September 11, 2015
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Costs may outweigh benefits for coverage of anesthesia during screening colonoscopy

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A recent cross-sectional analysis raises uncertainty about the cost–benefit ratio of the 2014 CMS rule change regarding coverage of anesthesia during screening colonoscopy, leading researchers to suggest payment bundling with fixed anesthesia fees for endoscopic procedures.

This change waived cost sharing for anesthesia services during screening colonoscopy for patients at low risk of sedation-related complications in an effort to increase screening rates. Researchers from the RAND Corporation in Boston referenced published literature to quantify costs associated with screening colonoscopy, and used a scenario without the CMS rule change to compare incremental Medicare costs for anesthesia services within three scenarios based on the 2013 rate of anesthesia use, and a 10% and 20% increase to that rate. They calculated the benefit as cost per colorectal cancer prevented using Medicare claims data on anesthesia utilization rates, Behavioral Risk Factor Surveillance System data on colonoscopy screening rates, and published literature on the association between colonoscopy screening rate and cancer incidence.

The investigators calculated a $5.5 million increase per year in costs to Medicare with the 2013 anesthesia utilization rate of 50%, and $16.7 million with a 70% rate compared with the scenario without the CMS rule change. Approximately two-thirds of these costs were allocated to low-risk patients in all scenarios.

They estimated a 0.03% increase (95% CI, –0.01 to 0.07) in colonoscopy screening rate for each percentage point increase in the anesthesia utilization rate, and each percentage-point increase in colonoscopy screening rate was associated with a 0.12% reduction in colorectal cancer rate.

“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 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,” they wrote.

The investigators concluded there is a high cost relative to the benefits of Medicare coverage of anesthesia services during screening colonoscopy for patients at low risk of sedation-related complications, and proposed payment bundles for endoscopic procedures that include fixed fees for anesthesia services as a potential solution. “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,” they wrote.

“The promise of bundled payments is to create incentives for high quality and change the physicians’ perspective on what is important,” David Lieberman, MD, of Oregon Health & Science University, and John Allen, MD, Yale University School of Medicine, wrote in a related editorial. “Another approach is reference pricing. In this model, a purchaser of health care services sets an upper limit of coverage and all billed charges beyond this upper limit are the patient’s responsibility. Patients can choose among a wide variety of facilities and have no co-pay if the price is less than the reference price.” – by Adam Leitenberger

Disclosure: The researchers report no relevant financial disclosures. Lieberman reports being on scientific advisory boards for Exact Sciences, Given Imaging, Ironwood Pharmaceuticals and Motus GI. Allen reports being under contract for internal consulting with gMed, Olympus and Pentax.