In December 2007, Aetna released their revised Clinical Policy for Anesthesia Services for Gastrointestinal Endoscopy, which will become effective on April 1, 2008. Similar to policies previously issued by WellPoint, Humana, Oxford Health Plans/United Health Group and HealthAmerica/Coventry, Aetna considers the attendance of an anesthesia professional for average-risk individuals undergoing standard upper or lower endoscopic procedures as not being medically necessary.
This statement represents the recommendations of the AGA Institute (AGA) in response to Aetna's Clinical Policy Bulletin 0740: Anesthesia Services for Gastrointestinal Endoscopy, which is scheduled to become effective on April 1, 2008.
The AGA is one of the nation's oldest not-for-profit medical specialty societies and the largest society of gastroenterologists, representing more than 16,000 physicians and scientists who are involved in research, clinical practice and education on disorders of the digestive system.
The Importance of Safe, Comfortable Colonoscopy
This year an estimated 147,000 Americans will be diagnosed with colorectal cancer and 56,500 will die from this disease, with an approximate 1-in-18 lifetime probability of developing colorectal cancer. The larger tragedy behind these numbers is that colorectal cancer is one of the most treatable cancers, if detected in its early stages. Increased efforts to educate the public on the importance of screening for colorectal cancer and expanded coverage of colorectal cancer screenings will greatly reduce the mortality rates from this disease.
At a time when compliance with screening recommendations for colorectal cancer with any test still are discouragingly low, there are differing opinions as to how the nation should promote screening tests. Approximately 25 percent to 40 percent of adults over age 50 report receiving screening tests, depending on age and gender. As a result, only 37 percent of cases are diagnosed when the disease is still localized; diagnosis at later disease stages results in substantially lower survival. Ongoing debate about screening strategies is likely to continue for the foreseeable future, because not only are access, preference and use of current tests shifting, but also new technologies are being introduced into clinical practice. Given the current uptake of colorectal cancer screening, we are concerned about payer initiatives that may limit patient access to and acceptance of such services.
The Importance of Safe Endoscopic Sedation
The AGA encourages practitioners to develop a structured sedation protocol suited to the needs of their patients and practice, as noted in the August 2007 AGA Institute Review of Endoscopic Sedation. Our commitment to patients is that they have access to medically necessary technologies, pharmaceuticals and services delivered by the appropriately trained health-care professional, to ensure that they undergo colorectal cancer screening and other endoscopic procedures in an environment that promotes safety, patient comfort and quality of care.
The AGA is greatly concerned about payers issuing policies regarding anesthesia services for gastrointestinal endoscopy. We recognize that the use of propofol in endoscopy is a complex topic, from a medical and scientific standpoint. We note that Aetna's policy covers the use of monitored anesthesia care (MAC) for those with sedation-related risk factors, consistent with the Joint Working Group recommendations from the AGA, ASGE and ACG. In addition, we note that the policy does not restrict the gastroenterologist-directed or administered use of propofol sedation by non-anesthesia professionals who possess the appropriate training for the use of this agent.
It is unfortunate that policies from payers that specifically restrict the choice of sedation modality by the attending physician have had the perverse effect of leading the public to believe that colonoscopy-based colorectal cancer screening is painful. In fact endoscopy, when performed by a gastroenterologist or other similarly trained endoscopist, is comfortable, safe and effective. During fellowship training, a gastroenterologist receives instruction in the pharmacology and administration of sedation agents for the performance of endoscopic procedures. Clinicians frequently administer moderate sedation as it provides a relief of pain and a partial level of amnesia so that patients do not remember the procedure. Some clinicians have received training in the use of agents that produce deep sedation, such as propofol. It is appropriate for the patient to inquire whether the provider performing the endoscopic procedure has received such training.
We recognize the complexity of this issue, where questions about the medical necessity of and the payment for MAC services are irreversibly intertwined. In an era of value-based health care, it is appropriate to ask whether the service provided results in an improvement in health outcomes for the patient. To date, the evidence has not consistently demonstrated an advantage with the use of propofol in average-risk patients undergoing standard upper and lower endoscopy. Ultimately a qualified health-care practitioner should be the decision maker regarding the use and administration of sedation agents in conjunction with the patient. If an individual provider lacks appropriate competency in the administration of sedation, then it should not pose a barrier to the patient receiving quality care in a safe environment and practitioners should be able to employ and be reimbursed for the use of an anesthesia professional.
