The American Gastroenterological Association (AGA) has asked Aetna to defer implementation of a policy that would deny coverage for an attending anesthesiologist during upper or lower endoscopic procedures, including colonoscopies, for average-risk patients.
The AGA said that the policy restricts physician choice and may have an impact on colorectal cancer screening rates.
“AGA members worry that our efforts to increase colorectal cancer screening will be undercut by payers that decrease physicians' control of screening methods, sedation agents, and the presence of medical team members—in this case, anesthesiologists,” said the organization in a letter to Aetna's chief medical officer, Dr. Troyen A. Brennan.
Aetna's policy, which was announced in late 2007, is due to go into effect on April 1.
The insurer has had some discussions with the AGA and with representatives from the American Medical Association, but is “still on target to implement this policy on April 1,” said Aetna spokeswoman Susan Millerick in an interview.
“We continue to meet with medical societies and advocacy groups to explain our position, hear their views, and answer their questions,” said Dr. Brennan in a statement. “We remain open to dialogue on this policy, and additional ways to more closely align care to the evidence base and improve care quality for all of our members,” he added.
The New Jersey Gastroenterology and Endoscopy Society, the New Jersey Society of Colon and Rectal Surgeons, and the New Jersey State Society of Anesthesiologists have also registered their displeasure with the policy, and have discussed suing to stop the implementation.
“We believe that a patient's physician, not his or her insurer, should determine the appropriate sedation agent, provider, and monitoring environment for an endoscopic procedure,” asserted Dr. Matthew Askin, NJGES president, in a statement.
The Aetna policy was outlined in letter to physicians and was also posted on Aetna's Web site. Essentially, monitored anesthesia care will be covered only when patients have “sedation-related risk factors.” Aetna said it would continue to cover conscious sedation.
In reviewing its claims, Aetna found that use of an anesthesiologist varied from a high of 70% of procedures in New York to as low as 6% in Maine. In Chicago, only about 12% of procedures are monitored by an anesthesiologist, said Dr. Robert McDonough, head of Aetna's clinical policy unit, in an interview. “It's hard to believe that there are more persons who have risk factors in New York than in Chicago,” he said.
Without evidence to support monitored sedation in every patient, Aetna saw the need to reduce the delivery of what it viewed as unnecessary services. “Our obligation to our plan sponsors and our members is to contain unnecessary services when we encounter that,” Dr. McDonough said.
He said that Aetna was not trying to interfere with a physician's medical judgment. “We do allow a broad range of discretion for the gastroenterologist.”
After implementation of the new policy, about 20%–30% of the procedures in the New York area would still use an anesthesiologist and be covered, he estimated.
Dr. McDonough also said that no research has shown that having an anesthesiologist in attendance—or not having one—has any impact on screening rates.
Aetna is following WellPoint, Humana, Oxford Health Plans, and HealthAmerica/Coventry, all of which have issued similar policies on monitored anesthesia care.
Although the AGA said it is concerned about these policies, it did note that they are “consistent with the Joint Working Group recommendations from the AGA, ASGE, and ACG.”
The AGA also stated on its Web site that the policies do not prohibit a gastroenterologist or other trained professional from administering deeper sedation with propofol. “Ultimately a qualified health care practitioner should be the decision maker regarding the use and administration of sedation agents in conjunction with the patient,” the AGA stated.