A new policy from Blue Cross Blue Shield Massachusetts, starting Jan. 1, will restrict coverage of monitored anesthesia care (MAC) for patients undergoing endoscopic procedures like colonoscopies.
Patients classified as American Society of Anesthesiologist class I or class II will no longer receive coverage. These patients usually do not have accompanying comorbidities. The coverage restriction also applies to bronchoscopy and certain pain procedures.
The decision has been decried by national groups — including the American College of Gastroenterology, the American Society for Gastrointestinal Endoscopy and the American Gastroenterology Association —as they warn it will lead to less safe clinical conditions for patients and a lower overall quality of care. They said it will also worsen the state’s backlog of screenings. Their meetings with legislators and BCBSMA leaders have so far not persuaded the insurer to change its mind, which stands to save money should the changes take effect next month.
With disease rates rising for reasons unknown, colonoscopies have been shown as one of the best ways to identify and prevent colorectal cancer. This policy acts as a “regressive” move, said Max Tilson, M.D., vice president of the Massachusetts Gastroenterology Association and a physician for Integrated Gastroenterology Consultants.
“My concern is that with this enactment of limitations on coverage, we’re going to make an existing public health problem worse,” he said.
Amy McHugh, BCBSMA director of media relations said in an email to Fierce Healthcare that among the groups spared from the new policy are those with conditions that warrant a more regular cadence for colonoscopies, patients who have a failed procedure, patients with a fear of medical procedures and patients with a chronic condition that warrant the use of deep sedation.
“We do not support a one-size-fits-all approach,” she said.
New policy could increase state screening backlogs, docs say
In March, the state insurer announced that some patients would not be covered for MAC, instead only covered by moderate sedation, otherwise known as conscious sedation. BCBSMA said moderate sedation is “comparably safe and more cost effective” in certain patients, and that the cost would be the same for members regardless of sedation type.
BCBSMA postponed the coverage change in May until January. In a letter shared with Fierce Healthcare, the health plan gave more insight to GI groups earlier this week regarding its Jan. 1 enforcement of the new policy.
“Your organizations claim that MAC is recognized as the standard of care by most insurers for GI endoscopy procedures,” said Sandhya Rao, M.D., chief medical officer and senior vice president of health and medical management at BSBSMA, in the letter. “We have done extensive research and have medical policy benchmarking that suggests otherwise.”
GI groups are unconvinced by the insurer’s rationale.
“This is all about money for the payer,” said Scott Ketover, president of the Digestive Health Physicians Association. “This is not about quality of health care.”
Critics of the policy say patients arrive day of the appointment expecting to be put under for a colonoscopy, and that being told their health plan doesn’t cover MAC is scary for patients that don’t want to be awake for an uncomfortable procedure. Since BCBSMA is a major presence in the state, the new policy will impact a large proportion of patients.
If moderate sedation begins but a patient is not comfortable enough for the physician to continue the procedure, which happens in about 10% of cases, they must reschedule for another date where it’s then likely MAC would be administered anyway.
Tilson said that significant backlogs for endoscopic procedures exist throughout the state, partly due to the colorectal cancer screening guidelines being lowered from age 50 to 45. He worries the bottleneck is going to get even bigger at a time when there is a backlog of 65,000 people needing procedures in Boston-based hospitals.
Physicians worry about workforce impact and safety standards
Lauren Bleich, M.D., president of the Massachusetts Gastroenterology Association and a practicing physician, said if a patient fails a colonoscopy prep in early January, they might not get another appointment until the summer months. Assuming the new policy is enacted, that would cause further strain on the system, ultimately resulting in more stressed providers and patients dealing with the brunt of BCBSMA’s decision.
“The other thing with conscious sedation is that many nurses are not trained in this art,” she said. “It is an art administering medications, so we will have limited access for our Blue Cross patients to receive these procedures.”
BCBSMA told providers that administering moderate sedation is still a core competency for endoscopists on the Accreditation Council for Graduate Medical Education, and The Joint Commission requires a trained nurse to perform moderate sedation. It also said it is seeing anecdotal reports that suggest longer wait times with MAC than without.
“Historically when we’ve done this, we’ve been able to do maybe 10 or 11 procedures per day,” refuted Tilson. “Now that we’ve switched to anesthesia-based sedation, which is a much faster onset and much faster recovery, we’re able to do anywhere between 15 and 16 procedures a day.”
Physicians also say MAC is the normal standard of care these days – and has been for many years. Tilson said 60 to 70% of all endoscopic procedures in Massachusetts opt for MAC over moderate sedation, and it would be an even greater percentage if other big hospitals in Boston didn’t use moderate sedation due to resource constraints.
BCBSMA said 60% of procedures is not enough to constitute MAC as a standard of care.
Ketover noted that quality of care and safety is improved with a dedicated anesthesiologist on hand. He believes that just because procedures can be completed with moderate sedation, that doesn’t mean they should.
“Why should we pay more for MAC service? My answer to that is it’s a completely different service,” he said. “In fact, I believe so strongly in it that if we invented endoscopy today, it would exclusively be done with MAC.”
“Part of my challenge to insurance company executives on this issue is I said, ‘I will donate my time and I will give you two colonoscopies: one with conscious sedation and one with MAC. Afterwards we can talk about your experience and which one you would prefer to have next time," Ketover said.
He said that some patients which fall under ASA-1 and ASA-2 categories are generally healthy but may be on antidepressants or using drugs like marijuana or alcohol. This makes the patient hard to sedate, requiring more conscious sedation medication to have the same outward effect. Moreover, long-term effects of patients that are put into deep sedation, versus moderate sedation, are not known.
“I think this reliance on ASA status for who gets MAC and who doesn’t is a fallacy,” he said. “I think everybody should get MAC. I think that's what insurance companies should be paying for, and it's not just about propofol.”
Propofol is the drug currently administered during MAC in the state. It is not used for moderate sedation.
Tilson said local payers have tried similar changes in the past but have been thwarted by public pressure. But the MAC policy appears to have only been successfully introduced in Iowa (PDF) across Wellmark Blue Cross Blue Shield plans, and now, across Massachusetts if plans are carried out.
Tilson believes national carriers wouldn’t attempt this policy. He points to the pushback UnitedHealthcare received earlier this year when it rolled back its plan to mandate prior authorizations for endoscopic procedures, calling the BCBSMA policy potentially more damaging.
“If a UnitedHealthcare provider tried to do that, I think you’d see an even louder outcry,” said Tilson. “My concern is that if they’re successful implementing this in Massachusetts, they’re going to do it nationally. If you increase the barriers of screening in Massachusetts, that’s one thing. But doing it nationally is just unconscionable.”