Further, it is not appropriate to attempt to restrict privileging, credentialing and/or payment for the provision of sedation services, when the practitioner possess the appropriate training to provide such services, but deems the use of an anesthesia professional as medically necessary.
We are dedicated to working with all stakeholders involved — gastroenterologists, surgeons, primary care providers, anesthesiologists and others — to provide clear recommendations to physicians, patients, purchasers and payers regarding the appropriate use of sedation for endoscopic procedures. The AGA will continue to work to ensure that payer policies do not pose a barrier to patients receiving medically necessary colorectal cancer screening and endoscopic services.
Capecitabine and oxaliplatin effectively treats advanced esophagogastric cancer, shows a report in last week's New England Journal of Medicine.
Doctors in the United Kingdom evaluated capecitabine, an oral fluoropyrimidine, and oxaliplatin, a platinum compound, investigating the effect of these interventions as alternatives to infused fluorouracil and cisplatin, respectively, for untreated advanced esophagogastric cancer. In a factorial design, the team randomly assigned 1,002 patients, with patients in Group 1 receiving triplet therapy with epirubicin and cisplatin plus either fluorouracil and patients in Group 2 receiving triplet therapy with epirubicin and cisplatin plus capecitabine. Patients in Group 3 received triplet therapy with epirubicin and oxaliplatin plus fluorouracil, while those in Group 4 received triplet therapy with oxaliplatin plus capecitabine. The primary end point was non-inferiority in overall survival for the triplet therapies containing capecitabine as compared with fluorouracil, and for those containing oxaliplatin as compared with cisplatin.
The team found that for the capecitabine-fluorouracil comparison, the hazard ratio for death in the capecitabine group was 0.86. For the oxaliplatin-cisplatin comparison, the hazard ratio for the oxaliplatin group was 0.92. The upper limit of the confidence intervals for both hazard ratios excluded the predefined non-inferiority margin of 1.2. The researchers found that median survival times in Groups 1 and 2 were 10 months, while medial survival times in Groups 3 and 4 were 9 and 11 months, respectively. Survival rates at one year were 38 percent, 41 percent, 40 percent and 47 percent for Groups 1, 2, 3 and 4, respectively. In the secondary analysis, overall survival was longer in Group 4 than in Group 1, with a hazard ratio for death of 0.80 in Group 4. Progression-free survival and response rates did not differ significantly among the regimens.
The team found toxic effects of capecitabine and fluorouracil were similar. As compared with cisplatin, oxaliplatin was associated with lower incidences of grade 3 or 4 neutropenia, alopecia, renal toxicity and thromboembolism. However, as compared with cisplatin, oxaliplatin was associated with slightly higher incidences of diarrhea and neuropathy.
Many gastroenterology practices are performing endoscopic procedures in the office, particularly practices in locations where a certificate of need for an ambulatory surgery center is difficult to obtain. Procedures performed in the office are more efficient, less costly and can be more patient friendly than procedures performed in a hospital. Office procedures can also generate additional revenue for the practice. However, while there are appropriate ways to increase revenue, others may put the practice at risk.
Many practices that perform office-based procedures have negotiated an "enhanced fee" with payers. Negotiating an "enhanced fee" may entail some leg work on the part of the practice. Payers appreciate and are moved by numbers. Presenting a well thought-out argument that includes the cost of each procedure, including the hospital's facility fee when performed in the hospital setting, compared to your proposed charge for performing the same procedure in the office, usually will persuade the payer to negotiate an "enhanced fee" for the practice. The result is a win/win situation: the payer saves money, the practice makes money and patients are satisfied.
