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For MAC with colonoscopy, should payers dictate medical policy?
In April, Aetna will join several other payers, including WellPoint and Humana, that say it isn't medically necessary to have an anesthesia professional present for average-risk individuals undergoing standard upper or lower gastrointestinal (GI) endoscopic procedures.
Under Aetna's new policy, monitored anesthesia care (MAC) will be covered only under certain circumstances. (See box.)
"There is no generally accepted evidence demonstrating that average-risk patients require MAC for routine GI endoscopy," according to Aetna.
Others, such as United Healthcare (UHC), say that "if the particular and unique patient circumstances call for MAC during colonoscopy, that MAC is covered by UHC, and the anesthesiologists providing the MAC are contracted with UHC." Medicare coverage varies by state according to its carriers and fiscal intermediaries, but coverage often is 100%, according to sources interviewed by Same-Day Surgery.
Association sources and others interviewed by SDS expressed concern that payers are dictating policy regarding anesthesia services for colonoscopy.
It's an issue of safety, some maintain. About 1% of all malpractice claims in the United States involve gastroenterology, and about 40% of these involve procedure-related mishaps.1 Sedation-related complications probably account for 40%-50% of procedure-related serious adverse events.2-3
"Doesn't it make sense to have a second provider supplying that sedation?" says Meena S. Desai, MD, president and CEO of Nova Anesthesia Professionals in Villa Nova, PA.
Additionally, preliminary research indicates that when an anesthesiologist provides anesthesia during colonoscopy, there is improved colon polyp detection.4
When payers do reimburse MAC for colonoscopy, providers typically administer propofol. The American Gastroenterological Association (AGA) said in a recent statement, "We recognize that the use of propofol in endoscopy is a complex topic, from a medical and scientific standpoint," For example, the association noted that issues regarding medical necessity of MAC and reimbursement are "irreversibly intertwined." Evidence has not consistently demonstrated the advantages of propofol in average-risk patients having standard upper and lower endoscopy, the association said. "Ultimately, a qualified health care practitioner should be the decision maker regarding the use and administration of sedation agents in conjunction with the patient," it said. "If an individual provider lacks appropriate competency in the administration of sedation, then it should not pose a barrier to the patient receiving quality care in a safe environment, and practitioners should be able to employ and be reimbursed for the use of an anesthesia professional."
It isn't appropriate to restrict privileging, credentialing, or payment for sedation services when the physicians are trained to provide such service, but they think an anesthesia professional is medically necessary, the association said.
Patient satisfaction said higher with MAC
Critics of the payers' policy on no reimbursement say that providers achieve better results and have higher patient satisfaction when MAC is offered.
While colonoscopies can be performed with just sedation, most patients want to be asleep while having their colonoscopies, says Beverly Philip, MD, professor of anaesthesia at Harvard Medical School and medical director of the Day Surgery Unit at Brigham and Women's Hospital in Boston. "Patients are aware that anesthesia with propofol is pleasant and safe when given by anesthesia professionals," Philip says. "Relief of physical or emotional discomfort may be unnecessary to some insurance companies, but may be necessary in the eyes of patients."
Nova Anesthesia Professionals has started providing anesthesia services to a GI practice that previously was providing its own conscious sedation, Desai says. Patient surveys indicate that 100% of patients would have the procedure done again with an anesthesiologist, she says.
Hector Vila, MD, anesthesiologist at M. Lee Moffitt Cancer Center in Tampa, FL, agrees that many patients want to be unconscious. "That type of anesthesia is best delivered by an anesthesiologist or anesthesia professional, as it involves deep levels of anesthesia and loss of normal protective airway reflective reflexes," he says. When MAC is not reimbursed, conscious sedation typically is provided instead. "Patients say, 'If I have to be conscious, I'm not having the procedure,'" Vila says.
That statement leads to a second concern of critics: With no reimbursement for MAC, many patients will opt not to have the screening. "I have great concerns that it's going to become a barrier for those seeking this really important screening test," he says.
Conscious sedation, by definition, means you react appropriately to pain, Desai says. "If you said that to patient, who would come in for colonoscopy if you were going to react appropriate to pain?" she asks.
While 90% of patients may be happy with conscious sedation, that means 10% are unhappy and may forego the test without anesthesia, Vila points out. "If someone just wants to save money, it shouldn't prevent something that has high patient demand for such an important test," he says. Colorectal cancer is the third-leading cause of death by cancer in the United States, sources point out.
Limiting patient access?
Leaders of the associations also are concerned. "Given the current uptake of colorectal cancer screening, we are concerned about payer initiatives that may limit patient access to and acceptance of such services," the AGA said in its statement.
While few other options are available, one recent study looked at fospropofol disodium, the prodrug of propofol, which is being evaluated for sedation in colonoscopy.5 The study concluded that a fospropofol disodium 6.5 mg/kg dosing regimen was safe and well tolerated. Lawrence B. Cohen, MD, associate clinical professor at The Mount Sinai School of Medicine in New York City, who gave the presentation, said, "As far as fospropofol is concerned, I believe that it will provide GI doctors with a sedation drug that offers many of the benefits of propofol — rapid onset, quick recovery, amnesia — but without the warning that the propofol label carries." Propofol currently carries a warning label limiting the use of propofol to clinicians trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure.
What will payers do next?
Critics also raise concerns that Aetna and other payers are setting a precedent of dictating medical policy.
In a letter posted on the web by Jeffrey L. Apfelbaum, MD, president of the American Society of Anesthesiologists (ASA), to chief medical office at Aetna, he said, "The ASA has grave concerns about the interference with patient-physician and physician-physician relationships as well as the threat to patient safety resulting from this Aetna policy." (Editor's note: To access a link to the letter and the Aetna policy, go to www.asahq.org.)
Aetna is imposing "a very simplistic view of the detailed judgments made by a physician caring for an endoscopy patient," said Apfelbaum, who says there are often subtle considerations. He also said the growing volume of anesthesia services for GI endoscopy is coming at the requests of gastroenterologists and their patients. He raised concerns that Aetna's policy will lead to some providers providing "depths of sedation for which they are unqualified and thereby compromise the safety of patients undergoing endoscopy." Apfelbaum added that it is equally disturbing that Aetna's position puts anesthesiologists "in the position of second-guessing or disputing the medical judgment of gastroenterologists and even questioning requests from our physician colleagues for assistance in the care of patients who they believe would benefit from our presence." He pointed out that cardiologists and radiologists don't refuse to consult when requested. "Clearly, these strategies are not used, but the Guideline addressing anesthesia services for endoscopy takes precisely this approach by putting the payment for the anesthesia service in jeopardy when the request for this service is taken in good faith," Apfelbaum said.
It's a bad precedent, Desai says. "For colonoscopies, it's a step backward for colon cancer screening," she says.
Those types of payer guidelines take patient care decisions out of the hands of physicians, Desai says. If a poor patient outcome occurs due to a payer's policy, is the insurance company setting itself up to practice medicine, and if so, is it assuming liability, she asks.
Desai expresses concerns about where payers will go next in terms of dictating medical practice. "Insurers begin with insidious little insertions, and then progress to much larger things," she says. "Will they start denying breast biopsies? Why would we need them?" she says. "What about removal of skin lesions, or cataracts, or any other thing that can be done with sedation?"