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Consultative Remarks Pertaining to Aetna’s Fall 2006 Proposed MAC Policy Change

Prepared by Anesthesiologists for the Safe Administration of Propofol [ASAP]

Summary Conclusions:

  • The current policy will not achieve its desired effect of enduring medical loss ratio reductions [MLRS] attributable to office-based and ambulatory anesthesia and, in particular, anesthesia for GI procedures.

  • There is a lack of clear outcomes data to support the efficacy of the proposed changes.

  • The impact on screening prevalence, cancer detection rates and patient access has not been studied.

  • The policy clearly gives the impression that a large corporation ( Aetna) is attempting to practice medicine by deciding who, when and where patients should receive anesthesia or other care.

  • Limiting access to anesthesia services based on age and arbitrary health conditions may be legally challenged.

  • This policy is punitive to Aetna’s in-network providers who have worked to contain costs.

Supporting Remarks:


We appreciate the opportunity to review and comment on your proposed policy change for coverage of Anesthesia Services for GI Endoscopy As a longtime “friend” of the insurance industry Somnia, Inc. has contracted with managed care organizations [MCO] on behalf of professional corporations for over a decade. We believe strongly that the real issue has to do with out-of-network ratios and the high CPMPM resulting from this billing mindset. Rather than limiting anesthesia access to patients above or below a certain age, or to patients who have arbitrary medical conditions, we feel that more effective management of the in-network and out-of-network segments will serve two goals-- stabilization of cost and maintenance of broad access.

The highly fragmented nature of office-based surgery [OBS] and anesthesia [OBA], combined with the highly idiosyncratic operational, financial and clinical inputs, makes management by MCOs a formidable task. Nevertheless, we view this policy as punitive to individual providers and groups who have worked diligently with sMCOS to promote and provide safe, high quality and efficacious anesthesia care and, at least in our case, effectively manage a network of providers with an eye on cost containment.

The indelible message that will resonate throughout the office-based and ambulatory surgery industry is that the best financial strategy is to bill out of network, for as long as possible, in anticipation of an eventual extinction or erosion of reimbursement. Moreover, as we all know, the same provider(s) who feel it apropos to bill $1,000 for a 15-minute colonoscopy, or others who feel aggrieved by a policy, will find some ingenious way to work around any operationally realistic policy.

Clinical Efficacy/ Dual Standard of Care/Medical Necessity:

The limitations of any policy and its clinical endpoints are that a patient who wants, and from their surgeon’s perspective requires anesthesia care, will eventually prevail. Labor epidurals and pain management blocks are two cogent examples, where the endpoint of patient comfort and peace of mind have overcome the paucity of irrefutable clinical outcome studies. Anesthesia for cancer screening colonoscopy will be viewed through the same crucible sooner or later. A policy that limits coverage based on age is also worrisome, given the public concern over age-discrimination. Patients who feel that NOT suffering from certain co-morbidities serves as a penalty when it comes to being covered for anesthesia care can levy a similar claim. Indeed, the American Society of Anesthesiologists likely had this in mind when they amended their medical necessity statement (attached).

Patients who forego screening colonoscopy because their anesthesia care is not covered will serve as a cohort whose predictable misfortune will not play well in the court of public opinion. Similarly, your actions might be viewed as forcing the hands of gastroenterologists who are not comfortable serving the dual role of anesthesiologist and colonoscopist. As to this latter point, the ASA position statement on Deep Sedation reads, “Because of the significant risk that patients who receive deep sedation may inadvertently enter a state of general anesthesia, privileges to administer deep sedation should be granted only to practitioners who are qualified to administer general anesthesia or to appropriately supervised anesthesia professionals”

Finally, solicitation of advice from the ASA, NYSSA, MSSNY and large hospital-based groups [HBG] is imperfect. For example, the MSSNY constituency is very broad and many gastroenterologists and anesthesiologists instead join their state-specific specialty societies. Similarly, HBGs, the ASA and the NYSSA consists of mainly hospital-based providers who have numerous goals and objectives that may or may not represent the interests of the OBS and OBA providers and their patients. To the extent that some anesthesia groups may have been offered enhanced professional fees by MCOS—specifically for hospital based encounters outside of the endoscopy unit— it is clear that worrisome, if not deleterious, conflicts of interest exist. Speaking with exclusive OBS and OBA providers, either directly or through well-regarded industry champions, is the only way to achieve buy-in. We are dismayed that the NYSSA, ASA and large hospital based groups were solicited for input while some of the larger OBA groups were contacted later in the process and, at that, only after they reached out to Aetna.

Suggestions and Recommendations:

In summary, there are at least 6 reasons why we view your approach to this issue as challenged and risky from financial, operational and legal perspectives: 1) The public focus on cancer detection, pain control and medical safety is not outcomes-based—labor epidurals and acute pain blocks serve as two examples; 2) The unfounded and unwarranted segmentation of benefits based on age and medical co-morbities may be viewed as discriminatory and challenged in court; 3) The reality that any policy will be viewed as punitive, by and to, the very in-network OBA providers you rely on to contain costs; 4) The propensity for ill-intended non-par providers to find ways to work around any realistic policy; 5) Solicitation of advice from the ASA, NYSSA, MSSNY and HBGS is imperfect and may be subject to competing interests and self-serving mischief and 6) The possible claim of the corporate practice of medicine given the likely impact on cancer screening, cancer detection and anesthesia patient safety.

The situation Aetna faces can be scaled by either reducing the overall number of patients who receive anesthesiology care at current case reimbursement or keeping the trend-line stable and reducing the average cost per case so that CPMPM remains stable. It is our recommendation that the second alternative is a superior choice. It can be achieved by hard-lined, thorough, comprehensive and detailed management of the current OBS/OBA network. A focus on routing out overt and covert gaming of the system by the minority of OBS and OBA providers is imperative.



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