The risky way of generating additional revenue is to bill the payers a separate facility fee under a separate corporate name than the practice, with the Place of Service (POS) code 24. POS 24 is defined by CPT as an "Ambulatory Surgery Center — a freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis." Because of the AGA's concern that practices following this course may be at risk, the AGA solicited a legal opinion from Eric Zimmerman, Esq. of the law firm McDermott Will & Emory, legal experts on health-care reimbursement issues. Mr. Zimmerman notes that:
An office-based surgery practice may bill a third-party commercial payer an "enhanced fee," but only facilities licensed (as an ambulatory surgery center) may bill a facility fee. In addition, to the extent that a physician submits claims to a payer using site-of-service indicator "24," that physician is effectively communicating — or describing itself — to the payer that it is a "center," further subjecting such practice to scrutiny and possibly being viewed as operating an ambulatory surgery center without the required licensure. A physician who is furnishing medical services without proper licensure and other required state approvals could be subject to recoupment and disciplinary action in addition to any fraudulent insurance claims that could be made by third-party payers.
Additionally, a physician who seeks payment for facility costs for services furnished in the office could be vulnerable to charges of civil and criminal fraud. The risks are greatest where the physicians are billing as "out of network" providers, meaning they do not have a contract with the payer ... Even in instances where the physician submits some form of notice with the claim attempting to alert the payer to the fact that the service was not furnished in such a facility, such notice may not be regarded as adequate…
Negotiating an "enhanced fee" for office-based procedures from your private payers is possible. When done right, these can provide additional revenue for the practice that performs procedures in the office. However, physicians who wish to seek any additional fees beyond those that are standard for a procedure performed in the office setting (e.g., an "enhanced fee") would be advised to do so only when such fees are in contractual privity with the payers, the payers expressly agree to pay such enhanced fee and the physicians do so in a manner that could not be misconstrued by the public or regulators as furnishing services in a facility setting. Depending on state regulations, the practice may also need to obtain approval by the state's Department of Health or similar entity. Otherwise, charging a facility fee in the absence of a contract with the payer could put the practice at risk.
For only $82.50, you can place an ad of 100 words or less in two consecutive issues and for $165 in four consecutive issues. Ads can also be placed in AGA Perspectives, AGA's bi-monthly magazine. If you place ads in both AGA Perspectives and AGA eDigest, you will receive a 10 percent discount. For more information, contact Jennifer Halbert at jhalbert@gastro.org or (301) 654-2650.
AGA Institute
Gastroenterology and Clinical Gastroenterology and Hepatology – Journal Science Editor — The editors of Gastroenterology, the leading journal in the field of digestive disease, and Clinical Gastroenterology and Hepatology, the AGA Institute's official clinical practice and research journal, seek a Science Editor to assist with the scientific and medical content of both journals. The Science Editor will apply his/her expertise to writing and editing specific journal sections, editing abstracts and titles of original articles, and attracting cutting-edge research to the journals by attending relevant scientific meetings and networking at academic centers.
Qualified candidates must possess an MD or PhD degree in an area relevant to gastroenterology/hepatology, with demonstrated medical/scientific research and publication/presentation skills, and the analytical and scientific judgment and ability to identify and evaluate emerging trends in medicine/science. Strength in translational writing for medical professionals a must. Work can be performed from a home office.
Interested candidates should send CV with names and contact information of three references to karmitage@gastro.org.
Oregon
Portland and Salem – Gastroenterologists — Northwest Permanente, P.C., a stable, physician-managed multi-specialty group providing care to over 490,000 Kaiser Permanente members, has excellent opportunities for BC/BE gastroenterologists (100 percent GI) with therapeutic ERCP skills to join ten fulltime physicians and two physician assistants in the Gastroenterology Department. One position is with our group in Portland and the other is in Salem, the state's capital, 45 miles south of Portland. Ours is a collegial and professionally stimulating practice in one of the most successful managed care programs in the country. In addition to a quality lifestyle inherent to the beautiful Pacific Northwest, we offer a competitive salary/benefit package which includes a comprehensive pension program, professional liability coverage, sabbatical leave and more.
To submit your CV and apply for either position please visit our Web site at: http://physiciancareers.kp.org; phone (800) 813-3763. We are an equal opportunity employer and value diversity within our organization.
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Gail Hecht, MD, AGAF
Applications are due in February for:
Several states, including NY, now require medical practices to be accredited if endoscopy procedures are performed. Hear from representatives from AAAHC, the Joint Comission and individuals who have gone through this process by listening to the audio of this Oct. 22 teleconference.
Investing in the Future: