Aetna to stop paying for anesthesiologists during colonoscopies

At a January meeting between Aetna representatives and one of Atlanta's largest gastroenterology groups, about 50 doctors handed over letters of resignation, threatening to pull out of the insurers' network.

They were protesting a change in Aetna's policy regarding anesthetizing patients undergoing colonoscopies, said Steven J. Morris, MD, managing partner of Atlanta Gastroenterology Associates.

As of April 1, Aetna is ending coverage of anesthesiologist-supervised sedation in endoscopy procedures.

Physicians, including Dr. Morris, are appealing to Aetna to rethink their decision. Opponents say the move will discourage people afraid of the procedures from being screened for colon cancer. And for some, the very idea of Aetna declaring anything medically unnecessary is an affront.

"We have an insurance company telling us to change the standard of care," Dr. Morris said. "This is a ridiculous situation."

Aetna is not alone in changing policy. Humana made a similar change last year. WellPoint did the same in June 2006, though spokesman Jim Gavin said, "Our clinical guidelines can be implemented across the country at the option of our health plans," so the rule isn't enforced everywhere.

For decades, physicians have used a combination of a narcotic and a benzodiazepine, which can put a patient in a conscious sedation. Doctors differ in their opinions of that method.

"These drugs have inconsistent and unpredictable effects," said Steven J. Stryker, MD, a surgical oncologist and professor of clinical surgery at the Northwestern University Feinberg School of Medicine in Chicago.

John J. Vargo II, MD, a gastroenterologist with the Cleveland Clinic disagreed with that assessment but said patients do have an easier recovery with a drug called propofol.

Propofol, a faster-acting drug that can induce a heavier sedation, is labeled by the Food and Drug Administration for use under the supervision of an anesthesiologist, and many practices follow that label.

Aetna's decision, Dr. Morris said, would mean no payment for what he considers the new standard of care. "With propofol, I can promise a pain-free procedure," he said.

Anesthesiologists also are asking Aetna to reconsider. In a Jan. 11 letter to the firm, American Society of Anesthesiologists President Jeffrey Apfelbaum, MD, wrote: "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. The consequences of this Aetna policy decision will rest with Aetna."

In defending the policy, James Cross, MD, Aetna's national head of medical policy and program administration, noted that three gastroenterologists' specialty groups in 2004 issued a joint statement saying that "there are data to support the use of propofol by adequately trained nonanesthesiologists."

The American Gastroenterological Assn. issued a statement Jan. 17 clarifying its position. The group didn't back away from its contention that nonanesthesiologists can administer propofol safely, but its members believe a physician should decide when a specialist in anesthesia is needed.

"It is not appropriate to attempt to restrict privileging, credentialing and/or payment for the provision of sedation services, when the practitioner possesses the appropriate training to provide such services, but deems the use of an anesthesia professional as medically necessary," the statement read.

Dr. Stryker said insurers should focus more on increasing its members' use of screenings such as colonoscopies. "Limiting the anesthetic choices will clearly deter some individuals from undergoing colonoscopy who might otherwise choose this if they can be assured a pain-free procedure with no recollection," he wrote in an e-mail to AMNews.

Dr. Cross said Aetna does encourage preventive screening and believes it can better spend its money expanding the number of colonoscopies performed than pay for unnecessary anesthesiology services where they aren't needed.

Despite some opposition to Aetna's decision, spokeswoman Susan Millerick said the company still is moving ahead with the April 1 planned effective date.