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| Updated Sep. 1, 2010 |
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Aetna Drops Coverage of MAC for Colonoscopy Gabriel Miller | ||||||
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If at first you don’t succeed, try, try again. Thus, for a third time, insurance giant Aetna has taken measures to remove anesthesiologists from colonoscopy suites, this time by telling physicians that they will no longer cover monitored anesthesia care (MAC) during colonoscopy for patients without sedation-related risk factors. In a letter sent to physicians on Dec. 28, the insurer maintained that “there is no generally accepted evidence demonstrating that average-risk patients require MAC for routine GI endoscopy.” The change will be effective April 1. Although the move follows similar policy decisions by WellPoint last year and by Humana about six months ago, it remains controversial. In some areas of the country, propofol under MAC is seen as the standard of care for the procedure, said some gastroenterologists. “Most of us feel that we are much more comfortable and the patient is more comfortable [with propofol and MAC], and we’ve gotten used to the patients’ safety and comfort with an anesthesiologist present,” said Jerome H. Siegel, MD, co-director of the Advanced Fellowship in Therapeutic Endoscopy at Beth Israel Medical Center and clinical professor of medicine at Albert Einstein College of Medicine, both in New York City. “It’s ridiculous [to end coverage of MAC], because patients are so much better off.” Although there are long-standing and unresolved questions about how propofol should be delivered and who is capable of administering the quick-acting sedative, anesthesiologists and gastroenterologists generally agree that Aetna’s decision may be seen as using a blunt instrument for a complex problem. For example, a handful of the many issues related to the topic include the high cost of anesthesiologists relative to the overall costs of the procedure; the differences between office-based and hospital-based practices; the effects of conscious sedation with midazolam and pethidine on patients versus faster-acting propofol; and, perhaps most fundamentally, the difficulty of studying firm end points in anesthesiology. Marc Koch, MD, MBA, the president of a private anesthesia services company in New Rochelle, N.Y., and the founder of Anesthetists for the Safe Administration of Propofol, an advocacy group that does not receive drug industry funding, said that he has met with nearly all of the major insurance payers on this issue, and while he agrees that insurance companies have a right to reduce the anesthesiology line-item costs associated with colonoscopy, payers have refused to address many of these issues. “It was my takeaway that a lot of what [insurance companies] were grappling with were out-of-network, fairly exorbitant payouts to anesthesiologists,” Dr. Koch said. “Rather than approaching this with a way to contain these costs, they instead took a very broad and dirty way of doing this.” The three gastroenterologists who were interviewed for this article said that they used anesthesiologists during colonoscopies with propofol because of safety concerns; they all agreed that anesthesiologists allowed them to focus more on their jobs and that anesthesiologists provided a significant benefit for their patients. But gastroenterologists also cited the expense of MAC. They said that charges may run as high as $600 to $800 for anesthesia services, and one gastroenterologist recalled a case when an anesthesiologist charged $1,500 for a higher-risk patient on heparin, even though the gastroenterologist was the physician largely at risk for complications. Yet these gastroenterologists continue to use anesthesiologists because they are the most qualified clinicians to manage an airway in the event that a margin is overshot, particularly in an office-based setting where the nearest hospital may be miles away. “You have a lot of back-up in the hospital,” said Howard Siegel, MD, a private-practice gastroenterologist who also works at Beth Israel Medical Center. “In a hospital you can be full of bravado; in the office, it’s just us.” He added that, considering the safety risks of deep sedation, “It’s interesting that they allow us to give propofol in the office, but at Beth Israel [Medical Center], when I do endoscopies, the head of anesthesia won’t allow it.” The question of gastroenterologists giving propofol is complicated and ongoing, but some anesthesiologists contend that Aetna’s move—on heels of other insurers—presages other cutbacks as the number of office-based procedures increases. “Today’s colonoscopy could be tomorrow’s arthroscopy or breast biopsy,” said Dr. Koch, adding that currently nearly 20% of all surgeries occur in offices. “It will not end with colonoscopy, it is not unique by itself. If you are thinking, ‘This doesn’t involve me,’ when they curtail benefits next year for doing a breast biopsy, it will affect you. All of what we’re talking about here can be viewed within the greater context.” |
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