KUALA LUMPUR, Oct 3 — An anaesthesiologist and critical care specialist has questioned a third-party administrator (TPA) if clinicians should cancel or postpone surgeries if they need to suddenly change their anaesthesia choice.
Dr Abdul Jabbar Ismail, who currently works at a university hospital in Sabah, said MediExpress (Malaysia) Sdn Bhd’s directive to panel hospitals to prioritise local anaesthesia (LA) as the first-line anaesthesia modality over general anaesthesia (GA) indicated a new additional insurer approval for the type of anaesthesia, on top of surgery type.
Currently, insurers simply look into a guarantee letter (GL) request by a surgeon for whatever procedure and the surgeon is then empowered to do whatever is necessary for the patient if the GL request is approved. On surgery day, the anaesthesiologist decides the suitable mode of anaesthesia for the patient.
Dr Jabbar posted on X yesterday that the type of surgery wasn’t the only indication for LA or GA choice, citing patient factors that could make them unsuitable for local anaesthesia even if the operation was a daycare procedure or appeared to be “simple”.
“In addition, even if you ‘approve’ beforehand the mode of anaesthesia, when the surgery day comes, plenty of other factors necessitate the LA method to be changed to GA on the day of surgery. So now what?” questioned Dr Jabbar.
“Do we cancel the surgery? Do we postpone and ask for a new approval? Where do we draw the line when insurance dictates every decision by the specialists?”
When contacted for further comment, the anaesthesiologist cited common occurrences like the patient suddenly becoming scared and anxious just before surgery. “Should I deny the patient’s right to have GA?”
He stressed the importance of shared decision-making between doctor and patient and patient autonomy.
“Gone are the days when doctors told everything and instructed everything,” said Dr Jabbar. “Nowadays, for anaesthesia, we discuss in detail the pros and cons, expectations, and options laid out, and let the patient decide.”
The anaesthesiologist also listed nine clinical factors that required clinicians to change their choice of anaesthesia from LA to GA just before or even during a procedure:
- Unexpected complications intraoperatively, like requiring extended surgical incision.
- Planned for surgery but on the day of surgery, it turns out the mass has grown bigger and the required amount of LA exceeds a safe dose for the patient, so GA is needed.
- A simple mass excision turns out to have deep extension of the mass and is uncomfortable for the patient, hence requiring GA.
- Sedation (commonly used during LA) associated with unexpected side effects. Some patients respond too much or are too sensitive to a normal dose for other patients, thus requiring airway securement, hence GA.
- Simple surgery but uncomfortable positioning like swelling at the back requires the patient to be prone. The surgeon may not have anticipated it, but it turns out that GA is needed.
- Some patients somehow don’t have the intended effect of LA after injection, even after the maximal safe dose is reached (usually 2mg/kg, typical bupivacaine).
- Sudden bleeding during surgery, thus requiring immobility of the patient, so GA is needed.
- Rare allergic reaction to LA, necessitating GA.
- Surgery for patients needing strict blood pressure control due to medical conditions might be risky if done under LA. Although painless, the tissue damage from excision can trigger inflammation, increase blood pressure, and cause myocardial ischemia (reduced blood flow to the heart that prevents the heart muscle from receiving enough oxygen).
“Doctors now have to prioritise cheaper costs instead of patient safety? When will MOH (Ministry of Health) take action and intervene about insurance dictating specialists’ clinical decisions? This is very worrying indeed,” Dr Jabbar posted on X, tagging Health Minister Dzulkefly Ahmad’s account.
The Malaysian Medical Association (MMA), DRSFORALL, and former Health director-general Dr Noor Hisham Abdullah, who is currently chairman of UCSI Healthcare Group, have all condemned MediExpress’ LA-first policy as a threat to patient safety.
A general surgeon previously posted on Threads last month that he had a young patient with massive upper gastrointestinal bleeding. After resuscitation, an urgent upper scope was done, showing an actively bleeding spurter at the lower end of the oesophagus, which was clipped. Bleeding stopped and the patient was admitted for blood transfusion.
“Then insurance company requested for patient to be scoped as daycare despite all the data above being submitted to them…wtf…they are really one of the most annoying and frustrating things Drs have to deal with having to justify admission etc.,” he wrote.
“They really try every trick in the bag to reject the claim or request for patient to be treated as daycare.”
Besides instructing the priority of LA over GA for procedures and surgeries, MediExpress’ October 1 memo to panel health care providers directed “appropriate justification” for GL approval if the TPA deemed the procedure to be more suitable as a daycare service rather than inpatient treatment.
