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Objectively Pro-Cancer Death Health "Insurance" Giant, Aetna

Sarah's picture

Aetna thinks it's better for their company not to pay for an anesthetist/anasthesiologist's service during a colonoscopy -- and while colon cancer mortality rates have dropped over the past 4-5 years, colonoscopies are the only way of catching this killer early. Can you imagine

how many fewer people will be willing to have this test, if they cannot have anesthesia?
Doctors have been fighting Aetna over this; thus, the "delay" in

ARTFORD, Conn., Feb 27, 2008 (BUSINESS WIRE) -- Aetna (NYSE: AET: 51.40, -0.51, -0.98%) today announced that it will delay the effective date of a new clinical policy addressing the medical necessity of an anesthesiologist's services during routine upper and lower endoscopic procedures, such as a colonoscopy. Aetna has always covered moderate sedation, which is delivered by the treating physician, and is the type of sedation used for the majority of colonoscopies across the country. In the new policy, which was announced in late December, Aetna continues to cover moderate sedation, but only covers monitored anesthesia care for high-risk patients. The policy was scheduled to be effective on April 1, 2008. Aetna will now delay implementation until patient-friendly alternatives - which will not require the added expense of an anesthesiologist - are approved by the Food and Drug Administration (FDA) and available in the marketplace.

And Aetna wants you to believe they're behaving responsibly.


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Submitted by lambert on

Maybe not for this; but for murder by spreadsheet, definitely.

[x] Any (D) in the general. [ ] Any mullah-sucking billionaire-teabagging torture-loving pus-encrusted spawn of Cthulhu, bless his (R) heart.

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Submitted by bringiton on

The issue Aetna is contesting isn't whether or not the patient gets sedation - the correct term, since it really isn't anesthesia but a form of sedation where the patient is essentially dissociated from reality and has their memory download ability interrupted - but whether or not that kind of sedation requires an MD anesthesiologist to be in attendance.

This is a battle about money, about anesthesiologists - MD doctors - losing billable services to registered nurse-anesthetists. For the healthy patient, this kind of sedation is very, very safe. Done all the time in doctor's offices and clinics for plastic and oral surgery with either an RNA or in many cases just the MD surgeon or DDS and an RN. In hospitals, however, this has always been the MD anesthesiologist's turf and their billable patients, but MDs cost more than an RNA so Aetna wants to push them out to reduce the cost.

For a stable healthy patient, is it any more risk with an RNA? No, not at all. Will fewer patients get colonoscopy as a result? No, I don't think so.

Not every decision by the insurers is wrong, only 98.6% of them. This one is in the other 1.4%. Who knew, eh?

Submitted by [Please enter a... (not verified) on

BIO you explain sweetly and calmly why it is more important that money spent for health care should stay in AETNA's pockets rather than be dispensed into the purses of MD anesthesiologists. You should perhaps write ad copy, or better yet congressional hearing testimony, for them you make it sound so reasonable.

However this still seems to leave one group--perhaps as many as 1/4% ? hung out to dry if not die. This only applies to those "high risk patients" who before now have been deemed worthy to have an MD-level service provided. So this "new policy" was going to replace the MD with a "patient-friendly" (don'tcha just love the picture they paint with words?) sedation procedure. Maybe MD anesthesiologists are just inherently a grumpy and surly bunch.

But this procedure doesn't exist just what is going to be provided for this "high risk patient"? Presumably they can have the "moderate sedation" they and you describe as standard. Yet somebody somewhere for some reason has determined that they are "high risk" and therefore need that MD and his magic tubes and gasses. ("High risk" for what exactly is not clarified...panic attack? Allergic or other bad reaction to the standard sedative? Sudden cardiac arrest? Hard to tell. Is this maybe what happens when you have number-shufflers and shekel-grabbers deciding medical care instead of, like, physicians?)

