Preventing Colorectal Cancer, a not-for-profit organization, advocates for colonoscopies as the Gold Standard colorectal cancer screening method. This issue brief is one in a series of
publications arming consumers, providers and others with information about patient colorectal health screenings. In particular, it will provide guidance on how to best select the facility where a colonoscopy procedure may take place. This issue brief explores a number of factors including quality, cost and health status, along with other variables.
With the dramatic rise of health care costs in recent years, it has never been more important for patients to be their own
advocate when making important, and often expensive, health care decisions. Though health insurance
helps cover the brunt of some of the most expensive procedures, patients are still feeling the effects of high costs in their out-of-pocket expenses. Today’s consumers are educated and informed when they make big purchases such as a new car, and health care spending should be no different. As a consumer of medical services, patients should be prepared to research and compare options in order to receive optimal care and keep health care expenses down.
Colonoscopy Settings Defined
Colorectal cancer, the second most deadly cancer in the United States, is also one of the most treatable cancers if caught early. The best way to catch colorectal cancer—the Gold Standard method—is by having a colorectal cancer screening colonoscopy with propofol. The recommended screening age for most Americans is 50, unless they have a genetic predisposition or familial connection to colorectal cancer.1
When the time comes to schedule a colonoscopy, doctors will suggest some options for patients to consider in terms of where and how the colonoscopy is administered.
Office-Based Surgery (OBS)
Ambulatory Surgery Centers (ASC)
Hospital Outpatient Departments (HOPD)
OBS: Office-based surgery is performed in a stand- alone office by a licensed physician and requires some level of anesthesia. OBS locations are often Medicare- approved sites.
ASC: Ambulatory surgical centers are health care facilities focused on providing same-day selected surgical care and procedural services outside of the hospital.
HOPD: Hospital outpatient departments can be defined as any type of medical or surgical care performed at a hospital that a doctor does not expect will turn into an overnight stay.
Factors to Consider
While many factors should be considered when deciding where to go for a screening colonoscopy, this issue brief highlights several of the most important characteristics to consider in order to select the best location. To help facilitate the right choice, a printable checklist is included at the end of this issue brief to track, compare and rank facility options.
In a nutshell, factors to consider include:
Regulatory and quality oversight
Online quality check
Patient’s health status
Provider’s credentials and experience
Convenience is one of the most important factors that influence the location and facility type where a patient typically goes to have their colonoscopy. Factors such as office hours, scheduling the appointment, transportation options, travel distance and waiting times all influence a patient’s decision. Patients who require nearby parking and handicap accessibility often value these features as well.
Most convenience factors can vary greatly depending on where an individual lives and what location they select for their medical procedure. As a result, it is difficult to make a broad comparison
between OBS, ASC and HOPD sites. However, OBS and ASC locations are generally free-standing and in the suburbs, which gives patients better access. In fact, many clients of OBSs and ASCs have noted an ease in scheduling and shorter wait times. However, a local hospital may end up being the closest and easiest place to schedule an appointment.
Understanding how much a patient can expect to pay for their colonoscopy screening is critical to managing health care expenses.2 Though in most cases the cost of a colonoscopy procedure will be covered by an insurance company, the patient should be aware of many details to minimize their out-of-pocket expenses.
With the passage of the Affordable Care Act, colonoscopy screenings are now required to be covered as a preventative service.3 However, in order to ensure that insurance covers as much of the colonoscopy costs as possible, the patient, family member or advocate should be well educated about the specific facility where the screening will take place and how much insurance will pay.
For example, before scheduling an appointment, the patient should make sure that the location selected is listed as an in-network provider by their insurance plan. A colonoscopy performed at an out- of-network facility may only be partially covered by insurance, if at all, leading to far greater out-of-pocket expenses. In-network provider directories are available from health plans, so patients should contact their insurance plans or visit their websites to confirm thatthe colonoscopy will be scheduled at an in-network location.
In addition to verifying that the colonoscopy location is in-network, patients should also gather information regarding ancillary charges that may
be added to the colonoscopy procedure. For instance, some locations may charge additional fees for facility use, preparation, gastroenterologists, anesthesia and consultation, which may or may not be covered by insurance. If the patient’s colonoscopy involves anesthesia such as propofol, some locations will charge additional fees to cover the anesthesiologist or nurse anesthetist who will be monitoring the procedure. Preparatory kits that are given to the patient in the days before the procedure may also incur additional charges.
