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Are Insurers Limiting Sedation Options?

Wednesday, August 28, 2013


An advocate of colonoscopy screening to prevent colorectal cancer, PCC not only supports efforts to increase the incidence of this Gold Standard in screening, but also vocalizes its concerns on issues that may threaten the quality and effectiveness of this life-saving procedure. While colorectal cancer is the second leading cause of cancer deaths in the United States, it is also one of the most preventable forms of the disease. Unfortunately, under new health insurance reforms, colorectal cancer screening colonoscopies are covered in full by insurers, but patients may denied anesthesia coverage for this procedure.

Troubled by the number of insurance providers with policies that restrict anesthesia services for routine gastrointestinal endoscopy, PCC has communicated its concern with insurers.

“A colorectal cancer screening colonoscopy is the Gold Standard of care for preventing this deadly disease,” says Randall Madry, PCC executive director. “This procedure can identify and remove potentially cancerous polyps in the colon before they may develop into cancer. No other screening activity prevents colorectal cancer, they only tell you when you have already developed the dreaded disease.” When caught early, colorectal cancer is 91% curable. When caught late, it is 97% fatal. When prevented, it never happens.

Less than one-half of age-appropriate people get their colonoscopy – mostly out of fear of discomfort. PCC believes insurance companies that refuse to pay for anesthesia for this procedure only encourage that fear.

Most leading experts now agree an important adjunct to a traditional colonoscopy is offering the anesthetic option of propofol during the screening procedure. Among other benefits, studies have shown a higher detection rate of precancerous polyps using propofol when compared to traditional sedation methods.

“The inconsistent interpretation by health plans about whether propofol is a covered benefit must be resolved with a consistent and clear clinical policy,” Madry says. “It is simply the right thing to do.”

The administration of propofol to patients undergoing colorectal cancer screening colonoscopies is the Gold Standard in most of the nation, but some insurance payors think that they know better than the attending physician or anesthesia provider and are refusing to pay for the service.

Please embrace the mindset that together we can make ongoing impacts in preserving the Gold Standard of care by campaigning for transparency in reimbursement methodologies, and fighting for the coverage of anesthesia during colonoscopies.

Randall H.H. Madry
Preventing Colorectal Cancer

Our Business Model Is Changing: A Gastroenterologist's Perspective

Wednesday, July 31, 2013


There are multiple disruptive innovations and technologies that will define health care in the next few years and reshape our business model. The major driver of structural change today is the move from fee-for-service to value-based reimbursement, largely the result of federal programs created in an effort to cap the financial risk of the Center for Medicare and Medicaid Services (CMS).

Bundled Payments

Bundled payments will probably be one of the first methods deployed to control costs as it is conceptually the easiest idea to implement even in a fee-for-service model. This will likely be applied to colonoscopy first, as the players can limit their exposure to gastrointestinal (GI) services significantly and this procedure is responsible for at least half of the cost of GI services. Some self-insured companies have already established “colonoscopy packages” for their employees, where the employee receives a fixed benefit for their preventative health benefits, which includes a colonoscopy. This places a cap on the expenditure and forces the employee to shop for the least expensive provider of the service.

Value-Based Purchasing

Value in the consumer space can be defined and quantified fairly well, but value in health care has been an elusive concept to define and then manage. There are two ways to increase the value of what we provide; we can either increase the quality of our services or decrease the cost.

Since quality has been so difficult to define, the predominant way we have increased value has been to decrease the cost of the services we provide. Reimbursement for services has been falling for 20 years. Accordingly, we have all worked harder and longer to the point that for most of us we cannot increase our volumes any further. Unfortunately, we spend less time with each patient, which affects our patient satisfaction and our view from the consumer’s standpoint. It’s therefore time to focus on quality.

Quality today is synonymous with outcomes. We therefore have to be able to define and manage outcomes. This is a difficult task from an organizational point of view as true evidence-based data on outcomes is limited. Nevertheless, this has to be our focus. At the same time, in order to continue to decrease cost, care must be moved down to the least expensive provider. This will require changes in the structures of our practices so that each health care professional is working to the limit of his/her licensure and still producing quality outcomes. This will require the development of protocols and practice guidelines that can provide guidance to these lower level providers.

Mandated Reporting of Quality Measures

CMS has developed a full set of clinical quality measures as part of the Medicare and Medicaid Electronic Health Record (EHR) incentive program. These have been developed in conjunction with the National Quality Forum as well as other agencies and are founded on evidence-based medicine. Since they are a component of the EHR incentive program, the challenge for providers will be to implement them into EMRs. Although this technology is in its infancy, Clinical Decision Support (CDS) tools provided through information technology will be a major enabler for improvement in quality in the future and will limit variation in medical care that is currently affecting outcomes.

These types of tools will mold and shape the care provided and allow lower level providers to participate in the provision of care through these guidelines. This will be an essential feature in any program that is designed to improve quality and control cost.

Regardless of the fate of the current version of health care reform, a process is already in place that will drastically change the way providers deliver care. It will succeed today through the use of information technology and the implementation of CDS tools which will enable us to utilize a less expensive and more patient focused workforce than we were able to use in the past. There is definitely a storm coming followed by a major climate change. It should be interesting and certainly will be challenging.

Lawrence Kosinski, MD, MBA, AGAF, FACG, is managing partner at Illinois Gastroenterology Group, and chair of the AGA Practice Management and Economics Committee. This article first ran in EndoEconomics, May 2012 Issue.

Lawrence Kosinski, MD, MBA, AG


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