I suppose next they'll say we don't need
an anesthetic for a prostate biospy.

Insurers cut coverage of colon exam anesthetic
Aetna to classify drug as 'medically unnecessary'
Friday, December 28, 2007

Health insurers are clamping down on the number of patients who get a
powerful anesthetic during an increasingly common form of colon cancer
screening.

The anesthetic, propofol, eliminates the discomfort that discourages many
patients from getting colonoscopies, a procedure in which doctors examine
the lower intestine with a snakelike device that can identify and if
necessary remove developing tumors before they become dangerous.

Critics say the trend is a step backward in the battle against cancer of the
colon and rectum, which trails only lung and prostate cancer as a cause of
cancer death among Americans, according to the U.S. Centers for Disease
Control and Prevention.

Aetna, one of the nation's largest private health plan managers, is the
latest insurer to restrict coverage. The company will send a letter to
doctors today that says it plans to classify propofol as "medically
unnecessary" for most such procedures. As of April 1, Aetna plans to stop
paying for its use in those cases.

The change by Aetna covers about 16.6 million members and comes on the heels
of similar moves last year by WellPoint and 6 months ago by Humana. Other
insurers say they have no plans to follow their lead, including
UnitedHealthcare, which has 26 million members. Medicare leaves coverage up
to local insurers that administer its plans, most of which cover the
anesthetic only in high-risk cases.

Many specialists say there is scant evidence that propofol helps enough to
make it worth the cost. Aetna said its billing records showed that 77
percent of colonoscopy patients in the New York metropolitan area were
receiving the drug, compared with 10 percent or less in other regions. No
data has surfaced linking such regional practice differences to better
outcomes.

All three major medical associations for specialists who perform
colonoscopies have published guidance statements saying the anesthetic was
not needed for routine procedures.

"This is like a lot of hard-to-explain geographical variations in medical
practice in this country," said Aetna's chief medical officer, Dr. Troyen
Brennan.

A recent book looking at such patterns and at overuse of medical products
and procedures - "Overtreated" by Shannon Brownlee - concluded that they
inflate health care spending in the United States by at least 20 percent.

With millions of colonoscopies performed each year and specialists advising
all Americans over 50 to get screened, the use of propofol could become a
multibillion-dollar point of contention.

"It's perfectly appropriate to say this doesn't look like a good place to
spend health care dollars," said Dr. Douglas Rex, a colonoscopy specialist
at the University of Indiana.

Propofol was originally marketed as Diprivan. It is now relatively cheap
because its patent has expired and a generic version is available. But
propofol is tricky because it acts rapidly and no rescue drug is available
to counteract its effects if a patient begins to have trouble breathing.

The Food and Drug Administration has recommended that it be administered by
trained specialists who are not otherwise involved in the procedure.

As a result, most doctors want an anesthesiologist to assist them when
propofol is used. The use of an anesthesiologist can add $300 to $1,000 to
the cost of a colonoscopy, insurers say.

Aetna's policy is a slightly revised version of one it tried to introduce in
2006 but withdrew in the face of strong resistance.  It includes an expanded
list of exceptions where Aetna will pay for use of propofol and an
anesthesiologist, including patients over 65, pregnant women, and patients
with illnesses that make the use of other drugs more risky.

Brennan said Aetna believed the exceptions would cover 10 percent to 20
percent of colonoscopy screenings.

The data showing no advantage in typical screenings is "probably true," said
Dr. David Finley, UnitedHealthcare's senior medical director responsible for
quality and affordability programs in the Northeast. "But we ended up after
a lot of discussion last year deciding we didn't want to intervene in the
decision as to which patient gets the anesthetic," he said.

Many doctors say the freedom to choose the treatments used is an important
principle to preserve no matter what the cost to insurers because there is
little agreement on what really amounts to a medical necessity.

"The term 'medical necessity' leaves out psychological conditions," said Dr.
Ervin Moss, executive medical director of the New Jersey State Society of
Anesthesiologists, who said patient comfort can play a role in the success
of colonoscopies. A few doctors have reported that they found more polyps,
which can be precursors to cancerous tumors, after they began hiring
anesthesiologists to administer propofol.

Patients who fear the procedure often opt for less-invasive screening
techniques, including CT scanning (known as "virtual colonoscopies"),
testing of feces and sigmoidoscopy (which examines less of the intestine).
But those tests are not as effective and do not allow doctors to immediately
deal with any problems.

The propofol conflict is particularly challenging for gastroenterologists,
the specialists who perform colonoscopies and other endoscopic procedures
that involve snaking devices into the digestive system.

"There's no doubt patients prefer propofol," said Dr. Lawrence Cohen, a
gastroenterologist in New York. Many doctors are fans because propofol can
make procedures move more quickly and, because patients are usually stiller,
lead to a more thorough exam.

Using an anesthesiologist also shifts a potentially distracting task
normally handled by the doctor or a nurse at no extra cost - administering
drugs that keep the patient comfortable - to a third party.

In the traditional colonoscopy, patients are given a combination of a
narcotic, such as Versed, and a tranquilizer, such Valium.

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