Reimbursement and Managed Care News for March 2008

By Stanton R. Mehr
Published: Monday, Jun 21, 2010
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National Managed Care Plans Stop Paying for Anesthetic in Colonoscopy

Aetna (Hartford, CT) has announced that it will join Humana (Louisville, KY) and WellPoint (Woodland Hills, CA) in no longer reimbursing for a drug they deem is medically unnecessary for most patients undergoing colonoscopy. The drug in question is propofol, the anesthetic used in many patients, but is not proven to result in better outcomes.

Aetna’s decision was based on its finding that although 77% of patients undergoing colonoscopy in the New York metropolitan area received the drug, other regions demonstrated use rates of 10% or less. The health plan found that outcomes were unrelated to the drug’s use. Additionally, no rescue drug is presently available for propofol, and it is a rapid-acting product. Although the drug is generic and is relatively inexpensive, the health plan pointed out that it seems to be an unnecessary risk, a belief that is supported by major professional gastroenterological associations.

Furthermore, the use of propofol generally requires the services of an anesthesiologist, which can add between $300 and $1,000 to the cost of the colonoscopy. Aetna will continue to pay for the use of propofol in patients over 65 years of age, those who are pregnant, and patients in whom the use of alternative drugs may be risky, but the company believes this may cover only 10% to 20% of colonoscopies performed..

The open question is whether this payment decision will result in greater patient discomfort and subsequent resistance to undergoing routine colonoscopy in the future. Patients will likely be given a combination of a sedative and tranquilizer, but this does not anesthesize the patient during the procedure. Others have experimented with the use of small doses of propofol administered without the use of an anesthetist, while using the sedative-tranquilizer combination, with success. However, under the new policy, the use of propofol will still go uncovered by the three national insurers. For now, UnitedHealthcare has indicated that it does not plan on following suit.

Feder BJ: Aetna to end payment for a drug in colonoscopies. New York Times December 28, 2007.

Managed Care Organizations Will Not Pay For Care Resulting From Preventable Errors

In a move widely seen as following Medicare’s lead, large managed care organizations announced recently that they would no longer pay hospitals for the care of treating a list of eight preventable injuries and infections. This may be the precursor to a much larger list of medical errors, however.

In October 2008, the Centers for Medicare and Medicaid Services will implement its new policy that it will not reimburse for services provided to treat complications of the medical errors listed in the Table. Aetna (Hartford, CT) and WellPoint (Woodland Hills, CA) have announced that they will follow suit, and apply this principle to their commercial populations. They will utilize a list of events that should “never occur,” according to work by the National Quality Forum, which includes, maternal death in a low-risk pregnancy, failure to prevent bedsores, or infection through the use of contaminated devices. The insurers also report that in 2009, the list of non-reimbursable services will include treatment for blood clots in the legs and lungs while under hospital care, pneumonia contracted through ventilator use, and nosocomial blood infections. The Table also lists some of the other medical errors that the National Quality Forum indicates as those should never occur.

UnitedHealth Group (Minneapolis, MN), Cigna (Philadelphia, PA), Humana (Louisville, KY), and the Blue Cross Blue Shield Association (Chicago, IL) are also examining similar policies for use in the near future. They hope to force hospitals to improve their safety records and procedures through the one incentive they understand well—payment.

  Sample of Nonreimbursable Services to Fix

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