures naturally and necessarily tend to take longer.

“A policy like this would completely devastate teaching hospitals like my institution,” he said. “The surgeon is teaching the surgical resident, showing them the anatomy, lecturing, helping the resident learn how to perform the surgical procedure. It’s the same with the anesthesiology faculty member teaching the resident. You would effectively be punishing the institutions that train the next generation of surgeons and anesthesiologists, and then instead of paying the best of the best to be teachers, you would drive down the quality of care not just today but in the years and decades to come.”

Papadakos likened the proposal to limit anesthesia payments to an arbitrary average time limit to a customer at a steakhouse deciding to only pay the price of an average steak, regardless of what they actually ordered.

“You can’t go to a high-end steakhouse, order the Kobe rib eye, get the bill, and decide you’re paying the Longhorn Steakhouse price. It’s completely outrageous,” he said.

Echoing Arnold’s comments, Papadakos said this proposal is only the most recent and bold in a long line of harmful and profit-driven practices. In a commentary article, Will Humble, the executive director for the Arizona Public Health Association, noted that Anthem has exhibited a consistent pattern of underpaying reimbursements and inappropriately denying coverage, leaving 53% of submitted bills unpaid for the second quarter of 2021—a dine-and-dash adding up to $2.5 billion. In 2022, its parent company Elevance Health cleared a profit of $6 billion.

“The insurance companies seem to spend most of their time denying coverage and devising ways not to pay for it,” Papadakos said. “Meanwhile, hospitals are closing all over the country because they can’t afford to keep the lights on.”

As for what happens next, Arnold said the ASA is working with lawmakers and regulators to ensure that policies like this will never see the light of day. He added that Anthem, and the insurance industry more broadly, has a long road ahead if they hope to rebuild broken trust with medical professionals and the general public.

“We do believe that there are opportunities for the restoration of relationship,” he said. “But because of the repeated abusive steps taken by the commercial insurance industry, it will take time and effort on their part. They need to receive the message, once and for all, that they can’t keep putting profits before patient care.”

—By Ajai Srinivas

Arnold and Papadakos reported no relevant financial disclosures.