Clinically speaking, no one can question that colonoscopy is ideally suited for the outpatient setting. But now the economics of colonoscopy are under attack from all sides, as a number of recent announcements and studies have posed business questions about how the procedure is performed. Observers of the specialty offer their views on how these issues are affecting the practice of colonoscopy.

Is colonoscopy overused?
The statement that received the greatest amount of attention and grabbed the most news headlines was the one suggesting that colonoscopy was overused.

Last month, the American Board of Internal Medicine Foundation, the advocacy group Consumers Union and 9 medical societies, including the American Gastroenterological Association, joined forces under the title "Choosing Wisely" to issue a list of 45 medical tests and procedures (5 from each society) that patients might be undergoing with unnecessary frequency and which may be needlessly inflating healthcare costs.

Two of the AGA's contributions to the effort addressed colonoscopy. First, physicians shouldn't repeat any method of colorectal cancer screening for average-risk patients within 10 years of a high-quality, negative-result colonoscopy. Second, they shouldn't repeat the procedure for at least 5 years among patients who've had 1 or 2 polyps smaller than 1cm removed through a high-quality colonoscopy.

These recommendations are by no means revolutionary: In fact, they're evidence-based guidelines drafted and long agreed to by the GI specialty's 3 professional organizations: the AGA, the American College of Gastroenterologists and the American Society of Gastrointestinal Endoscopy. "We didn't blaze new trails. These already had support in the medical literature," says Lawrence R. Kosinski, MD, MBA, AGAF, a managing partner at the Illinois Gastroenterology Group in Chicago and chair of the AGA Institute's practice management and economics committee.

In Dr. Kosinski's view, the main point of the recommendations isn't "shouldn't repeat," but rather "high-quality." The GI field isn't seeing a spate of unscrupulous practitioners milking insurers' reimbursements by overperforming colonoscopies, he says. But are physicians confident enough in their colonoscopies to stand by the results for the allotted intervals?

"Some may not have explained the prep thoroughly enough, so patients' GI tracts are not as clean," he says. "Or maybe they're not as sedated as they should have been, resulting in having to rush through the procedure. Some doctors may be uncomfortable waiting 10 years, knowing they may have missed something. You should be performing a high-quality colonoscopy so you can live with the guidelines."

Douglas K. Rex, MD, FACG, the director of endoscopy at Indiana University Medical Center in Indianapolis and a past president of the ACG, agrees. "We have evidence that when colonoscopy is repeated after a shorter time, the rate of finding polyps is very low," he notes. "Shortened intervals are not logical or cost-effective."

What is logical and cost-effective, however, is improving baseline screenings. "What we really need is people who perform quality colonoscopies," says Dr. Rex. The question is, how can this quality be measured to ensure consistency? There are voluntary national databases, but by and large the matter is up to individual practitioners, and "we want quality across the board," he says. "We don't want it to be operator-dependent. Imagine how that would work in the airline industry."

Dr. Kosinski suggests that it is up to facilities or practices to monitor polyp-capture rates. Each individual physician should be finding them at a rate that roughly approximates the national average, or else their colonoscopies might not have been performed adequately.

Must anesthesia be in the room?
A study appearing in the March 21 issue of the Journal of the American Medical Association examined the increased use of anesthesia services to sedate colonoscopy and upper GI endoscopy patients, a trend it said adds about $1.1 billion in case costs per year.

The study, conducted by a Rand Corporation researcher, observed that most of the patients who received anesthesia were considered low-risk (that is, American Society of Anesthesiologists' physical status class 1 or 2). It questioned the value the services provided and whether they might be limited to control costs as more and more patients undergo screenings.

According to anesthesiologist John Woody, MD, who practices at the Surgery Center of Lakeland Hills Boulevard in Lakeland, Fla., the value is not in dispute. "Anesthesia participating in colonoscopy isn't just a luxury," he argues, "it is an advancement in providing the best possible care to patients."

The cost of anesthesia services — in particular, the use of propofol — is the cost of quality patient care, he says. In fact, he notes that propofol can decrease case costs in more ways than one: quicker inductions and recoveries, more efficient use of a physician's time, ability to schedule more cases, and decreased risk of respiratory compromise or other adverse reactions (such as tachycardia or hypertension).

Also, patients are more willing to undergo and tolerate colonoscopy. "Many patients avoid the procedure due to their past experience with sedation that was incomplete," says Dr. Woody. Happier patients means a happier staff. "Holding down screaming patients isn't good for anyone."

These cost and efficiency benefits have been a saving grace for his center, since more cases equals healthy revenue, even with shrinking reimbursements. "We could not make it without Diprivan," he says. "Our surgery center would shut down." In the end, the patient population reaps the overall benefit. Screening more patients means catching more polyps, he says. While anesthesia services add costs to the procedure, treatment for undetected cancer is much more expensive.

Still, the study's cost question is one that March E. Seabrook, MD, FACG, of West Columbia, S.C.-based Consultants in Gastroenterology and chair of the ACG's national affairs committee feels is well worth asking. "Proper sedation is an important part of a successful procedure," he says. "The real question is, how much is that worth? This is a valid issue."

