Aetna to End Payment for a Drug in Colonoscopies

By BARNABY J. FEDER
NY TIMES
www.nytimes.com

Aetna, one of the nation’s largest private health plan managers, is the latest insurer to clamp down on the use of a powerful anesthetic during an increasingly common form of colon cancer screening.

The company will send a letter to doctors on Friday, saying that it plans to classify the drug 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 six 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, propofol, only in high-risk cases.

Critics say Aetna’s decision would be 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 federal Centers for Disease Control.

The anesthetic eliminates the discomfort of undergoing a colonoscopy, a procedure in which doctors explore the lower intestine to identify — and if necessary remove — developing tumors before they become dangerous.

But many specialists say there is scant evidence that the anesthetic 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 anesthetic, 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 A. 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 be screened, the proper use of this anesthetic 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 K. 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. That is especially true in areas like New York City, where many colonoscopies are performed in doctor’s offices. But using an anesthesiologist can add $300 to $1,000 to the cost of a colonoscopy, according to insurers.

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.

Dr. Brennan said that 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 H. Finley, United Healthcare’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 that 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 using 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 exams less of the intestine). But those tests are less effective and do not allow doctors to deal immediately 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 B. Cohen, a gastroenterologist in New York. Many doctors favor propofol because it can make procedures move more quickly and because patients are usually more relaxed, which can 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, like Versed, and a tranquilizer, like Valium.

Dr. Cohen has tried to find a middle ground with a procedure that uses small doses of propofol that he and his staff administer along with the other drugs. “It adds an extra 60 seconds to the front end of the procedure, but we’ve been doing it in our group of three gastroenterologists for six years with no complications,� he said. Data for results with 16,000 endoscopic patients, most of them colonoscopies, will be presented at a scientific meeting in May.

Such results are not surprising. While propofol has been linked to patient deaths in unrelated procedures, Dr. Rex said estimates that it has been administered “off label� by gastroenterologists and trained nurses in more than 450,000 colonoscopy screenings without a single major adverse outcome being reported.

Despite that record, many hospitals and clinics have rules forbidding the off-label use. The number of states restricting nurses from administering the anesthetic has grown to 22 from 12, said Deborah A. Krohn, a lawyer and part-time endoscopy nurse in Towson, Md., who has advised nurses and hospital risk managers about potential liability.

Specialists see no end to the two-pronged battle over whether to use propofol routinely in colonoscopies and, if so, who should administer it.

“There are so many layers of controversy and unsettled science in this it isn’t surprising we’ve struggled for so many years, and are likely to for many more,� said Dr. Alexander A. Hannenberg, an anesthesiologist in Newton, Mass., who is in line to become president of the American Society of Anesthesiology in two years.
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