As best i can tell the high-risk person is supposed to suck it up (okay, poor phrasing given the procedure in question, but there ya go) and accept the chance of death from a diagnostic procedure, or do without said procedure until its cost is whittled down to where it balances this patient's worth.

or else STFU and die and restore the serenity of AETNA's accounting and shareholder-relations departments. Yeah, that'll do it.


bringiton's picture
Submitted by bringiton on

Dear sweet, calm, reasonable Xan;

Perhaps, in calling me out as qualified to shill for the health insurance industry and possessing callous disregard for the well-being of the sick and elderly, you have forgotten that just the other day I was railing against the wastefulness of for-profit health care insurers and calling for them to be done away with. Does that seem to you a bit…cognitively dissonant? One day damning the insurers, the next defending a decision they’ve made as correct, must I be either a madman or a fool?

Or just maybe, and yes for some this will be a stretch, I actually know whereof I speak, have my facts straight, and would be willing to explain in excruciating detail to anyone who simply asks – without any need for impugning my motives or painting me as a moral monster.

First, the excruciating detail. Time was, having a colonoscopy was an absolutely excruciating experience. For those who have not had the opportunity, consider how bad you think it must feel and then multiply by, oh, say, a factor of five. Somewhat like giving birth, but in reverse. The choices were to just endure it, or be knocked out; anesthetized, made wholly unconscious. Healthy people could withstand the pain physically, but the emotional scars are something else and yes, many people having had the experience once would certainly put off having it again, risking their physical well-being to avoid the emotional trauma.

For patients with cardiovascular disease or other serious health problems, however, reaction to the pain could be enough to kill them; the only safe way to perform colonoscopy was with general anesthesia, the same as would be done for a major operation, and the only way that could be safely done was under the direct management of a trained MD anesthesiologist.

But science marches on, and all that. Two things have happened; better drugs, and better clinician training.

There are new drugs available, have been for some time, that are perfect for these kinds of procedures. One type acts to dissociate the patient’s consciousness from reality; that is, the patient is aware, awake, and able to answer questions and follow commands, but they re not fully conscious of where they are or who is speaking to them or what is being done to them, and they do not feel sensory input – including pain – at a conscious level. These same drugs also interfere with memory, so that any experiences are recalled as though from a dream. The so-called date-rape drug Rohypnol is an example of one class of drugs with these effects, and there are several others.

Even under the influence of these agents, however, patients still may feel discomfort so another type of drug is always given in addition, one that blocks completely any memory download. The combination allows patients to get through painful experiences like colonoscopy, wisdom tooth extraction, or a facelift without experiencing significant pain, without any memory of the experience, and without any significant side effects. This is an advancement that is all to the good.

Meanwhile, training of medical personnel has also advanced, including a new class of practitioner called a “registered nurse anesthetist” or RNA. These are registered nurses, RNs, who receive additional training in the management of patients under anesthesia. Their training is less extensive than that required for an MD, but it is more than enough to do the job and they are quite as competent within their legal scope of practice as any anesthesiologist. They also are less expensive, and so provide a cost-benefit to the health care system.

The relationship between MD anesthesiologists and RNAs is, to be sure, a tense and unstable one but the RNA is here to stay and anesthesiologists are having to adjust both their attitude and the their income expectations as a result. There have been a number of major developments and if anyone is interested we can discuss them in great detail, but the net of it is that more and more procedures requiring anesthesia are being supervised by RNAs, while MD anesthesiologists have retained –and appropriately so – authority over evaluating patients preoperatively and deciding both the proper course of anesthesia, the drugs to be used, and whether the patient can safely be given over to an RNA or is so ill that the direct supervision of an MD anesthesiologist is required. The expanding use of RNAs has reduced the income of MD anesthesiologists, and made them very sensitive to any new proposals that may threaten what revenues remain.

Meanwhile, extensive experience with these new sedation drugs has been gained, with hundreds of thousands of patients having received them with very few problems. As it turns out, healthy and stable patients can be given these drugs safely and effectively under no more supervision that the attending surgeon and a regular RN, and this is done thousands of times every day in surgical clinics for oral surgery and facial plastic surgery. Properly done, the risks are almost zero and while there have been deaths these have universally been at the hands of incompetent practitioners and a result of their mismanagement, not a consequence of the drugs themselves.

Additionally, newer, even safer drugs are expected to be approved during the summer and fall of 2008, as well as new monitoring instruments whose sensitivity and integrated sophistication can register even the slightest hint of disruption in patient status. With these drugs and the new monitoring equipment, an already very safe procedure will be even safer. Aetna has delayed implementing the new guidelines until these new tools are approved, but in the rest of the civilized world the procedures Aetna is proposing are already the routine – Aetna is not breaking any new ground.