The preference for propofol may make colonoscopy easier for the patient and physician. But, he says, it also makes it exponentially more expensive for insurers since most states' laws don't let gastroenterologists or GI nurses administer the drug themselves. "Anesthesia does drive up costs ... but our healthcare system is absolutely going broke," says Dr. Seabrook. "We need to make sure that the services we provide have value."

One possible solution is the choice of anesthesia agent used. "Do some people need propofol to get comfortable? Yes," he says. "Do most people need propofol? No." For those that don't, he often opts for a combination of Versed and Demerol (or fentanyl), which he finds as clean and well-tolerated as propofol. The results are generally good, he says, with about 71% of his patients saying they remember nothing from the case; about 24% reporting a slight memory of the case, but no discomfort; and only about 5% reporting discomfort during the case.

When is a screening not a screening?
Medicare has covered colonoscopies for the purpose of colorectal cancer screening since 1998, and 2010's Affordable Care Act waived the annual deductible and co-pay for Medicare beneficiaries undergoing the procedure. But an oversight in the healthcare reform law brought an unintended consequence.

While screening colonoscopies are covered for Medicare patients, therapeutic colonoscopies are not. This means that a patient scheduled for a screening may believe the procedure is covered, only to end up on the hook for co-insurance payments of $100 to $300 if polyps are discovered and removed or if a biopsy is taken during the procedure, unpredictable eventualities which would reclassify the procedure as therapeutic. Gastro-intestinal practitioners fear that this cost uncertainty may deter Medicare patients from seeking the beneficial screenings.

"The incentive should be for patients to undergo screening," wrote Robert Fusco, MD, of Three Rivers Endoscopy Center in Moon Township, Pa., in a recent e-mail. "Regardless of whether a polyp or lesion is found, it is much more cost-effective to waive the co-insurance than to pay the treatment costs of colorectal cancer."

That's why he, along with the Ambulatory Surgery Center Association and other GI observers, are backing a legislative fix making its way through Congress with bipartisan support. House Bill 4120, sponsored by U.S. Rep. Charles W. Dent, a Republican from Pennsylvania, seeks to close Medicare's inadvertent colonoscopy loophole by ensuring that screenings are free to all beneficiaries, even if therapeutic measures are unexpectedly required mid-procedure.

While Medicare's screening oversight doesn't affect surgical facilities from a revenue point of view, it's in a facility's interest to stand up for its patients, says Andrew S. Weiss, CASC, administrator of the Endo Center at Voorhees in New Jersey.

"We always try to act as an advocate for the patient," he says, in dealing with insurance companies and managing expectations so as to prevent unpleasant surprises when the bill arrives. "What we try to do is educate the patient as much as possible ... but [the screening oversight] is creating a lot of confusion with patients. 4120 is a step in the right direction. Hopefully it will close the loop on it."

The bill, which was introduced in the House of Representatives on March 1, is currently under consideration by the Subcommittee on Health.

Are physicians rushing through the procedures?
"Is production pressure jeopardizing the quality of colonoscopy?" asked the title of a survey published in the March issue of the journal Gastrointestinal Endoscopy. Approx-imately 92% of its respondents said "maybe."

For the study, researchers at Mount Sinai School of Medicine in New York City surveyed 1,073 members of the ASGE about the pressure they'd encountered to boost their throughput in the face of increasing demand and overhead, and decreasing reimbursement. Their findings shone a spotlight on the fatigue that GI physicians experience and how it might affect the work they do.

A total of 92.3% admitted that production pressure adversely affected how they conducted colonoscopies, which may have an impact on its quality and eventual outcome, researchers wrote. Among the adverse effects respondents reported were scoping a patient with an unfavorable risk/benefit ratio (69.2%), not having enough time to properly assess a patient in advance (13%), cutting short a colonoscopic inspection (7.2%) and postponing polyp removal for another session (2.8%).

Some practitioners, however, discounted the usefulness of the survey due to its low response rate and subjective premise. "Everybody feels production pressure," says Dr. Rex. "That's a part of life and a part of work and a part of working hard." He noted that, as compared to the 92.3% who expressed concerns over production pressure, very few said they'd ever shortchanged a procedure due to pressure. "Sometimes you schedule more cases than you can confidently do, but almost no one provides a bad job," he says.

"This is a reality of any industry that is driven by increasing productivity demands," says Dr. Kosinski. "Hopefully we're highly trained professionals making decisions in the best interests of the patient. None of us wants patients to be injured by our need to be productive."

This may require a more realistic, practical approach to scheduling cases, he says, recalling studies which have demonstrated a higher miss-rate in afternoon colonoscopies as compared to morning ones. He also advises using benchmarking and quality monitoring to supervise on the large and small scale. "If your internal quality is thorough, you'll have no fear of external reporting," he says. "And if you're conscientious about performing quality colonoscopies, the data is going to drive compliance."