Blog | Friday, March 23, 2012

QD: News Every Day--Limiting anesthesia during endoscopy eyed as potential source of savings

General anesthesia for endoscopy in low-risk patients has risen considerably, and an estimated $1.1 billion spent on the practice presents a target for health care cost-savings, researchers concluded.

Researchers conducted a retrospective analysis of claims data for samples of 1.1 million Medicare fee-for-service patients and 5.5 million commercially insured patients who had upper or lower endoscopy between 2003 and 2009.

Results appeared in the March 21 issue of the Journal of the American Medical Association.

Overall, 26.6% of Medicare patients and 28.6% of commercially insured patients received anesthesia. These represent 2.2 million gastroenterology procedures performed on Medicare beneficiaries and 7 million gastroenterology procedures performed on commercially insured patients.

Anesthesia services delivered to low-risk patients (American Society of Anesthesiologists physical status level of 1 or 2) fell from 78.6% in 2003 to 64.1% in 2009 among Medicare patients, whereas it remained constant in the commercially insured patients, from 86.5% in 2003 to 83.9% in 200).

Annual payments for anesthesia services among Medicare patients almost doubled in real terms, from $2.2 million in 2003 to $4.2 million in 2009 per 1 million enrollees, the authors noted. Annual payments per 1 million commercially insured patients increased more than 4-fold from 2003 ($1.9 million) to 2009 ($8.4 million).

Meanwhile, per-procedure cost for anesthesia services 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). Wide regional variations indicated that some of this practice is discretionary, and randomized trials have shown no difference in results or satisfaction whether sedation is done by an anesthesiologist or a nurse under the endoscopist's supervision, the authors noted.

This increased use of anesthesia services is partly due to the benefits of propofol, which requires training in general anesthesia, as well as insurers' payment policies and marketing by the anesthesiology community.

"Use of anesthesia services for low-risk patients during gastrointestinal endoscopies may have increased steadily to more than $1.1 billion per year and presents a target for health care savings," the authors wrote.

And editorialist noted that deep sedation or general anesthesia potentially allow for more complete exams that can be done in a shorter amount of time, although no randomized trials prove this. And, patients might prefer it.

Furthermore, medical malpractice drives this, because using an anesthesiologist transfers liability, doesn't lower reimbursement and lets endoscopists treat more patients per day.

Options such as bundled fees may change medical practice but might have unintended consequences on patients adherence to screening guidelines, the editorialist noted.

"Careful implementation of new policies regarding 'potentially' discretionary services need to incorporate the patient and clinician perspective while continuing to implement change that bends the cost curve," the editorial said. "This may require all parties, including patients, clinicians, and facilities, to have a greater stake in the financial consequences of their action."