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Table 1.  
Incremental Costs to Medicare Associated With the Coverage of Anesthesia Services
Incremental Costs to Medicare Associated With the Coverage of Anesthesia Services
Table 2.  
Cost per Colorectal Cancer Prevented in Association With Coverage of Anesthesia Services
Cost per Colorectal Cancer Prevented in Association With Coverage of Anesthesia Services
1.
Centers for Medicare & Medicaid Services; US Department of Health and Human Services.  Medicare program: revisions to payment policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, access to identifiable data for the Center for Medicare and Medicaid Innovation Models & other revisions to Part B for CY 2015: final rule with comment period. Fed Regist. 2014;79(219):67547-68010.
PubMed
2.
Lichtenstein  DR, Jagannath  S, Baron  TH,  et al; Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy.  Sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2008;68(5):815-826.
PubMedArticle
3.
Howard  DH, Guy  GP  Jr, Ekwueme  DU.  Eliminating cost-sharing requirements for colon cancer screening in Medicare. Cancer. 2014;120(24):3850-3852.
PubMedArticle
4.
Liu  H, Waxman  DA, Main  R, Mattke  S.  Utilization of anesthesia services during outpatient endoscopies and colonoscopies and associated spending in 2003-2009. JAMA. 2012;307(11):1178-1184.
PubMedArticle
5.
Austin  H, Henley  SJ, King  J, Richardson  LC, Eheman  C.  Changes in colorectal cancer incidence rates in young and older adults in the United States: what does it tell us about screening. Cancer Causes Control. 2014;25(2):191-201.
PubMedArticle
6.
Centers for Disease Control and Prevention (CDC).  Vital signs: colorectal cancer screening test use—United States, 2012. MMWR Morb Mortal Wkly Rep. 2013;62(44):881-888.
PubMed
Research Letter
November 2015

Medicare Coverage of Anesthesia Services During Screening Colonoscopies for Patients at Low Risk of Sedation-Related Complications

Author Affiliations
  • 1RAND Corporation, Boston, Massachusetts
JAMA Intern Med. 2015;175(11):1848-1850. doi:10.1001/jamainternmed.2015.4585

In 2014, the Centers for Medicare & Medicaid Services waived patient cost sharing for anesthesia services during screening colonoscopies.1 The current professional guidelines recommend that sedation be provided by the gastroenterologist-nurse team; a separate anesthesiologist or nurse-anesthetist should be involved and paid separately only for patients with an increased risk of sedation-related complications.2 The stated rationale is that the provision of anesthesia has become standard practice for colonoscopies and that eliminating cost sharing may increase the rates of these examinations. We examined the costs and potential benefit of the Medicare rule change.

Methods

We quantified costs based on published articles regarding the volume of screening colonoscopy,3 rate of anesthesia use,1 proportion of services performed in low-risk patients,4 and average costs per anesthesia service.4 Using a scenario without the rule change as the comparison, we computed incremental anesthesia service costs to Medicare using the following 3 scenarios: maintaining the 2013 rate of anesthesia use, a 10% increase to that rate, and a 20% increase to that rate. This study was approved by the institutional review board of RAND Corporation.

The benefit was calculated as cost per colorectal cancer prevented. We first estimated the association between anesthesia use and colonoscopy screening rates in 2008 for 143 metropolitan statistical areas. Rates of anesthesia use were derived from Medicare claims (detailed methods described elsewhere4) and colonoscopy screening rates from Behavioral Risk Factor Surveillance System data for patients aged 65 to 75 years, defined as the proportion of eligible respondents with at least 1 screening colonoscopy in the past 10 years. The two rates were correlated using a linear regression. We then used published data for the association between the rate of colonoscopy screening and colorectal cancer incidence5 to estimate additional screenings needed to prevent 1 case of colorectal cancer per 100 000 persons. Sensitivity analyses were conducted using the upper bound of the 95% CI of the estimated association between anesthesia use and colonoscopy screening (the lower bound is negative and does not generate a meaningful cost estimate) and assuming a 50% increase in the association between colonoscopy screening and colorectal cancer incidence, respectively.

