February 28, 2008

One month ago, it seemed certain that Aetna was going to implement its new “medical necessity” policy limiting the circumstances under which it would pay for anesthesia for screening upper and lower gastrointestinal endoscopies. Aetna had sent out individual “Dear Physician” letters advising you all of the new restrictions that it planned to introduce effective April 1, 2008.

We are extremely pleased, on behalf of our clients, their patients and the community, with Aetna’s latest announcement stating that it will continue to pay for anesthesia services provided for gastrointestinal endoscopies. The reason for this reversal is the likelihood that some patients, fearing inadequate sedation, will skip the routine screening colonoscopies whose importance in detecting cancers is well established. As stated by Troyen L. Brennan, MD, Aetna’s chief medical officer, in a press release issued on February 27 (http://www.aetna.com/news/2008/0227.htm):

“We have determined that in those few markets where monitored anesthesia care (MAC) has become the routine approach to sedation, implementation of our policy on April 1 would inconvenience our members in those markets and potentially depress cancer screening rates in the short term.”

The American Society of Anesthesiologists, the American Gastroenterological Association, and in particular the anesthesiologists and practice administrators in the mid-Atlantic states who worked tirelessly to keep this important public health service available are to be congratulated. Fairness requires us to commend Dr. Brennan and Aetna, too, for listening to the ASA, the AGA, the New York and New Jersey Societies of Anesthesiologists, the Tri-State Anesthesia Administrators Group and the individual proponents of providing anesthesia to all patients to whose care it makes a difference. Corporations do not often change their positions so quickly, not even when presented with persuasive evidence.

We must also note, however, that Aetna is not committing to cover routine endoscopies in perpetuity. Dr. Brennan further stated:

“Aetna hopes that the delay in implementing this policy will allow adequate time for the arrival on the market of attractive, patient-friendly alternatives to anesthesiologist-monitored sedation services. New medical devices, as well as new sedatives, are expected on the market during the late summer, and are in review with the FDA now. They are designed to provide a patient experience that is very similar, or perhaps better, than MAC, but can be managed exclusively by the GI performing the screening procedure. Both would eliminate the significant expense of having a second physician attending during a routine screening service for a healthy patient.”

The physicians receiving this note will have greater knowledge of the “new medical devices” and sedatives to which Dr. Brennan refers than our other readers. For the benefit of the latter, and with a request that our medical experts continue to equip us with the information we will need to do our job for you, we refer you to the following link on the Mayo Clinic’s public website: Colon polyps: Screening and diagnosis - MayoClinic.com. The web page summarizes some of the new technologies thus: 

• Pill camera. Colonoscopy is effective at detecting polyps in the colon, but the colonoscope can't reach the small intestine. Until recently, a barium X-ray was the only way to screen the small intestine, but the test is often inaccurate. Now doctors have found that a tiny camera fitted inside a capsule that you swallow can identify polyps in the small intestine with a high degree of accuracy. But because small intestine polyps are rare, the test isn't routinely performed. 
  
• New technologies. New technologies such as virtual colonoscopy (CT colonography) may make colon screening safer, more comfortable and less invasive. In virtual colonoscopy, you have a two-minute computerized tomography scan, a highly sensitive X-ray of your colon. Then, using computer imaging, your doctor rotates this X-ray in order to view every part of your colon and rectum without actually going inside your body. Before the scan, your large intestine is cleared of any stool, but researchers are looking into whether the scan can be done successfully without the usual bowel preparation. Although virtual colonoscopy potentially is a tremendous step forward, it may not be as accurate as regular colonoscopy, it is highly dependent on the skill of the doctor reading the test, and it doesn't allow your doctor to remove polyps or take tissue samples during the procedure.
• Another new test checks a stool sample for DNA from abnormal cells. In preliminary studies, the test proved highly accurate, but results in the first large trial of the test were disappointing. In that trial, the DNA test found more colon and rectal cancers than did the fecal occult blood test, but fewer than did colonoscopy.

We hope that we have provided our readers with some helpful information above. As always, we look forward to receiving your comments and further questions.