Anthem Blue Cross Blue Shield has reversed its decision on a controversial anesthesia reimbursement policy update, which would have introduced a new reimbursement structure based on CMS physician work time values.
Twenty-three anesthesiologists and certified registered nurse anesthetists connected with Becker's to discuss their thoughts.
Editor's note: Responses were edited lightly for clarity and length.
George Anastasian, MD. Chief of Anesthesiology at White Plains (N.Y.) Hospital: By initially declaring it will no longer pay for anesthesia care if the surgery or procedure goes beyond an arbitrary time limit, Anthem signaled it will not pay anesthesiologists to deliver anesthesia to patients who may need extra care because their surgery runs into complications or is otherwise difficult. Anthem's decision to reverse this proposed policy is a result of tremendous public pressure and negative publicity.
Emily Barton, CRNA. Certified registered nurse anesthetist at Mercy Fort Smith (Ark.): How could they think this would be acceptable? How can you blame anesthesia for the length of surgery? We are pushed so much to move and get done, but unless the procedure is complete, we can't stop the anesthesia. None of the CEOs are working for free. Anesthesia providers are now at a premium, so asking for anesthesia to again take the hit for profit after all the other cuts in reimbursement is just going to shrink the pool of providers. A reversal was absolutely necessary and all I can do is hope it signals a fresh look at the penalties being parsed out to drop reimbursement costs.
Robert Berndt, MD. Anesthesiologist in Beaumont, Texas: I applaud the recent decision not to implement the policy of not using actual time as a factor in determining reimbursement for anesthesia services. The rapid and vocal pushback by the ASA and individual leaders in the field of anesthesiology was to a large degree responsible for this. I think that Anthem was hoping to slip this under the radar and use a low average time conversion factor in order to reduce their costs and increase profit. Had they successfully implemented this policy, it probably would have been implemented in other states and by other insurance companies. It was pointed out that there is no evidence of any significant fraud involving misreporting of time units. This is typical behavior by the large insurance companies. They are in business to make a profit and do not feel a moral obligation to do the right thing by their insured patients if they can refuse to pay for care and get by with it legally. To them, it is a business decision and as long as it is legal and doesn't alienate a large number of their customers, they are OK with it.
The problem with redefining time is that there are a limited number of anesthesia procedure codes compared to the number of surgical CPT codes. Some of these surgical procedures are typically much longer than others. For example, a laparoscopic cholecystectomy would be expected to take an hour to an hour and a half whereas a colectomy involving upper abdominal dissection would be expected to take two and a half to three hours. Each of these surgeries use anesthesia procedure code 00790. There is also a significant difference in the time it takes different surgeons to perform the same operation. Some are very efficient and fast others are much slower but equally good outcomes. An unintended consequence of this policy could be preference for working with some providers over others. The ASA relative value code system uses time as a factor in calculating fees because anesthesiologists have no control over the time it takes to perform a surgical procedure but the time affects the amount of professional work involved.
Alan Bielsky, MD. Anesthesiologist at Children's Hospital Colorado (Aurora): What I would say is that the reversal in their decision fails to address the real elephant in the room. Why are insurance companies continuing to pay less for the same work? Why do they seek to standardize their approach to payment when every case is different? Furthermore, when was the last time that any of their employees took a pay cut for the same number of hours worked?
Brian Cross, CRNA. Owner of CS Anesthesia (Youngstown, Ohio): The short answer is I am very happy they reversed their decision. However, Anthem has already done this in many states by capping what the reimburse anesthesia providers for gastrointestinal procedures at $200 no matter how long the procedure takes. This has been going on for several years. Additionally, several insurance carriers have cut reimbursement to nurse anesthetists by 15%. Our national organization, the American Association of Nurse Anesthetists, has filed a lawsuit last month against the director of HHS for not enforcing the current rules that keep insurance companies from discriminating against non physician providers who provide the same care to patients as their physician counterparts, which CRNAs do under our scope of practice.
