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    Controversy Continues Over Insurers’ Coverage of Propofol for Colonoscopy

    By Jennifer Decker Arevalo, MA, contributor.   

    In a debate that has been raging for several years, another healthcare insurance company has decided to discontinue coverage for the use of propofol under monitored anesthesia care (MAC) for routine colonoscopies, citing high costs and moderate anesthetic alternatives that are just as effective.

    As of April 1, 2008, Aetna will join WellPoint and Humana in their denial of coverage; however, other insurance carriers, such as Cigna and UnitedHealthcare will continue to cover the popular, quick-acting sedative. Coverage by Blue Cross Blue Shield varies from state to state and Medicare coverage, which is determined by local insurers that administer its plans, is generally reserved for high-risk cases.

    The American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA) are asking Aetna to reconsider its new clinical policy for MAC for upper and lower gastrointestinal (GI) endoscopy for several reasons.

    In a January 11, 2008 letter to the insurance company, ASA president Jeffrey L. Apfelbaum, MD stated, “We are concerned that Aetna's new policy will induce some providers to provide depths of sedation for which they are unqualified and thereby compromise the safety of patients undergoing endoscopy.”

    Both the AANA and ASA issued a Joint Statement Regarding Propofol Administration in 2004 stating that “Whenever propofol is used for sedation/anesthesia, it should be administered only by persons trained in the administration of general anesthesia, who are not simultaneously involved in these surgical or diagnostic procedures. This restriction is concordant with specific language in the propofol package insert, and failure to follow these recommendations could put patients at increased risk of significant injury or death.”

    “The demonstrated high quality of care as delivered by a CRNA adds an additional layer of patient safety during GI endoscopy over that provided by an unassisted proceduralist in the unfortunate event that complications arise,” wrote AANA president, Wanda O. Wilson, CRNA, Ph.D. in a February 5, 2008 letter to Aetna.

    Although Aetna’s policy is based on a joint statement, issued in 2004 by three gastroenterology societies, recommending that “the routine assistance of an anesthesiologist/anesthetist for average risk patients undergoing standard upper and lower endoscopic procedures is not warranted,” the AANA and ASA disagree.

    “The new policy inappropriately reserves for Aetna medical necessity decision-making that rightfully belongs with patients and healthcare providers such as CRNAs and physicians,” wrote Wilson.

    Both organizations are also concerned that the decision to deny coverage will discourage people from undergoing screening procedures for colon cancer because of discomfort due to limited anesthetic choices, which is exactly why UnitedHealthcare chose to continue coverage of propofol under MAC.

    “Getting recommended routine screenings can save lives,” said Sam Ho, M.D., executive vice president and chief medical officer for UnitedHealthcare, in a February 6, 2008 company news release. “According to the Centers for Disease Control and Prevention, more than 60 percent of deaths from colorectal cancer could be prevented if individuals age 50 and older were screened regularly.”

    ”By covering propofol, an intravenous anesthetic that eases the discomfort associated with this procedure, and the anesthesiologist who administers the drug to ensure its safe usage, we are helping ensure that those members who require an anesthetic have access to this important colon-cancer screening procedure. Most people who undergo colonoscopies do not require an anesthetic; they have colonoscopies done with light sedation or, in some cases, no sedation at all.”

    This type of moderate or conscious sedation has traditionally been achieved using a combination of standard doses of narcotics and benzodiazepines and does not require the presence of an anesthesiologist or CRNA during GI procedures.

    However, propofol (originally manufactured by AstraZeneca with the trade name Diprivan) under MAC is considered the standard of care for GI procedures by most physicians across the country, as it provides their patients with faster onset and deeper sedation with less pain, fewer side effects and quicker recovery. Since propofol does have some risks, such as blood pressure drops, loss of airway reflexes and breathing problems, the FDA requires that it be used only under the supervision of an anesthesiologist or CRNA, which increases the overall cost of the procedure.

    Even though propofol is available as a relatively inexpensive generic, “having the drug monitored by a specialist can add $700 to $1,000 to the cost of a procedure,” said Troyen A. Brennan, M.D., MPH, senior vice-president and chief medical officer for Aetna, in a February 13, 2008 St. Petersburg Times article. “Anesthesiologists themselves have said if this usage grows, it could be in the $2- to $5-billion range in costs. Those are costs we can't afford."

    Many argue that the decision by some insurers to discontinue coverage of propofol sets a bad precedent indicating that costs are more important that patient care.

    Dale Wickstrom-Hill, DO, president of the Florida Society of Anesthesia, stated in a letter to the editor of the Wall Street Journal that “a patient's sedation should never be a monetary issue. It's about your right to choose the safest, most humane procedure. Just as gastroenterologists are specialists, and if they and insurance companies wish to minimize risk, they should encourage, not discourage, the use of the most advanced drugs delivered by the most qualified specialists.”

    The AANA feels that Aetna’s change in policy puts “patient safety and outcomes at risk. It erects new barriers between patients and the safest, most comfortable, most thorough and efficient method for delivering life-saving diagnostic GI endoscopy screenings.”

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