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In reply—Anesthesia-Assisted Sedation Getting Notice by Medicare

      We thank Dr Hirsch for his letter in response to our article on preprocedural considerations in gastrointestinal endoscopy. We are delighted in his interest to encourage further discussion about the current state of anesthesia-assisted sedation in routine endoscopy. These are timely and controversial issues given the media’s increasing scrutiny of the economics of endoscopy and other preventive services in health care.

      The weird world of colonoscopy costs. The New York Times. June 9, 2013:SR10.

      We fully agree with Dr Hirsch’s observation that the need and indication for anesthesia-assisted sedation are rarely documented in patients’ medical records. Dr Hirsch accurately states that “while it is common for the physician to note the indication for the endoscopy, it is rare to see discussion about the stability of the patient’s medical conditions and the indications for the type of anesthesia support planned.”
      In our article, we went further in stating that the preoperative evaluation of patients for any endoscopic procedure should be a shared responsibility between the referring clinician and the endoscopist, especially in open-access endoscopy practices. We believe that a conscious effort in assessing perioperative medical issues and sedation requirements may decrease the inappropriate use of anesthesia-assisted sedation. We recognize that anesthesia services can be costly, but they are essential in the provision of safe and effective endoscopic services for selected patients. Inappropriate use of anesthesia-assisted sedation includes both indiscriminate use in low-risk patients and underutilization in high-risk patients undergoing complicated endoscopic procedures.
      Dr Hirsch raises concern about the possible reduction in reimbursement for endoscopy that may result from the increasing awareness of the cost of anesthesia-assisted sedation. Although there is a general perception that reimbursement for health care services in the United States will imminently decline, it is difficult to predict the exact impact of these ever-changing reimbursement policies on endoscopy and the provision of anesthesia. The only certainty is that the utilization and reimbursement of anesthesia in endoscopy is heavily influenced by economics and regulatory issues.
      • Brill J.V.
      Endoscopic sedation: legislative update and implications for reimbursement.
      Several studies have reported the safety of propofol sedation as administered by endoscopists.
      • Sáenz-López S.
      • Rodríguez Muñoz S.
      • Rodríguez-Alcalde D.
      • et al.
      Endoscopist controlled administration of propofol: an effective and safe method of sedation in endoscopic procedures.
      • Rex D.K.
      • Overley C.
      • Kinser K.
      • et al.
      Safety of propofol administered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases.
      • Yusoff I.F.
      • Raymond G.
      • Sahai A.V.
      Endoscopist administered propofol for upper-GI EUS is safe and effective: a prospective study in 500 patients.
      In a review of 569,220 cases of propofol sedation administered by endoscopists, only 0.09% (489 cases) required mask ventilation as a result of oversedation.
      • Rex D.K.
      • Deenadayalu V.P.
      • Eid E.
      • et al.
      Endoscopist-directed administration of propofol: a worldwide safety experience.
      In the analysis by Rex et al,
      • Rex D.K.
      • Deenadayalu V.P.
      • Eid E.
      • et al.
      Endoscopist-directed administration of propofol: a worldwide safety experience.
      substituting anesthesia professional services with endoscopist-administered propofol saved $5.3 million per patient-year saved. Despite the published evidence, the Centers for Medicare & Medicaid Services still considers the use of propofol for colonoscopy to be equivalent to deep sedation. This reaffirms propofol’s black box warning to limit its administration to anesthesia professionals who are qualified to provide general anesthesia. As such, the price of anesthesia-assisted sedation is strongly tied to the cost of having an anesthesia professional provide sedation and not on the actual advantages of propofol over opiates and benzodiazepines.
      • Brill J.V.
      Endoscopic sedation: legislative update and implications for reimbursement.
      The objective of our article was to provide evidence-based and practical recommendations for requesting anesthesia-assisted sedation in endoscopy. As gastroenterologists, we share Dr Hirsch’s sentiments about making sure that patients undergoing routine endoscopy will continue to have comfortable, safe, and effective endoscopic procedures regardless of the current pressures from cost containment and endless politics of determining reimbursements for health care services.

      References

      1. The weird world of colonoscopy costs. The New York Times. June 9, 2013:SR10.

        • Brill J.V.
        Endoscopic sedation: legislative update and implications for reimbursement.
        Gastrointest Endosc Clin N Am. 2008; 18 (viii): 665-678
        • Sáenz-López S.
        • Rodríguez Muñoz S.
        • Rodríguez-Alcalde D.
        • et al.
        Endoscopist controlled administration of propofol: an effective and safe method of sedation in endoscopic procedures.
        Rev Esp Enferm Dig. 2006; 98: 25-35
        • Rex D.K.
        • Overley C.
        • Kinser K.
        • et al.
        Safety of propofol administered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases.
        Am J Gastroenterol. 2002; 97: 1159-1163
        • Yusoff I.F.
        • Raymond G.
        • Sahai A.V.
        Endoscopist administered propofol for upper-GI EUS is safe and effective: a prospective study in 500 patients.
        Gastrointest Endosc. 2004; 60: 356-360
        • Rex D.K.
        • Deenadayalu V.P.
        • Eid E.
        • et al.
        Endoscopist-directed administration of propofol: a worldwide safety experience.
        Gastroenterology. 2009; 137: 1229-1237

      Linked Article

      • Anesthesia-Assisted Sedation Getting Notice by Medicare
        Mayo Clinic ProceedingsVol. 89Issue 3
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          In their article “Preprocedural Considerations in Gastrointestinal Endoscopy” published in the September 2013 issue of Mayo Clinic Proceedings, Gorospe and Oxentenko1 make note of data indicating an increasing percentage of “indiscriminate use of anesthesia-assisted sedation,” also known as monitored anesthesia care (MAC), for endoscopic procedures, referring to data that suggest that 60% of the anesthesia-assisted procedures are performed in low-risk patients. The issue of the added costs of anesthesia-assisted sedation was also highlighted by an article in The New York Times2 discussing a patient who was faced with a $2800 bill for anesthesia-assisted sedation services that were not covered by her insurance because, even though the gastroenterologist and facility were in the approved provider network, the anesthesiologist was not.
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