Katy Dean, CRNA in Yorktown, Va.: It would be interesting to hear how Anthem BCBS came up with the policy in the first place. Who thought it was actually a good idea to limit pay for anesthesia based on a preset time for surgery? Who on the board at BCBS would want that policy applied to their loved one? I do not believe Anthem BCBS had any other choice but to reverse their decision. The bigger question is who will monitor insurance companies moving forward to assure that policies like this, which are directly detrimental to patient care, will not come up in the future.
Bob Ebener, DO. Anesthesiologist in Middleburg, Fla.: As an anesthesiologist, I am certainly glad that Anthem decided to reverse this decision. Reimbursement for anesthesiology services are undervalued as it is. Limiting anesthesiology reimbursement by putting a time cap on it is truly unfair and unacceptable, as we are committed to care when surgery is ongoing.
Ladan Eshkevari, PhD, CRNA. Editor-in-Chief of the AANA Journal and Professor at Georgetown University (Washington, D.C.): Obviously, the decision to base anesthesia billing on surgical time was ludicrous as anesthesia providers have no control over surgical procedure times. That is purely a surgical denominator, and as long as the surgery is ongoing, so should the anesthesia time. I am not sure what prompted such a huge misstep, but I am not surprised by the lack of commonsense policy. Most of us providers have gotten fairly used to arbitrary insurance carrier policies that impact the health system and really affect patient care in negative ways. The decision-makers were obviously completely disconnected from reality; I was glad to see they had reversed it.
Megan Friedman, DO. Anesthesiologist and Director of Pacific Coast Anesthesia Consultants (Los Angeles): Anthem's decision to reverse its policy on anesthesia reimbursement is a critical win for patient safety and equitable care. The original policy's time caps failed to consider key factors affecting surgery duration, such as patient-specific health conditions, unforeseen intraoperative complications and surgeon variability. No two surgical cases are the same, and these rigid limits could have discouraged anesthesia providers from taking on complex or longer procedures, potentially compromising patient outcomes.
The policy also posed significant financial challenges. Many facilities and ASCs already provide stipends to maintain anesthesia services due to insufficient reimbursement rates. Additional cuts could have increased these stipends, straining resources further for hospitals and ASCs. This financial burden would only compound the existing workforce shortage, with 78% of facilities reporting difficulties in anesthesia staffing and over half of anesthesia providers nearing retirement age.
Compounding these challenges is the growing demand for skilled anesthesia care driven by an aging population. Adults aged 65 and older account for a disproportionate share of surgical patients, often with complex comorbidities requiring advanced anesthesia expertise. The combination of workforce shortages, increasing procedural complexity and financial pressures highlights the need for policies that align with clinical realities and prioritize patient outcomes. Anthem's reversal demonstrates the importance of such an approach, ensuring healthcare systems can continue to provide high-quality care in the face of growing demand.
Dewey Galeas, CRNA. Certified registered nurse anesthetist in Grovetown, Ga.: In regards to Anthem BCBS reimbursement policy, I can say — the motor- and skill-impaired surgeon is an eternal albatross to anesthetic practice. The anesthesia provider assumes a duty to the patient and can't end the anesthetic simply because we are "out of quarters" for the anesthesia pony. Tertiary and larger institutions/practices absorb this as a loss leader in the practice. Smaller, fee-for-service providers/ASC practices are unable to do so.
Robert Gordon, MD. Anesthesiologist in Ramsey, N.J.: Insurance companies exist to make money like any other business. In this case, the less they reimburse, the more they make. An already reduced anesthesiology community would have walked out. Anthem tried and were quickly shot down.
