Are you planning to have a colonoscopy in the near future? That’s great – because this is a very important cancer screening procedure for people ages 50 and above that can easily save your life.

You may have heard that we were changing the way we will cover sedation services during colonoscopies and other routine endoscopic procedures. We have some important updates to share with you.

We have decided to delay the start of our new policy until gastroenterologists who now rely exclusively on monitored anesthesia (which requires the presence of an anesthesiologist) have time to transition to alternative forms of sedation that will be available in the near future. These alternative forms of sedation, like the moderate sedation that our policy has always covered and will continue to cover, can be given to you by the doctor performing the procedure.

We are delaying this policy for two reasons. First, in some parts of the country, doctors now routinely use monitored anesthesia care (which requires that two doctors be part of the procedure instead of one). In some cities and surrounding areas, many gastroenterologists do not offer their patients moderate sedation at all for endoscopies. Because of this, in some places our members may not be aware of the alternatives available to them, or might have trouble finding a doctor who will manage the sedation services without an anesthesiologist.

We also are very disappointed that some individuals have chosen to misinterpret our policy, and have been communicating to our members and the public that we would no longer cover sedation during colonoscopies. This is not true. However, this misinformation can cause confusion and could negatively affect colon cancer screenings among our members. This is unacceptable to us.

Fortunately, new approaches and technologies are being introduced in the market that will give doctors and patients more options for anesthesia for endoscopies. Giving doctors more time will allow them to begin using these new patient-friendly alternatives.

It’s most important that you and all of our other members continue to have colonoscopies as recommended to screen for colon cancer. Your health and your access to affordable quality health care are top priorities for us.

What is moderate sedation?
Most doctors in most parts of the country use moderate sedation during routine colonoscopies and other upper- and lower-endoscopic procedures. Aetna has always covered moderate sedation, and will continue to cover it. So the policy change will not affect most members.

Moderate sedation, given to you by the doctor who is performing the procedure, will help you relax, will control any pain, and will help you to not remember the procedure. This is the most commonly used sedation and is proven to be safe and to promote patient comfort.

What is monitored anesthesia care?
In certain parts of the country, some doctors who perform these procedures have started having anesthesiologists present during the procedure to administer a deeper sedation. This is called monitored anesthesia care. Bringing in an anesthesiologist allows the doctor to do more procedures in a day. The effects of the monitored anesthesia also disappear more quickly. However, for patients who have no sedation-related risks, medical organizations agree that monitored anesthesia is no safer than moderate sedation.

It is interesting to note that doctors’ use of monitored anesthesia varies greatly depending on where they practice. For example, more than 60 percent of our members who had colonoscopies/endoscopies in the metropolitan New York area had monitored anesthesia with the procedure last year. At the same time, only 12 percent of our members in Chicago had monitored anesthesia during the same types of procedures. Yet there was no evidence that either set of members had better outcomes.

As you can imagine, having two doctors involved in the procedure rather than one adds significantly to the cost. As a member of our health plan, your insurance premiums as well as your out-of-pocket costs are directly affected by the cost of the care you receive. It is our responsibility to help you receive quality and cost-effective care.

What are the new alternative forms of sedation?
The Food and Drug Administration (FDA) now is reviewing alternative forms of sedation, including a new medical device and new sedative. These are expected to be available to doctors by the summer of 2008.  Both the sedative and the device that delivers sedatives are designed to provide a patient experience that is very similar to, or perhaps better, than monitored anesthesia care. However, they can be given exclusively by the gastroenterologist performing the colonoscopy or endoscopy.

What will Aetna’s new policy be on sedation during colonoscopies and endoscopies?
When our new policy goes into effect, we will only cover monitored anesthesia (or the services of an anesthesiologist during a routine screening colonoscopy) for members with sedation-related risk factors. This includes children, anyone over age 65, and people with conditions ranging from pregnancy to epilepsy.

As we said above, we of course will continue to cover the commonly used moderate sedation for all members. Once the FDA approvals are in place for the new sedatives and medical devices, we expect to add coverage for these to our policy as well.

This policy is consistent with position statements from the American Gastroenterological Association, American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy.

When will the new policy go into effect?
We will implement our new policy after the new alternative forms of sedation have been introduced in the marketplace and doctors have had time to adopt them. Once we are confident that this has happened, we will announce a new date.

We hope you find this explanation helpful. Most of all, we hope you will go to your doctor for all recommended screenings, including colonoscopies beginning at age 50. You can find information on screenings important for you on our Living Well webpage; choose Men’s Health, Women’s Health or Children’s Health, then the appropriate age range.

Who will be covered for monitored anesthesia when the policy does go into effect?
Examples within these categories include those who are:

• Pregnant;
• 18 years of age or younger;
• 65 years of age or older;
• Have epilepsy;
• At increased risk for complication due to certain classes of physical status according to the American Society for Anesthesia;
• In danger of airway compromise, including those with oral, neck or jaw abnormalities; sleep apnea; or those who are morbidly obese;
• Uncooperative or combative;
• Dependent on opiates or sedatives;
• Scheduled for certain complex or prolonged procedures; or
• Who have a history of drug or alcohol abuse; or a history of previous problems with sedation.

What happens if my doctor uses monitored anesthesia care after you implement the policy, and I’m not covered for it? Will I have to pay the bill?

Doctors who participate in our network will only be allowed to bill our members for non-covered services if the following three conditions are met:

1. Aetna has provided information on its policy and confirmed that the services are not covered; and,
2. You, as the member, were advised in writing by the physician prior to the services being rendered that the service may not be covered; and
3. You agreed in writing to pay for such services after being so advised.

If these conditions are met, you may be responsible for payment. However, we understand that policy changes can be confusing. So for the first six months the policy is in effect, we will reach out to members to make sure they are not inappropriately paying for services. This will be accomplished by sending letters to members whose claims for monitored anesthesia are denied, giving them a form to fill out if they did not receive advance notice from their physician.

However, if a member chooses to receive non-covered services from a physician who does not participate in the Aetna provider network, the member can and most likely will be billed directly by that doctor.

Isn’t this all about costs?
Costs are indeed a factor. It’s no secret that health care costs continue to rise, which is reflected in insurance premiums. Aetna must do its part to help keep insurance affordable for employers and individuals who purchase it. Given two equally safe and effective options, this policy reflects the option that costs an average of at least 25 percent less, and even less in some markets, such as New York.

Is Aetna making a decision that my doctor should make?
No, we are not imposing our judgment on the individual case before each physician, but rather we are asking that physicians follow evidence-based guidelines of care in each case, and not routinely choose a course of care that is unnecessary and adds significant expense to this important screening test.

We do not create the science or the evidence-based medicine guidelines, but our policies are formed by them. In order to keep health care as affordable as possible, we can only pay for procedures that comply with the best evidence of what is safe, necessary and effective. There is no clinical evidence that monitored anesthesia care services are better for endoscopic patients with no high-risk factors. The current clinical evidence shows that health outcomes are similar; only the cost is different. The new sedatives and medical devices that are expected this year will offer patients and doctors even more covered alternatives for sedation.

The ultimate decision on your care belongs to you and your physician. We are simply stating what we cannot pay for procedures that lack a clear evidence base. We have an obligation to our customers and members to make these choices about what is appropriate to cover and what is not, and to help ensure that our patients receive consistent, high quality care.

How does this involve the drug Propofol?
This is not about Propofol, or any individual drug for that matter. This policy addresses the situations in which Aetna will consider monitored anesthesia care medically necessary in the context of routine GI endoscopic procedures, and reimburse accordingly.

(Note: Propofol is one of a few drugs used for monitored anesthesia care.)