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James D. Cross, M.D.

Director, Medical Policy Administration

151 Farmington Avenue

Hartford, CT 06156

Dear Dr. Cross,

I am writing to comment and object to Aetna’s decision to change their reimbursement for monitored anesthesia care for GI procedures.

In justifying this change you refer to the joint policy statement of the ACG, AGA and ASGE of March 2004 as well as Aetna’s consultation with the ASA and GI societies.  I do not believe it is the responsibility of any healthcare organization (ASA, ACG, Aetna etc..) to make determinations or recommendations regarding medical necessity.

Aetna’s policy change sets an ominous precedent. It alters the role of health insurance organizations in patient care by stepping squarely over the line into the doctor – patient relationship.  I believe this policy change results in Aetna making a medical decision on behalf of doctors and patients that will dictate who can and cannot receive the services of an anesthesiologist.

The AMA believes that patients should have access to equivalent health care regardless of healthcare setting, patient health or the ability to pay.  Aetna’s new policy ignores this and creates a dangerous dual standard of care. Seemingly, GI patients in the doctor’s office do not have access to the same anesthesia care that patients can expect/request in a hospital or ASC—despite the relatively austere resources. In addition, patients with similar health profiles can be excluded from receiving the care of an anesthesiologist on the basis of an arbitrary age limit.

Finally, the proposed reimbursement changes are wholly unacceptable.  Anesthesia is and continues to be reimbursed based upon a nationally accepted and recognized base/time unit methodology that takes into account the relative complexity of the anesthesia care. There is neither justification nor due process that can substantiate this policy’s proposed change in pay schedule. Although it represents a creative way to circumvent contracts predicated on unit rates, it smacks of unfair trade practice.

Anesthesiology is a discipline within the practice of Medicine that involves the medical management of patients who are rendered unconscious and/or insensible to pain and emotional distress during surgical, obstetrical and certain other medical procedures. There is no circumstance when it is considered acceptable for a person to experience emotional or psychological duress or untreated pain amenable to safe intervention while under a physician’s care.  The decision to administer anesthesia to a patient for almost any medical/surgical procedure is elective.  That is, there is incomplete outcome data, patient safety data or financial impact data to definitively support or contradict the decision to provide anesthesia care to any patient for any diagnostic or therapeutic intervention.  Similar to the conclusion reached in the joint statement of the GI societies, I believe there are no randomized clinical trials to substantiate Aetna’s policy change.

The decision as to the medical necessity of anesthesia for a particular patient is a judgment of medical practice that must consider all patient factors, procedure requirements, potential or deduced risks and benefits, surgeon requirements or preferences, and competencies of the practitioners involved. The decision to perform a specific anesthetic technique is best made by a physician trained in the medical specialty of anesthesiology in conjunction with the patient and the physician performing the surgery/procedure.

Your policy change is inappropriate.  I request that you rescind it based upon the possible negative impact on patient care/outcomes as well as the policy’s medical decision making implications.



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