Matthew Gummerson, MD. Anesthesiologist in Dallas: It was completely appropriate for Anthem BCBS to reverse their anesthesia reimbursement policy. Like many other policies, this seems to have been made in haste by individuals who have clearly never been inside an operating room or taken care of surgical patients under anesthesia. As an anesthesiologist, we have no control over the surgeon’s technical efficiency, surgical planning or ability to deal with known or unanticipated complications. As fellow physicians, we trust that they will always do what is in the best interest of the patients, regardless of how long it takes — as we do. We simply would never turn off the anesthesia machine in the middle of the surgical procedure and walk out of the operating room when the arbitrary insurance coverage time is up. This was a laughable policy and I'm glad that they reversed course, as this really wasn't a decision based in reality. We are honored to care for vulnerable patients and keep them safely under general anesthesia for as long as they need. As a last thought, I don't think this was a broader policy shift or statement as to anesthesia reimbursements across the board, but an experiment to explore what the possible fervent reactions might be from the anesthesia community. It was significant.
Bob Johnstone, MD. Chair of the Department of Anesthesiology at West Virginia University (Morgantown): Anthem's attempt to stop paying for anesthetics after specific durations was uninformed (anesthesiologists don't determine how long surgeries take), irritating (they didn't consult with anesthesiologists or surgeons beforehand) and possibly harmful to patients. It illustrates why patients and providers hate insurers.
Calvin Johnson, MD. Professor of Anesthesiology at Cedars-Sinai Medical Center (Los Angeles): Anthem BCBS' decision to reverse its anesthesia reimbursement policy is a positive step toward ensuring fair compensation for anesthesia providers. The initial policy raised significant concerns regarding patient access to care and the financial viability of anesthesia practices. By reversing the policy, Anthem is demonstrating responsiveness to the concerns raised by providers and stakeholders, which is crucial for maintaining trust and collaboration between payers and the healthcare community.
John Kezele, CRNA. Certified registered nurse anesthetist at Franklin County Medical Center (Preston, Idaho): First and foremost, unlike my surgeon colleagues, I only have control over procedure times that I directly perform. For example, acute pain block like an interscalene block, or chronic pain procedures where I am the primary provider performing the procedure. Whereas most of my time involvement during a surgical procedure is providing anesthesia for the patient and surgeon. This is where the challenge is. I can't control the surgical time of individual surgeries. Some surgeons perform the exact procedure faster or longer than other providers.
Historically, an anesthesia provider was fairly compensated for the individual time caring for the patient, from arrival in the OR to transferring care in the recovery room, which I call door swing time. From door to door we are the guardian angels. The surgical procedure is often timed from incision to closure — those times vary widely based upon the complexity of the procedure. The time from arrival in the OR to incision can be up to 60 minutes. Anesthesia is caring for the patient the whole time, and even after the surgeon finishes their part. The anesthesia provider is caring for the patient until they can be safely transferred to lesser acute care. This is what is called anesthesia time.
Apparently Anthem doesn't understand how everyone on the surgical team functions. As an independent CRNA practicing for 30 years, recently my QZ billing status has come under attack by many payers that think that because I am a nurse anesthetist providing care, I am subject to be paid less to provide the same service. In the face of rising cost, including wages, I find payers are reducing payments, including an additional 15% because I am an independent functioning anesthesia provider. Anthem's policy was just another cost-saving tactic to help define a "failed market." They aren't the only ones. CMS has been doing the same.
Mike MacKinnon, DNP, CRNA. Owner of Mackinnon Anesthesia (Show Low, Ariz.): It is the right thing to do, but I'm concerned about the decision-making process that led to this policy. My assumption is the recent murder of the UnitedHealthcare CEO and the subsequent outrage regarding commercial insurance companies had more to do with the reversal than anything else. At least the timing suggests that's the case, as they announced this policy in the second week of November and not until it hit the news again after the CEO murder was another light shed on this issue and they decided to reverse. My guess is this was to avoid more negative press "eyes" on them.
Matt Mazurek, MD. Assistant Professor of Anesthesiology at Yale School of Medicine (New Haven, Conn.): I am deeply concerned and disappointed that Anthem, or should I say Elevance Health Inc., considered this proposal in the first place. My colleagues in the ASA and AANA feel the same way. The response on social media was immediate, forceful and broadly opposed. We were not in favor of their ridiculous and insulting proposal. If they thought it was a good idea, why did they decide to roll it out in only three states, including Connecticut, New York and Missouri? If they were confident, they would have rolled this out to all 14 states, not just three. I do not know how anyone at Elevance Health thought this proposal would be accepted by any anesthesiologist or CRNA or healthcare system. They did the right thing but only because there was overwhelming and immediate pressure. They messed around and found out.
