In response to an article recently posted on the American Society of Clinical Oncology’s Web site titled, “The Extra Cost of Monitored Anesthesia Care,” written by Dr. Lawrence B. Cohen, I find it disconcerting that there remains an obvious economic focus to question the appropriate means by which patients receive comfort care for rather uncomfortable invasive GI procedures.
Although Dr. Cohen does a stellar job in highlighting the clear and unquestionable benefits of patients receiving anesthesia for their GI procedures to include faster recovery and discharge, improved patient satisfaction, and overall quality outcomes in polyp detection rates specifically under deep sedation, he carefully waits until the very last paragraph to make his real point when he says that, “fundamentally, the question poised in this discussion is an economic one.” Without question, the crux of Dr. Cohen’s argument is essentially that in this era of health reform, when the cost of care is highly scrutinized and will be forever more, how can we ignore this additional “layer” of cost for the mere presence of a qualified anesthesia provider to administer deep sedation, and specifically, propofol, when it can arguably be administered at a reduced cost by the GI physician or someone under their direction.
Its difficult to find fault with Dr. Cohen and his like-minded thinking GI colleagues from having this economic-focused position on this issue since several commercial insurance carriers, most notably Aetna, have for years pitted GI v. Anesthesia in this battle over who, if anyone, should provide and most importantly, get reimbursed for providing anesthesia for GI procedures. The result has been an ongoing merry-go-round of GI anesthesia procedures being shuffled in and out of ambulatory centers and acute care hospitals by stringent regulatory guidelines and mostly due to the now almost exclusionary use of Propofol for the GI procedures.
So although Dr. Cohen wants to take issue with who ultimately pays for this level of service, the reality is that the real issue lies in the safe use of deep sedation, and specifically propofol, when providing anesthesia for GI procedures. Although it’s been studied and surveyed, it’s still not clear why the provision of deep sedation (Propofol) for GI procedures has mostly been a level of care and service provided and desired at only certain locales throughout the country. There is no question, especially for those of us who have had it on board, that the administration of Propofol is clearly IV General Anesthesia, or deep sedation. So the issue really becomes, if deep sedation/propofol is provided, who should be providing it? The GI physician who rightfully so is focused on the GI procedure and who likely does not have advanced airway management and rescue capacity skills if the desired level of sedation were to become unmanageable, or should it be an Anesthesia provider who is solely focused on sedating and monitoring the patient and capably trained to utilize advanced airway management and rescue skills if needed?
The term or label used to describe the required presence on an Anesthesia provider in situations where the sedative agent dictates both the presence and skills of someone qualified to administer and recover from the use of deep sedation is called “monitored anesthesia care.” Unfortunately, the term doesn’t come close to aptly describing the need for an anesthesia provider’ which goes well beyond that of just monitoring the patient. In fact, both CMS and the Joint Commission caution against the use of procedural or elective deep sedation by non-anesthesia providers because the possibility always exists for the patient to fall into a deeper state of sedation thus requiring airway management and rescue capacity skills not typically seen in non-anesthesia providers.
If the endpoint, as Dr. Cohen suggests, is purely economics, and whether anesthesia for GI should even a reimbursable service regardless of who provides the service, who pays for it, or at which level the service is reimbursed, then the issue takes on a whole other light that questions the provision of “advanced” standard of care anesthesia services for other elective procedures.
It’s clear that providing deep sedation (Propofol) for GI procedures is neither a GI or Anesthesia “standard of care” in that it is not absolutely required to produce the desired procedural outcomes and the service clearly varies by locale and mostly, by patient request. Thus, one could argue that anesthesia for GI is similar to other ”advanced” standard of care anesthesia services such as post-op pain management or pain management for obstetrics care; two important areas of anesthesia care where the use of anesthesia by a qualified anesthesia provider does not materially impact the successful outcome and results of the procedure, and yet the issue of who administers and ultimately pays for those “additional” anesthesia services is never questioned.
The advent of numerous health reform initiatives focused on the quality and costs of care will most certainly impact the provision and decisions of care and services provided. For now, the issue of “monitored anesthesia care” for GI procedures remains a relatively straightforward in that the administration of deep sedation, IV Propofol, especially for elective GI procedures should be administered by an anesthesia provider appropriately trained and qualified to administer such levels of sedation as per the “black box” warning contained in the Propofol package that currently reads, “For … monitored anesthesia care … propofol injectable emulsion should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure."
As with most all other healthcare services, the question of who will ultimately bear the costs of those services, to include the federal or commercial insurance payer or the patient, is as it should be, a secondary issue to the safe and appropriate care of the patient.
Quality Assurance Officer
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