In general, facility fees and ancillary charges tend to be highest in HOPDs, as they are the largest structures with the greatest additional resources available within the facility. Though the additional facility fees may sound like a drawback, it is important to note that HOPDs have the greatest access to additional emergency equipment, services and personnel in the event something goes wrong.
Regulatory & Quality Oversight
Any type of medical facility is subject to oversight from state, federal and private agencies to ensure they follow quality guidelines, and colonoscopy locations are no different. The kind of regulatory requirements a facility is subject to will vary based on the facility type, type of patients that go to the particular facility for treatments and the jurisdiction where it operates. Therefore, it is important to have a basic understanding of what these requirements are in order to make sure that the facility is a quality-based organization.
The Centers for Medicare and Medicaid Services (CMS) sets standards for any location that seeks reimbursement for procedures performed on Medicare or Medicaid patients. In addition, several other entities set rigorous standards that facilities must meet in order to be awarded accreditation. As a patient, it is important to look for an accreditation seal from an organization such as The Joint Commission (TJC), Accreditation Association for Ambulatory Health Care
(AAAHC) or American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) in order to make sure the facility has been evaluated for quality and safety.
Since regulations can vary from state to state, selecting a facility that is officially accredited by a nationally-recognized agency is an important first step. Patients can feel confident that an accredited facility will meet most industry, quality and safety standards.
Taking Extra Precautions with Office-Based Surgery Settings
State requirements for OBS locations are perhaps the most variable across different regions of the country, making accreditation critical. According to the American Medical Association (AMA), “Guidelines or regulations for office-based surgery should be developed by states according to levels of anesthesia defined by the American Society of Anesthesiologists (ASA) excluding local
anesthesia or minimal sedation. Physicians who perform office-based surgery with moderate sedation/analgesia, deep sedation/analgesia or general anesthesia should have their facilities accredited.”4
Online Quality Check
One of the biggest drivers that will steer a patient to get a colonoscopy at a particular location is a referral from their doctor. However, with the enormous amount of real-time information available over the internet today, tools are available to help consumers evaluate the quality of the facility before setting foot inside.
After a patient receives a recommendation on where to go from their doctor, family or friends it is a good idea to do a web search for the facility and collect more information. In addition to learning about convenience factors such as accessibility, operating hours and appointment scheduling, many facilities will publicly list any current accreditations they hold to demonstrate their level of quality.
Searches on websites such as healthgrades.com offer real reviews from past patients who provide an honest look at the facility, its doctors and their services. The Office of Inspector General (OIG) also offers a searchable list of health providers who have been excluded from participation in Medicare,
Medicaid and all other federal health care programs for various reasons.5 It is always a good idea to verify that the facility is not included in this list.
Patient’s Health Status
Where the procedure is performed can also depend largely on the health of the patient. Generally speaking, if a patient is in good health, the colonoscopy can be performed in any type of location.
However, if the patient is higher-risk, chronically ill, has advanced age or another comorbid condition that might increase the risk of a procedure, then the physician may recommend the procedure take place in a hospital setting like an HOPD. Hospitals and hospital-like settings boast the ease of access to additional services in an emergency, a feature that is particularly important for older Americans. The availability of other in-network services, such as instant on-site access to emergency equipment, personnel and services, is an important consideration for higher-risk patients.
Though colonoscopies are generally low-risk procedures and all facility types are required to have a plan and training for patient emergencies, if a patient or their doctor believe access to additional ancillary services should be a priority, then an HOPD setting might be the best choice. But remember, this often comes with a higher cost.
Provider’s Credentials & Experience
Provider systems and health plans granting physicians “staff privileges” or “in-network” status must credential their participating providers to check on their malpractice history, education background, medical license, specialty board certifications, insurance coverage and other background information to ensure they are well-qualified to provide colonoscopy screenings and/or other medical services.
In all cases, physicians must maintain a current medical license and have sufficient continuing education credits to maintain any certifications applicable to their specialty. In addition, at least one credentialed physician (or a physician who successfully completed a course in advanced resuscitative techniques) must be present in the office or must be immediately available until the patient is discharged from the facility. Generally speaking, other medical personnel should be, at a minimum, trained in basic life support techniques.
In OBS settings, the AMA notes that physicians must have admitting privileges at a nearby hospital or a transfer agreement with another physician who has admission privileges. If neither is available, then the physician must maintain an emergency transfer agreement with a nearby hospital to allow for prompt transition of a patient in case of an emergency.
A colonoscopy with propofol is the Gold Standard of screening for colorectal cancer. Whenever anesthesia is used for a procedure, an anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) must be present to monitor the patient.
In addition to being properly licensed and certified, two other important factors in choosing the physician who will perform a colonoscopy are the personal experience the doctor has with the procedure and the volume of colonoscopy procedures that are performed at the facility. Higher volume of colonoscopies at a particular location indicates greater experience, familiarity and efficiency with the procedure.
While the volume of procedures performed will depend on the particular facilities under consideration, ASC facilities are typically known for focusing on a select number of procedures at a high volume, which allows doctors to perfect their craft and deliver high quality results to patients.
All patients undergoing a colorectal cancer screening should feel they are being provided with safe, comfortable and clinically superior colonoscopy. In order to ensure that a patient receives nothing less than the highest standard of care, make sure to select a provider that offers anesthesia with propofol for colonoscopies.
The Benefit of Propofol during a Screening Colonoscopy
As the Preventing Colorectal Cancer (PCC) nonprofit board has been advocating for years, a screening colonoscopy with anesthesia through propofol is the Gold Standard procedure for the prevention of colorectal cancer. The administration of propofol during a colonoscopy screening has been linked to increased rates of polyp detection during the exams because of decreased patient motion, as well as higher patient satisfaction rates because anesthetized patients experience less discomfort during the procedure. Propofol anesthesia can be offered in the full range
of facility types, including OBSs, ASCs and HOPDs, as long as the drug is administered by a qualified anesthesiologist or CRNA.6
For more information on Propofol, see PCC’s Issue Brief 2: The Benefit of Propofol at www.preventingcolorectalcancer.org
In the end, choosing where to have the colonoscopy performed is an important decision based on the factors discussed above, including the patient’s health status and cost.
Above all, the patient should look for a certified facility—one that will meet specific licensing or accreditation requirements. That way, patients can ensure that the physician performing the procedure is knowledgeable and reliable, and the facility has access to appropriate emergency resources should a difficult situation arise. There are many options for colonoscopy facility types, each with many different factors to consider, so patients should select a location based on the criteria that is right for them given their particular circumstances. We hope the checklist below can help the patient make the right decision on terms of location where a colonoscopy takes place.
As always, regular screening colonoscopies are the best way to catch pre-cancerous polyps early and prevent colorectal cancer. Colorectal cancer screening with colonoscopy, the Gold Standard, is an exceptionally effective tool in the fight against this dreadful disease. Thankfully, the future holds many bright possibilities for the progress towards the cure for colorectal cancer.
To help facilitate the decision making process, click here for a printable checklist to track, compare and rank facility options.
About Preventing Colorectal Cancer:
Headquartered in Annapolis, MD, PCC is a not-for-profit 501(c) 6 advocacy organization with the primary mission to educate both public and private stakeholders about the opportunities to reduce the incidence of colorectal cancer through promoting effective screening, prevention and care options for patients. Membership is open to all individuals and groups. For more information, see www.preventingcolorectalcancer.org.
326 First Street, Suite 29
Annapolis, MD 21403
2 Preventing Colorectal Cancer. Issue Brief #4: Why We Need Pricing Transparency. link
3 Preventing Colorectal Cancer. Issue Brief 5: The Impact of Health Insurance Reform on Colorectal Cancer and Issue Brief 7: Take Advantage of the Patient Protection and Affordable Care Act Preventive Care Clause to learn more about how colonoscopies are covered by insurance under the Affordable Care Act. See www.preventingcolorectalcancer.org for links to the issue briefs.
4 H-475.984 Office-Based Surgery Regulation. (2013). Retrieved May 6, 2015 link
5 Office of Inspector General. US Department of Health and Human Services. Exclusions Search. link
6 Preventing Colorectal Cancer. Issue Brief #2: The Benefit of Propofol. link