For hospital procedures however, including colonoscopy and endoscopy, MD anesthesiologists have retained either direct administration or supervision rights – and the derived income stream – even for the use of these very safe drugs. What Aetna is proposing is that for healthy patients undergoing colonoscopy and endoscopy under sedation – and this is for healthy patients only – there is no need for an MD anesthesiologist to be in attendance. This will reduce income for anesthesiologists so, quite naturally, they are resisting the proposal, but this is an argument they will lose.

But, a reasonable person might ask, who determines which patients are low risk or high risk? Who decides which patients are healthy enough to be safely treated without an MD anesthesiologist present, and which patients are so ill that they need the kind of monitoring and ready intervention that only a trained physician can provide? The answer, as mentioned above, is that for a hospitalized patient the decision is made by an MD anesthesiologist, independent of the treating physician. The guidelines that describe the assessment process have been developed by the American Association of Anesthesiologists (an adaptation for out-patient procedures is here) and all of the state regulatory agencies have adopted them as standard-of-practice requirements.

To be sure, the bare-bones formal guidelines are limited and to some degree outdated due to the development of safer drugs and safer surgical techniques, so if anything they would if strictly followed lead to a very conservative decision. Under Aetna’s guidelines, consistent with state requirements, all hospital patients undergoing this kind of procedure will be evaluated by an MD anesthesiologist for risk. The anesthesiologist will determine the patient’s risk classification, which drugs are safe to use and whether or not the physical presence of an MD anesthesiologist or RNA will be required during the procedure. State law and national hospital accreditation policies will determine this process, not Aetna.

So, to be clear, Aetna is not – repeat, NOT – denying the usual and customary sedation that is now universally provided for colonoscopy patients. That is simply not in the proposal that was published late last year, the scope of which is discussed in the press release Sarah linked to in her original post. What they are proposing is that for sedation of a healthy, low-risk patient there is no need for an MD anesthesiologist or RNA to physically be in the room. For patients determined to be high-risk by MD anesthesiologists themselves, the guidelines will cover the presence of a trained MD or RNA as the evaluator deems appropriate. Based on decades of experience and the safe outcomes with literally hundreds of thousands of patients having procedures of similar risk with similar sedation, this is in my informed estimation a reasonable, safe and economically beneficial step and one that, from a patient perspective, changes nothing.

I do want to be clear that I share your and Sarah’s suspicion of health insurance companies and encourage the close and critical examination they are being given here. Certainly based on their track record, suspicion and doubt as to motivation should be the default approach. It just happens that this is one of only rare instances where the policy change is justified and reasonable. The same argument would hold if we had single-payer government-run not-for-profit universal health care. It does not make sense to spend more money than necessary for no patient benefit, regardless of the method of health care. This proposal, and my argument in support of it, sounds reasonable, simple and straightforward precisely because it is.

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Submitted by Sarah on

procedure, done 10 years ago, now, via the VA healthcare system -- but, I am thankful to say, they had it contracted out to the local teaching hospital, and yes, there was a nurse-anesthetist attendant.

were I (who am not a high-risk patient, as although diabetic and overweight I don't have hypertension or erratic heartbeat, and I'm not usually subject to panic attacks -- throwing up after we've turned the potential suicide over to trained medical personnel and scrubbed all the blood out of the floorboards notwithstanding) told that I, for the next of these procedures I was to have, would be allowed a valium and 30 minutes to digest it -- I flat wouldn't have the test.

In my small unscientific sample -- the half-dozen or so people who've talked to me about this in the last three days, not only am I not alone, but NONE of the potential (all over 45 years old) patients would voluntarily have this test done -- and three of the six have had it, once, already, with anesthesia (not "sedation": each of us drank the gallon of gut-flush the day before and was knocked cold for the procedure).

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Submitted by bringiton on

Aetna isn't asking people to do without sedation. And the sedation they cover isn't a valium and leather strap to bite on; what Aetna authorizes is what any decent human being would want, dissociative sedation with an amnesiac on top. No more pain than what anyone would describe as discomfort and in any event no memory of even that.