These opinions are solely my opinion and not those of Yale School of Medicine or Yale New Haven Health.
Stan Plavin, MD. Anesthesiologist and owner of Oral Surgery Anesthesia Associates: Candidly, Anthem does these little tests in various marketplaces to see levels of tolerance and how the anesthesia community responds. It is deceptive and not without risk from a public relations stand point. Our reimbursement model is challenging in many ways and perhaps needs to be re-evaluated but for a policy to without any regard for patient care and focused only on the timing of an anesthetic reminds me more of riding an Uber than providing comprehensive medical care.
Rick Richter, MD. Anesthesiologist at Anesthesia Associates of Rock Hill (S.C.): I believe it was a retreat after testing the waters regarding reimbursement for anesthesia services. Anthem "won" the first round by curtailing payment for services of an unsupervised CRNA to 85% of a care team model payment. Anthem then "reached for the stars" by trying to eliminate the time component to reimbursement for anesthesiologists who have no control over the amount of time it takes a surgeon to perform the case. Anesthesiologists should resist any attempts to dilute the value of our services by insurance companies. Although the struggle for private practice physician groups (especially anesthesia groups) is real, transparency about the profit motives of insurance companies can maintain safe and comforting individualized care for patients that anesthesiologists and anesthetists have been known for. Otherwise, the supply of providers available will continue to dwindle.
Gerald Szelagowski, MD. Anesthesiologist at Buckeye Anesthesia Services and Consultants (Lima, Ohio): It's very interesting that Anthem's policy was so egregious in how it attempted to not pay for anesthesia services that even had friends and family members who are not in the medical field texting me regarding this ridiculous policy. When the general public, who have no knowledge of how anesthesia time is billed, is reaching out to members of the medical community concerned, that tells you how far Anthem is going to go in order to increase profits.
James Stockman, MSN, CRNA. Past President of the Texas Association of Nurse Anesthetists and CEO of Grasshopper Anesthesia Services: The reversal of BCBS' decision is entirely appropriate. It should have never been considered. BCBS' decision to cap anesthesia was shortsighted; anesthesia has little to no ability to determine the length of the surgery. It gave no consideration to mitigating factors such as having to convert a procedure from laparoscopic to open, or complications that might arise intraoperative. It essentially told a patient to choose a fast surgeon (regardless of skill). An insurance administrator shouldn't be determining the length of surgery.
Jeff Tieder, MSN, CRNA. Clinical Associate Professor at the University of Tennessee at Chattanooga: The issue of anesthesia reimbursement is of great concern to me as a provider and a patient. Anesthesia reimbursement continues to decline as the shortage of providers continues to mount. This is a simple supply demand issue that passes the costs on to the hospital, ASC and patients. Anesthesia providers are at the mercy of the surgeons we work with. We have little to no impact on the duration of the surgical time. This has always been understood regarding why we are reimbursed on time units rather than procedure. This, along with the CMS decrease in reimbursement, is a disturbing trend. Insurance premiums continue to increase throughout the United States, yet reimbursement continues to decrease.
Jay Weller, MD. Anesthesiologist at Seven Hills Anesthesia (Evendale, Ohio): The real problem underlying reimbursement for anesthesia professional services in the United States is CMS' conscious and intentional shifting of financial responsibility for the care of Medicare beneficiaries from the federal government to the private sector. With that said, sustainable payment reform will require a collaborative effort from providers and payers. Unilateral approaches like this one by Anthem BCBS are doomed not only to fail, but to add to the public's gross mistrust of the insurance industry. Anesthesiologists have no control over how long it takes to complete a surgical procedure, so the idea of cutting off payment at some arbitrary time made no sense from the beginning.