The proportion of outpatient endoscopies and colonoscopies in which the services of an anesthesiologist or nurse anesthetist were used doubled in a recent 6-year period, according to a report in the March 21 issue of JAMA.
Anesthesia services include deep sedation or general anesthesia and must be administered by an anesthesiologist or nurse anesthetist, in contrast to lighter sedation that is typically provided by nurses under the endoscopist’s supervision. Current payment guidelines hold that low-risk patients can be adequately managed with light sedation and that anesthesia services are only justified in high-risk patients, according to Hangsheng Liu, Ph.D., and his associates at the RAND Corporation.
In this study of a large, nationally representative sample of patients covered by both Medicare and commercial medical insurance, the rate at which anesthesia services were used during GI procedures rose from approximately 14% in 2003 to more than 30% in 2009, they noted.
The researchers performed a retrospective analysis of insurance claims data to track the use of anesthesia services for endoscopies and colonoscopies over time because this has been identified as an area in which "excess" health care costs can be trimmed. They analyzed a Medicare fee-for-service sample of 6.6 million patients and a sample of 5.5 million patients covered by commercial insurance companies.
A medical need for anesthesia services during GI procedures in these cohorts could not be determined directly from the medical data, so it was "approximated" by classifying patients according to American Society of Anesthesiologists guidelines, which factor in age, sex, comorbidities, and medical history.
Patients who met criteria for ASA status level 1 or 2 were considered low-risk; the use of deep sedation or general anesthesia in such patients was not required and was judged to be "discretionary." In contrast, patients with an ASA status level of 3 or higher were considered high-risk and were judged to be appropriate candidates for deep sedation or general anesthesia.
Overall, there were 2.2 million GI procedures performed in Medicare patients and 7.0 million in commercially insured patients, for a total of 9.2 million during the study period.
The proportion of procedures using anesthesia services more than doubled during the 6-year study period in both groups: from 13.5% to 30.2% for Medicare patients and from 13.6% to 35.5% for commercially insured patients.
Among low-risk Medicare patients, the proportion of GI procedures using anesthesia services rose from 18,989 per million enrollees in 2003 to 25,069 per million enrollees in 2009. Annual payments per million enrollees rose by 8% per year.
Among low-risk commercially insured patients, the proportion of GI procedures using anesthesia services rose from 3,938 to 15,108 per million enrollees, and annual payments rose more than fourfold, from $1.69 million to $7.05 million per million enrollees.
Applying these figures to national statistics, the annual spending for anesthesia services on low-risk patients who probably don’t need them was estimated to be $1.1 billion in 2009 – $129 million for Medicare patients and $945 million for commercially insured patients.
Thus, "the majority of gastroenterology-related anesthesia services are provided to low-risk patients and can be considered potentially discretionary based on current payment policies," Dr. Liu and his colleagues concluded (JAMA 2012;307:1178-84).
The use of anesthesia services varied substantially by geographic region, another indication that clinical necessity is not the chief factor driving the use of heavy sedation or general anesthesia during these procedures. In the most recent year for which data were available, the use of anesthesia services during endoscopy or colonoscopy was lowest in the western United States (14% of Medicare patients and 13% of commercially insured patients) and highest in the northeast (48% and 59%, respectively). This is a nearly fourfold difference.
The rise in the use of anesthesia services "has been partly attributed to the adoption of propofol, which by virtue of a short half-life and rapid onset of action is thought to be more convenient and to offer a more consistent level of sedation than regimens previously used, but in the United States ‘should be administered only by persons trained in the administration of general anesthesia.’ Insurers’ payment policies and marketing by the anesthesiology community have also been cited as drivers of increased use," the investigators noted.
They added that since the number of endoscopies and colonoscopies is increasing, the "discretionary" use of anesthesia in low-risk patients "represents a sizable target for cost savings."
This study was supported by Ethicon Endo-Surgery Inc. No financial conflicts of interest were reported.