So yes, avoiding colonoscopy because of anticipated pain could be a problem, but that is not the case here. Aetna very freely says they don't want patients to avoid colonoscopy and so they are willing to pay for this kind of heavy sedation, and in fact they were one of the first insurance carriers to do so.

By all means bash ‘em when they’re wrong, which is nearly all the time. The once in a while when they are right shouldn’t get them lambasted, IMNSHO, and for sure it isn’t helpful to mispresent what their policy actually is – weakens the force of argument on the real issues, is all I’m sayin’.

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Submitted by Sarah on

set of horns with the St. Elmo's fire playing on 'em, bringiton -- next thing you know there's going to be a stampede, and I guarandamnteeyou, that stampede is NOT going to be in the direction of the insurance companies as an industry spending money for patient care that they can get out of spending.

They're not in the business of patient care. They're in the business of profitmaking. According to this link, Aetna's announcement yesterday was that it was backing down from a policy change that would have denied payment for sedation. So if they're doing the right thing, I'll raise my voice with this one to reward good behavior.

Submitted by lambert on

I wanna be sedated, but I guess Aetna is not the insurance company for me....

[x] Any (D) in the general. [ ] Any mullah-sucking billionaire-teabagging torture-loving pus-encrusted spawn of Cthulhu, bless his (R) heart.

bringiton's picture
Submitted by bringiton on

This confusion seems to be about misinterpretation of the new policy announcement. From the link you just cited, Sarah:

Aetna retracts policy change
Insurer will delay plan to stop covering sedation during colonoscopies

By GARY HABER, The News Journal
Posted Thursday, February 28, 2008

Aetna Inc., amid an outcry from doctors, patients and state officials in Delaware and elsewhere, on Wednesday backed away from its plan to stop paying for the services of an anesthesiologist to sedate patients during many routine colonoscopies

But “stop paying for the services of an anesthesiologist to sedate patients” is not the same as “stop paying for patient sedation” is it? Yet that incorrect interpretation is exactly what ended up in the subhead of this and other articles.

What Aetna is proposing, and what WellPoint, Humana, Oxford Health Plans/United Health Group and HealthAmerica/Coventry have already implemented, is to stop paying for an anesthesiologist to provide sedation during colonoscopy or esophageal endoscopy. Instead, the sedation will be managed by the gastroenterologist and a registered nurse.

This is already the routine practice for sedation during highly painful procedures like wisdom tooth extractions and facelifts in low-risk patients, and in most of the world and much of the US it is also the routine for colonoscopies. Some years ago, however, anesthesiologists introduced gastroenterologists to the use of the drug propofol. Now, propofol is a wonderful anesthetic and I say that from personal experience, but it is a little dicey because there are no reversal agents – that is, if a patient gets an overdose there is nothing to be done about it except intubation and that requires an anesthesiologist.

Early on, there were some deaths in office practices from propofol overdose when it was used by surgeons who were not trained or qualified for its use. Anesthesiologists, sensing an opportunity, began to lobby for restricting the use of propofol and IIRC those restrictions are now in place in 20+ states. In New York, the use of propofol in colonoscopy increased from 10% to 75% of procedures following restriction of its use to anesthesiologists, essentially giving them a lock on a practice that pays $750 - $1000 per procedure.

But propofol is not the only drug that works well for colonoscopy. A well-known and widely used alternative, the combination of Fentanyl and Versed, also provides satisfactory sedation and many practitioners have also used a combination of Versed and intravenous Valium with excellent results. Additionally, propofol itself is becoming more widely employed by non-anesthesiologists with specialized training, and a prospective research paper reporting the safe use of propofol in 16,000 patients by nurses and surgeons without an attending anesthesiologist will be presented this May. All together, the best available estimate is that there have been approximately 450,000 patients treated with propofol during colonoscopy by nurses and surgeons only, without a single complication.

What is playing out here is a battle between the insurers, who indeed have their own financial bottom line as the sole driving force, on the one hand and on the other the anesthesiologists who stand to lose hundreds of millions of dollars in billings and, frankly speaking, have done a disservice to patients by falsely fear-mongering this issue as though patients would have to endure colonoscopy without pain relief; frightening people for no good reason, to preserve one’s own income, is hardly a noble stance. As these self-interested groups battle one another over money, concern for patient care has taken a backseat – pun intended.

