The Cost of Cutting Time: The Risks of Time-Based Anesthesia Reimbursements for Plastic Surgery

On November 1, 2024, Anthem Blue Cross and Blue Shield announced imminent insurance policy changes to enforce service-time targets and reimbursement restrictions on anesthesia services.1 Beginning February 1, 2025, for policyholders in New York, Connecticut, and Missouri, Anthem would have limited anesthesia reimbursements for surgical procedures by maximum time limits based on physician work times published by the Centers for Medicare & Medicaid Services. Following significant public opposition, Anthem reversed and redacted their policy updates on December 5, 2024.2 In formulating this policy change, Anthem appears to have neglected its financial responsibility to adequately compensate anesthesiologists and health care systems, instead favoring profitability. If implemented, this action would have exerted unconscionable pressure to minimize operative times, potentially endangering patient safety. As plastic and reconstructive surgeons, it is critical that we promote formal safeguards to stand against such practices, as they establish dangerous precedents for other commercial insurers to follow suit. Our specialty holds the privilege and responsibility of serving vulnerable patient populations, caring for patients battling cancer, children with congenital abnormalities, and survivors of traumatic injuries. Restrictions on operative times impose risks of poor outcomes to millions of those patients. Beyond safely completing procedures, plastic surgeons utilize intraoperative time to optimize aesthetic outcomes. For example, in breast reconstruction, surgical teams routinely pause to assess for symmetry and iterate to accommodate patient preferences for implant sizing. At best, timing restrictions stifle the plastic surgeon’s ability to deliver patient satisfaction. At worst, attempts to expedite surgery could hasten critical procedural steps, such as high-risk dissections or microvascular anastomoses, or forego informal risk mitigation strategies, such as brief pauses to assess for vascular congestion, prolonged bleeding, or early signs of tissue ischemia. In the age of value-based care, insurance providers must be held accountable for the financial burdens they impose on patients. For “overtime” procedures, decreased compensation will cascade through the health care system, driving financial toxicity while compromising both quality and safety of patient care. Using National Surgical Quality Improvement Program data, Blau et al.3 demonstrated that relative value units and operative durations across reconstructive procedures are unevenly distributed; when operative times are restricted, procedures, such as microsurgical reconstruction, become less economically sustainable, restricting access to care by patients’ socioeconomic status or proximity to well-resourced centers. We compared National Surgical Quality Improvement Program average operative durations3 to 2024 Centers for Medicare & Medicaid Services physician work time data4 to estimate hypothetical deficits in reimbursements for select procedures (Fig. 1). Our results demonstrate 20% reductions in intraoperative anesthesia reimbursements for free flap breast reconstruction, comprising an estimated average decrease of $533 in per-procedure physician-service compensation from commercial insurers nationwide.5 Beyond the financial impact, timing restrictions further threaten central tenets of plastic surgery by disincentivizing procedural innovation and constraining teaching efforts at academic institutions.Fig. 1.: NSQIP mean operative times were charted against CMS physician work times for common plastic and reconstructive surgery procedures. Time values are reported in minutes, with percentage reductions reflecting deficits in reimbursed intraoperative anesthesia services. CMS, Centers for Medicare & Medicaid Services; CPT, Current Procedural Terminology; NSQIP, National Surgical Quality Improvement Program.On November 14, 2024, the American Society of Anesthesiologists successfully called for concerned parties to contact state legislators and contest Anthem’s actions.1 Similarly, we call upon legislators and professional societies across medicine to ensure that analogous policies never take effect in restricting patients’ access to safe surgical care. DISCLOSURE Dr. Broyles serves on the scientific advisory board for Healshape LLC, receives consulting support from the Agency for Healthcare Research and Quality, and serves on the Medical Device Advisory Board for the US Food and Drug Administration. The remaining authors have no financial relationships or conflicts of interest to disclose.