Letter From ASA To ASAP
Dear Doctors Goldstein and Koch,
I am writing in response to your e-mail of November 7 that was sent to Doctors Apfelbaum, Cohen and me. As ASA President, I will be replying for our organization.
In your note, you express dissatisfaction with ASA and its discussions with Aetna Healthcare over their revised Clinical Policy Bulletin addressing anesthesia care for patients receiving GI endoscopies. Based on the content of your communication, I believe that you either misunderstand or misrepresent ASA's role in Aetna's recent proposal. I will outline below some historical background, ASA's involvement, its extent, the reasons for becoming involved, and the results accomplished.
By way of background, payments to physicians, particularly payments for anesthesiology services are under assault. This is abundantly clear in Medicare, and we continue to see efforts to erode legitimate payment for anesthesiology services in the private sector. These facts are symptomatic of the larger pressures in the economy to bring medical care and insurance costs under control, while at the same time Americans are being urged to undergo greater routine screening and other costly treatments in order to lead longer, healthier lives. The battleground between physicians and America's health plans has long been focused on who can define and decide "medical necessity." In aggregate, private health insurers have published thousands of medical necessity policies over the years, affecting virtually all physicians.
The current controversy surrounding payment for anesthesia related to endoscopy is but the latest skirmish in never-ending attempts by health plans to trim their costs through regressive policies and practices, without sufficient regard to quality care for our patients.
The number of endoscopy services performed has increased dramatically in recent years, partly reflecting the general growth in minimally invasive surgery and partly reflecting the widespread adoption of colonoscopy as a screen for colon cancer. Anesthesia care for endoscopy patients has increased dramatically in volume as well, a fact not lost on health-care insurers. Moreover, the initial time plus base units established for endoscopy CPT codes were originally assessed on the provision of care to some of the sickest patients; hence the rationale for receiving 5 base units.
Several gastrointestinal medical specialty societies have publicly stated that anesthesia care is usually unnecessary for routine endoscopy in healthy patients. In fact, these specialties have claimed that moderate sedation is an inherent part of their endoscopic procedures, a fact reflected in the AMA's Current Procedural Terminology (CPT) coding publication. Furthermore, the Medicare payment for endoscopy services includes recognition of the resources used in delivering moderate sedation.
Health insurers have noted that they are paying gastrointestinal specialists for sedation services, and that great geographic variations exist in the use of anesthesia care for these cases. More importantly they have not seen any significant difference in outcome between those patients receiving anesthesia or sedation, and consequently have had trouble justifying a payment for both moderate sedation and anesthesia care in the same patient.
Like other health insurers, Aetna has published several hundred medical necessity policies affecting virtually every physician with whom Aetna contracts. In the Spring of 2006, Aetna issued a medical necessity policy covering anesthesia care for GI endoscopy, limiting coverage to patients with physical status ASA 3 or greater and those older than 65 or younger than 18 years. Those not qualifying for anesthesia care under this policy would have anesthesia services paid at the moderate sedation rate, a value significantly less than the usual payment for anesthesia care and bypassing the RVS payment system. This unprecedented approach would have dramatically reduced the value of an anesthetic service while preventing the anesthesiologist the option of directly billing the patient for the "medically unnecessary" anesthesia care. In addition, acknowledging that the RVS was now fair game for negotiating a fixed rate payment would have really led us down the slippery slope of exposing all anesthesia CPT codes to modification by negotiation or mandate.
In response to this and similar policies, the ASA Administrative Council issued a statement, "The Medical Necessity of Anesthesiology Services," stipulating that these determinations "require medical judgment" and should not be made "independently by other organizations, such as healthcare specialty organizations or health insurance plans." You know of this policy as you included a copy in your communication to us.
Aetna , in response to the strenuous objections by ASA and many individual anesthesiologists, withdrew the policy pending internal review and refinement. Aetna sought the advice of many outside parties, including ASA, on methods to improve the policy. Aetna, however, did not budge from their decision to publish a medical necessity policy on anesthesia for endoscopy.
ASA made numerous suggestions to broaden the number and types of patients to be covered by Aetna, addressing such conditions as previously failed sedation, psychiatric and psychological disorders (including severe anxiety and drug dependence), difficult airway and many others. Aetna did not cover these conditions in the original policy for ASA physical status 1 and 2 patients. Ultimately, Aetna accepted most, but not all, of ASA's suggestions. Aetna's decision to accept many of our suggestions improved anesthesiology's payments for this service by accomplishing the following:
1) dramatically broadened the number of patients eligible for anesthesia coverage with full contracted payments for their anesthesiologists;
2) administratively simplified reporting of qualifying conditions for patients not previously eligible by age or ASA physical status;
3) reduced the need for post-procedure claim review with the associated delays in payments to our members;
4) eliminated the possibility of replacing base + time payments for non-covered patients to a flat fee at a very low rate;
5) preserved the option to directly bill the patient for anesthesia care not covered by Aetna's policy.
ASA understands that Aetna will be releasing the revised policy in the near future. ASA does not endorse this policy as we believe medical necessity decisions should rest in the hands of the physicians caring for the patient; however, Aetna neither accepted ASA's position on medical necessity nor abandoned their development of a medical necessity policy. In light of this, ASA leadership faced two choices - allow Aetna to refine their policy without our input or offer our expert opinion if asked. ASA made the latter choice and has made every effort to substantially broaden the availability of anesthesia care to those Aetna subscribers who reasonably require our services in order to safely complete an endoscopy.
As Dr. Guidry stated last June in a letter to the membership, avoiding discussion with health insurers is a "head in the sand" approach and is not in the interests of the great majority of 41,000 ASA members. While ASA does not endorse Aetna's new policy nor any policy which takes medical decision making out of the hands of the physician, the communications between ASA and Aetna have helped transform a clearly bad policy into one that is among the least restrictive of the many similar policies known to us. ASA has and will continue to champion sound medical necessity policies and has worked diligently to counter independent policies by some health plans that could harm our patients. Ultimately, I believe that more of our members have been helped by the course we have taken than would have happened had we stuck "our head in the sand," deciding never to talk to insurers about the specifics of their medical necessity policies. Thus, ASA was faced with a dilemma and opted to negotiate maintaining standards of care while successfully limiting our inevitable losses.
Going forward we will continue to provide recommendations to Aetna to improve their new policy. This is consistent with the Administrative Council's June statement in that we object to health insurers and others "independently" determining medical judgment. This objection implies that we have a role to play when we are asked to engage in dialog on these matters.
To date, Aetna and other insurers point to both the dearth of evidence demonstrating a health benefit for anesthesia care in otherwise healthy patients receiving routine endoscopies and the joint statement of the GI societies as a reason to deny payment in these circumstances. As we learn of compelling medical evidence to support the health advantages of anesthesia care in specific circumstances, such as is suggested by your study involving treatment of colonic polyps, we will advocate to Aetna and other health insurers to further broaden coverage in settings where that coverage has been restricted.
As the elected leader for the ASA, a large and diverse organization encompassing members with numerous but occasionally conflicting desires and goals, I must represent the broad interests of our membership, consistent with the policies approved by our Administrative Council, Board of Directors and House of Delegates. It distresses me to learn that ASA's actions in this matter may lead to your resignation from the organization. In this time of terrific pressures on our specialty from every direction, not standing together as a specialty will lead to disaster. Hopefully you will reconsider your intended plan.
Mark J. Lema, M.D., Ph.D.
American Society of Anesthesiologists
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