Results

Table 1 shows the cost calculations. Compared with the scenario without the rule change, the incremental cost to Medicare would be $5.5 million per year based on the 2013 rate of anesthesia use of 50%1 or $16.7 million if the rate increases to 70%. In all 3 scenarios, about two-thirds of the incremental costs to Medicare would be for low-risk patients. For every percentage-point increase in the rate of anesthesia use, we estimated a 0.03-percentage-point increase (95% CI, −0.01 to 0.07) in the rate of colonoscopy screening; each percentage-point increase in the rate of colonoscopy screening was associated with a 0.12-percentage-point decrease in the rate of colorectal cancer.5 Using a 2012 colonoscopy screening rate of 73.9% for patients who were 65 to 75 years old and a 2011 incidence of 151.3 cases per 100 000 people who were 65 to 75 years old, the incremental cost of anesthesia use per prevented incidence of cancer was $21.2 million for the 2013 rate of anesthesia use of 50%, $9.0 million using the upper bound of the 95% CI of the estimated association between anesthesia use and colonoscopy screening, and $14.1 million assuming a 50% increase in the association between colonoscopy screening and colorectal cancer incidence (Table 2).

Discussion

The results of our analysis cast doubt on the value associated with Medicare coverage of anesthesia services during screening colonoscopies for patients at low risk of sedation-related complications. Although our study is limited by its cross-sectional nature, the central finding of high cost relative to benefits is robust for a range of assumptions.

Our findings also raise questions about the role of the Centers for Medicare & Medicaid Services and other payers. Should payers promote evidence-based practices through their coverage decisions, or should they protect patients financially from prevailing practices even when such practices are not supported by current evidence?

A potential solution would be for payers to create payment bundles for endoscopy procedures that include anesthesia services in a fixed fee. Thus, physicians who perform colonoscopies and other endoscopic procedures would be exposed to the marginal cost of anesthesia services and have incentives to use these services only when medically needed.

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Article Information

Corresponding Author: Hangsheng Liu, PhD, RAND Corporation, 20 Park Plaza, Ste 920, Boston, MA 02116 (hliu@rand.org).

Published Online: September 8, 2015. doi:10.1001/jamainternmed.2015.4585.

Author Contributions: Dr Liu had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Liu, Mattke.

Acquisition, analysis, or interpretation of data: Liu, Predmore.

Drafting of the manuscript: Liu, Predmore.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Liu.

Obtained funding: Liu, Mattke.

Administrative, technical, or material support: Mattke, Predmore.

Study supervision: Liu, Mattke.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by Sedasys, a division of Ethicon US, LLC.

Role of the Funder/Sponsor: Sedasys had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Sedasys is the manufacturer of the SEDASYS Computer-Assisted Personalized System. The system is intended to allow trained physician-led teams to deliver minimal-to-moderate sedation with propofol to patients at low risk of complications during colonoscopy and other procedures. As of June 2015, Medicare had not established a reimbursement policy for the system.

References
1.
Centers for Medicare & Medicaid Services; US Department of Health and Human Services.  Medicare program: revisions to payment policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, access to identifiable data for the Center for Medicare and Medicaid Innovation Models & other revisions to Part B for CY 2015: final rule with comment period. Fed Regist. 2014;79(219):67547-68010.
PubMed
2.
Lichtenstein  DR, Jagannath  S, Baron  TH,  et al; Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy.  Sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2008;68(5):815-826.
PubMedArticle
3.
Howard  DH, Guy  GP  Jr, Ekwueme  DU.  Eliminating cost-sharing requirements for colon cancer screening in Medicare. Cancer. 2014;120(24):3850-3852.
PubMedArticle
4.
Liu  H, Waxman  DA, Main  R, Mattke  S.  Utilization of anesthesia services during outpatient endoscopies and colonoscopies and associated spending in 2003-2009. JAMA. 2012;307(11):1178-1184.
PubMedArticle
5.
Austin  H, Henley  SJ, King  J, Richardson  LC, Eheman  C.  Changes in colorectal cancer incidence rates in young and older adults in the United States: what does it tell us about screening. Cancer Causes Control. 2014;25(2):191-201.
PubMedArticle
6.
Centers for Disease Control and Prevention (CDC).  Vital signs: colorectal cancer screening test use—United States, 2012. MMWR Morb Mortal Wkly Rep. 2013;62(44):881-888.
PubMed
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