Utilization of anesthesia services for gastrointestinal endoscopy is increasing
Should a low-risk patient, i.e., one with an ASA physical status level of 1 or 2, receive general anesthesia for gastrointestinal endoscopy? If the use of anesthesia services increases cost for such patients, should it be allowed? Both questions are difficult to answer, yet the numbers of patients undergoing such procedures and the percent who receive anesthesia are also increasing. In the article “Utilization of anesthesia services during outpatient endoscopies and colonoscopies and associated spending in 2003-2009” published in the 21 March 2012 issue of JAMA, Dr. Soeren Mattke, RAND Corporation, Boston, Massachusetts, and colleagues describe their use of insurance claims data for patients with Medicare or commercial insurance who underwent upper gastrointestinal endoscopies and colonoscopies between 2003 and 2009. About 14% of commercial insurance patients had ASA status coded; for the remainder of patients with commercial insurance and those with Medicare, ASA status was based on a multivariate logistic model.
Between 2003 and 2009, 2.2 million gastroenterology procedures were performed on patients with Medicare insurance and 7.0 million on patients with commercial insurance. In patients with commercial insurance, the number of gastroenterology procedures increased by over 50% between the years of study; however, for patients with Medicare, the number of gastroenterology procedures stayed fairly constant. For both groups, the proportion of patients who received anesthesia services increased similarly with commercial insurance increasing from 13.6% to 35.5% and Medicare from 13.5% to 30.2%. Patients in the West region of the United States had the lowest use of anesthesia services; the highest use was in the Northeast. The proportion of anesthesia services delivered to patients with ASA status 1 or 2 decreased in patients with Medicare from 79% to 64% between the years of study while in patients with commercial insurance the proportion was constant. Though annual payments for anesthesia services per 1 million enrollees for patients with Medicare doubled, the cost per procedure remained constant. For patients with commercial insurance, annual payments per 1 million enrollees increased more than 4-fold and the cost per procedure increased by 14% between the years of study. Spending when weighted to the national level tripled between the years of study, with an increase to $1.3 billion, specifically $1.1 billion in 2009 for Medicare patients and $945 million for patients with commercial insurance.
Dr. Lee A. Fleisher, Department of Anesthesiology and Critical Care, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, in the accompanying editorial, “Assessing the value of ‘discretionary’ clinical care: the case of anesthesia services for endoscopy,” noted:
Should patients be denied the opportunity to undergo endoscopy or colonoscopy with the added benefit of anesthesiologists or anesthetists who can provide deeper sedation and incremental monitoring even if anesthesia is a discretionary service? Careful implementation of new policies regarding ‘potentially’ discretionary services need to incorporate the patient and clinician perspective while continuing to implement change that bends the cost curve. This may require all parties, including patients, clinicians, and facilities, to have a greater stake in the financial consequences of their action.