General Anesthesia and “Deep Sedation” vs. “Moderate Sedation” for Screening Colonoscopies
As both colonoscopy rates and use of anesthesia during gastrointestinal endoscopies are projected to increase in the coming years, the overall cost of colonoscopy screening programs will be closely scrutinized by payers and policy makers.
Liu, Waxman, Main and Mattke made the quoted prediction in their article Utilization of Anesthesia Services During Outpatient Endoscopies and Colonoscopies and Associated Spending in 2003-2009 (JAMA. 2012;307(11):1178-1184). This study involved a retrospective analysis of claims data for a 5% representative sample of Medicare fee-for-service patients (1.1 million adults) and a sample of 5.5 million commercially insured patients during the six year period 2003-2009. The authors determined that overall, the proportion of anesthesia services delivered to low-risk (ASA physical status 1 or 2) patients was more than two-thirds in the Medicare population, and more than three-quarters among the commercially insured population. Over the six-year period, annual payments for anesthesia services among Medicare patients almost doubled in real terms, from $2.2 million in 2003 to $4.2 million per 1 million enrollees; annual payments per 1 million commercially insured patients increased more than 4-fold from $1.9 million to $8.4 million. Looked at another way, the proportion of gastroenterology procedures using anesthesia services doubled in both populations, from approximately 14% in 2003 to more than 30% in 2009. The anesthesia payment per procedure, however, remained stable in real terms for Medicare patients ($147.20 in 2003 and $150.20 in 2009) and increased by 13.6% for commercially insured patients ($447.10 in 2003 and $508.70 in 2009).
As stated in one of the article’s concluding comments,
Our data estimate that use of anesthesia services for low-risk patients during gastrointestinal endoscopies may have increased steadily to more than $1.1 billion per year at the national level. Because anesthesia use is projected to increase further, addressing such potentially discretionary use represents a sizeable target for cost savings.
Payer policies on anesthesia coverage (general and monitored anesthesia care, or “MAC”) are proliferating along with the number of cases. Blue Cross Blue Shield of Minnesota’s policy on Anesthesia Services for Gastrointestinal Endoscopic Procedures states categorically that “The routine assistance of an anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) for average risk adult patients undergoing standard upper and/or lower gastrointestinal endoscopic procedures is considered NOT MEDICALLY NECESSARY.”
Blue Cross Blue Shield of Alabama goes farther in its MAC policy, providing that “Medical Necessity means that health care services are . . . 3. Not primarily for the convenience of the patient, physician or other health care provider; and 4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.” For examples of similar policies and a discussion of the principles of medical necessity as applied to MAC for routine endoscopies, see our Alert Anesthesia for GI Endoscopy: An Ongoing Problem of Medical Necessity dated January 21, 2013.
While there is a growing consensus among carriers that healthy patients undergoing routine screening colonoscopies do not require anesthesia as a matter of medical necessity, personal preference may be a different story. Some studies have shown that the general public may do at least as well with conscious or moderate sedation. An “expert” patient population consisting of 451 gastroenterologists and 460 endoscopy nurses surveyed for a recent Research Letter (Agrawal D, Rockey DC. Propofol for Screening Colonoscopy in Low-Risk Patients: Are We Paying Too Much?. JAMA Intern Med. 2013 ; ():0. Dol:10.1002/jamainternmed.2013.8417) indicated a marked preference for propofol over moderate sedation with versed/fentanyl—but, asked how much they would be willing to pay out of pocket for propofol, most said less than $100. Only 30 of the clinicians would be willing to pay more than $300 for propofol.
Muddying the waters further is the premarket approval granted by the Food and Drug Administration (FDA) to Johnson and Johnson’s SEDASYS® Computer-Assisted Personalized Sedation (CAPS) technology earlier this year. The SEDASYS® System is designed to achieve and maintain minimal-to-moderate sedation through the automated administration of propofol for routine colonoscopy or esophagogastroduodenoscopy (EGD) in healthy patients.
The use of propofol, many readers will recall, was long thought to be synonymous with at least deep sedation if not general anesthesia. Will the introduction of the SEDASYS® System bring about revisions in American Society of Anesthesiologists’ policy and position statements such as the 2009 Statement on the Safe Use of Propofol (“Even if moderate sedation is intended, patients receiving propofol should receive care consistent with that required for deep sedation.”) and Distinguishing Monitored Anesthesia Care From Moderate Sedation/Analgesia (Conscious Sedation) (2009) (“The administration of sedatives, hypnotics, analgesics, as well as anesthetic drugs commonly used for the induction and maintenance of general anesthesia is often, but not always, a part of Monitored Anesthesia Care. In some patients who may require only minimal sedation, MAC is often indicated because even small doses of these medications could precipitate adverse physiologic responses that would necessitate acute clinical interventions and resuscitation.”)?
The FDA having addressed the majority of ASA’s concerns regarding the safety of the SEDASYS® System, ASA has recently updated its three-prong strategy on SEDASYS® to lead efforts to enhance the safety of the device. Its Ad Hoc Committee has now released it proposed Guidance for Directors of Anesthesia Services for the SEDASYS® System. “This guidance will provide recommendations on specific clinical and administrative issues that Directors of Anesthesia Services and practicing physician anesthesiologists should discuss with Gastroenterology Services in order to integrate the device into practice in the safest and most efficient fashion,” according to the ASA website.
We echo ASA in encouraging anesthesiologists to review the proposed Guidance and to send their comments to sedasys@asahq.org by the deadline of October 28, 2013. After it reviews the comments, ASA will finalize the guidance document.
It will be interesting to see whether the introduction of the SEDASYS® technology bends the curve of the cost of colonoscopy screening programs in the years to come.