If there is interest in reading further, an anesthesia service provider group blog on the topic is here. There are a number of entries and I recommend reading them all to get a balanced viewpoint.

[“St. Elmo’s Fire on the horns” eh? :-) What’s the lyric? “Ah, they’re fiery and they’re snuffy, and rarin’ to go”]

Sarah's picture
Submitted by Sarah on

"We have determined that in those few markets where monitored anesthesia care has become the routine approach to sedation, implementation of our policy on April 1 would inconvenience our members in those markets and potentially depress cancer screening rates in the short term," Dr. Troyen A, Brennan, Aetna's chief medical officer, said in the release.

St. Elmo's fire on the horns is something I've seen a time or two, mostly in livestock in sale-barn or rodeo-backstage pens in the summertime. (Comes 'one step ahead of the storm,' as they say, or on those hot nights when there's lightning along the horizon and not a hint of rain on the breeze). It does NOT lead to docility among the beasts, nor among those who must handle/ interact with 'em. And I can only imagine what a havoc such ghost-fire would raise among a bunch of half-spooked steers in high-ozone air on unfamiliar ground -- or among a herd of buffalo.

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Submitted by bringiton on

Don’t want to be seen as an unqualified defender of health insurance companies, because I’m not, so if we’re down to the end of this thread that’s all right with me – but – just one more thing. From the same link:

Millerick, the Aetna spokeswoman, said the insurer received between 800 and 1,000 e-mails, letters and phone calls from subscribers and doctors, a tally she called "a fair amount of feedback."

Most of the people the company heard from were unhappy with Aetna's original decision to limit coverage and some mistakenly believed they would have to endure a colonoscopy without any sedative at all.

The insurer plans to undertake an education campaign later this year emphasizing the importance of colon cancer screenings and informing subscribers about their anesthesia options, Millerick said. [emphasis added]

And why would some people mistakenly believe that? Just as a wild guess, maybe because of the spread of misleading information such as that carried in articles like the one cited up-thread that says:

”Insurer will delay plan to stop covering sedation during colonoscopies”

Since the web site that carried this inaccuracy is delawareonline, an organ of The News Journal of Wilmington, Delaware, it may be reflective of the kind of misinformation that was spread throughout the area earlier by the same newspaper:

”Aetna, the nation's third-largest health insurer, with about 95,000 subscribers in Delaware, was blasted by a host of state officials in Delaware earlier this month after The News Journal reported the insurer's new policy.”

And what did the News Journal say earlier?

Aetna pulls full sedation coverage for colonoscopies
Friday, Feb 8, 2008
The News Journal Aetna Inc., eager to cut costs, is restricting coverage of a doctor-preferred anesthetic used during colonoscopies. Doctors fear the move will discourage patients from getting the vital cancer screening…

Doctors like this one, who stands to lose $600 -$1000 per procedure if Aetna’s policy change takes effect:

”Dr. Michael Katz, a Wilmington anesthesiologist, said that while Aetna's decision is ‘a step in the right direction,’ he's concerned it won't lead to a permanent change.
‘It indicates they may still look in the future to step between the physician and the patient, to determine what's best for the patient,’ he said.”

The misinformation spread to the Governor, who spoke out publically against the change, and to the legislature where one grandstanding member threatened to introduce legislation mandating that Aetna cover anesthesiologists for the procedure. The furor, based on a falsehood, spread to patients who in turn called their gastroenterologists.

As I explained above, the truth is that adequate sedation is commonly and safely provided for low-risk patients during colonoscopies without the need for an anesthesiologist and Aetna’s new policy would have provided for an anesthesiologist for higher risk patients. No patient would have been denied sedation as a result of the policy change.

The reason that some patients may have considered deferring a colonoscopy was the spread of misinformation, not because of Aetna’s perfectly reasonable policy. Had the media and government officials taken care to explain the policy accurately, patients would have been reassured rather than needlessly frightened. Whatever the truth may be, people need to know it to make informed decisions. Spreading misinformation, as the News Journal did, does a disservice to patients and the public in general.

I’m not bold enough to claim the last word; anyone has more to say, I’m willing to discuss it further.