Highmark Blue Cross Blue Shield, the fourth largest Blue Cross Blue Shield affiliated company, operates health plans in Delaware, Pennsylvania and West Virginia covering approximately 5.2 million lives. This spring, Highmark announced plans to enact a new monitored anesthesia care (MAC) coverage policy for non-high risk procedures such as colonoscopy and GI endoscopy.
Under the new policy, MAC would only be covered if the patient met Highmark's criteria for medical necessity. The policy, set to go into effect June 30, was met with a swift response from the affected medical community. The Pennsylvania Ambulatory Surgery Association, Pennsylvania Society of Anesthesiology, Pennsylvania Society of Gastroenterology and Pennsylvania Medical Society, amongst other groups, gathered to discuss the issue with Highmark representatives.
Highmark has since suspended the policy's implementation, but the possibility it will be eventually enacted remains. In prior years, Aetna has proposed a similar measure and the local Pennsylvania area Medicare carrier is now considering a similar measure. How would GI-driven ambulatory surgery centers and gastroenterologists be affected if such a policy were to go forward?
The immediate result of this policy would be increased patient financial responsibility if electing to have care knowing they do not meet the Medical Necessity criteria, or worse preventing patients from accessing care because of the increased financial burden. If patients fall outside the payer's defined medical necessity terms, they are subject to the costs of monitored anesthesia care. "This kind of policy has the potential to drive patients to different, more costly, healthcare settings," says John Gleason, executive director of Digestive Disease Associates and Berks Digestive Center for Health in Wyomissing, Pa.
This policy would not only impact patient costs, but how the procedure is experienced. Propofol has been an industry standard for colonoscopy and endoscopy for decades. Patients are still able to opt for conscious sedation, but it does not provide the same level of sedation. "Propofol is quick-acting and has a shorter recovery period," says Robert A. Puglisi, CASC, vice president of operations with Physicians Endoscopy. "Other drugs have longer recovery periods and intraoperatively leave patients open to more discomfort."
“Patient comfort is extremely important,” says Stanford R. Plavin, MD, president of Ambulatory Anesthesia of Atlanta and board vice chairperson of Preventing Colorectal Cancer. “Barriers to screening include fear and being comfortably sedated/asleep.” Comfort can also have a substantial affect on a procedure's outcome, as well as the patient's perception of care.
This type of policy presents a dilemma for gastroenterologists and providers. "This is a dual standard of care," says Dr. Plavin. "One patient is treated differently from others because of these parameters put forth. I think this is a clinical decision that should be made on the peer-to-peer level, not by someone that doesn't have that level of knowledge."
Faced with the choice of shouldering considerable costs or the possibility of being aware during what many consider an embarrassing, invasive procedure, patients may simply opt out. "This policy has raised concerns. How will it affect colorectal cancer screening?" says Mr. Gleason. Colonoscopy, though coming under fire as a costly and unnecessary procedure, has been thoroughly demonstrated as a key tool in colorectal cancer screening and prevention.
Highmark has halted the policy's implementation for now, but this situation is one in a series of similar payer efforts. If such a policy was enacted would it set a precedent that would spread from one market to many?
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Under the new policy, MAC would only be covered if the patient met Highmark's criteria for medical necessity. The policy, set to go into effect June 30, was met with a swift response from the affected medical community. The Pennsylvania Ambulatory Surgery Association, Pennsylvania Society of Anesthesiology, Pennsylvania Society of Gastroenterology and Pennsylvania Medical Society, amongst other groups, gathered to discuss the issue with Highmark representatives.
Highmark has since suspended the policy's implementation, but the possibility it will be eventually enacted remains. In prior years, Aetna has proposed a similar measure and the local Pennsylvania area Medicare carrier is now considering a similar measure. How would GI-driven ambulatory surgery centers and gastroenterologists be affected if such a policy were to go forward?
The immediate result of this policy would be increased patient financial responsibility if electing to have care knowing they do not meet the Medical Necessity criteria, or worse preventing patients from accessing care because of the increased financial burden. If patients fall outside the payer's defined medical necessity terms, they are subject to the costs of monitored anesthesia care. "This kind of policy has the potential to drive patients to different, more costly, healthcare settings," says John Gleason, executive director of Digestive Disease Associates and Berks Digestive Center for Health in Wyomissing, Pa.
This policy would not only impact patient costs, but how the procedure is experienced. Propofol has been an industry standard for colonoscopy and endoscopy for decades. Patients are still able to opt for conscious sedation, but it does not provide the same level of sedation. "Propofol is quick-acting and has a shorter recovery period," says Robert A. Puglisi, CASC, vice president of operations with Physicians Endoscopy. "Other drugs have longer recovery periods and intraoperatively leave patients open to more discomfort."
“Patient comfort is extremely important,” says Stanford R. Plavin, MD, president of Ambulatory Anesthesia of Atlanta and board vice chairperson of Preventing Colorectal Cancer. “Barriers to screening include fear and being comfortably sedated/asleep.” Comfort can also have a substantial affect on a procedure's outcome, as well as the patient's perception of care.
This type of policy presents a dilemma for gastroenterologists and providers. "This is a dual standard of care," says Dr. Plavin. "One patient is treated differently from others because of these parameters put forth. I think this is a clinical decision that should be made on the peer-to-peer level, not by someone that doesn't have that level of knowledge."
Faced with the choice of shouldering considerable costs or the possibility of being aware during what many consider an embarrassing, invasive procedure, patients may simply opt out. "This policy has raised concerns. How will it affect colorectal cancer screening?" says Mr. Gleason. Colonoscopy, though coming under fire as a costly and unnecessary procedure, has been thoroughly demonstrated as a key tool in colorectal cancer screening and prevention.
Highmark has halted the policy's implementation for now, but this situation is one in a series of similar payer efforts. If such a policy was enacted would it set a precedent that would spread from one market to many?
More Articles on Gastroenterology:
Controlling Costs, Physician Recruitment & More: 5 Gastroenterologists on Injecting Life Into Endoscopy Center Profitability
GI in the News: 5 Gastroenterologist Moves & Honors
2 Gastroenterologists on the Best GI Practice Marketing Ideas