Insurer Aetna Axes Coverage for Colonoscopy Drug

Dec. 29, 2007— -- As insurance giant Aetna plans to eliminate coverage for a powerful anesthetic used sometimes during colonoscopies, doctors are locked in debate over whether such a move is appropriate.

The drug propofol, also known by the trade name Diprivan, is more powerful than other sedatives traditionally used to help patients endure the discomfort of a colonoscopy in which a flexible tube is inserted into the lower intestine to search for potentially cancerous growths.

Some doctors say that the drug sedates patients more completely during the procedure -- and allows them to recover more quickly afterward. But the powerful effects of the drug usually necessitate the presence of a qualified anesthesiologist during the procedure, which can add between $250 and $400 to the total cost of the screening.

On Friday, Aetna sent a letter to doctors announcing its plans to classify the drug as "medically unnecessary" for most colonoscopies. On April 1, the company intends to stop paying for its use in these cases.

Dr. Donald David, director of gastroenterology at the City of Hope National Medical Center in Duarte, Calif., says he believes the pullback is a step in the right direction when it comes to controlling costs.

"I think that this is not unreasonable, as the cost of this kind of sedation often exceeds the entire payment to the [gastroenterologist] for the procedure," he says.

"Since this does not affect the great majority of patients who are having this done -- painlessly and without recollection for the procedure I might add -- this is not a bad thing as long as they cover it for the select few who need it. The money saved could be used to screen more individuals."

Others note that doctors have a number of alternatives when it comes to sedation during a colonoscopy.

"At present, there is no evidence that the use of propofol leads to better clinical outcomes," says Dr. David Weinberg, chairman of the department of medicine at Fox Chase Cancer Center in Philadelphia. "In most cases, it is not necessary. Colonoscopies were and are performed without this particular drug all the time."

But a number of doctors say the move by the insurance company could eliminate a useful tool.

"Patient satisfaction is much higher with propofol, and this is borne out in numerous studies," says Dr. David Posner, chief of gastroenterology at Mercy Medical Center in Baltimore.

"I have had two colonoscopies, one with the usual moderate sedation," he says. "I was hung over for four to six hours afterward. The second was with propofol, and I was awake and fully aware within 15 minutes and went shopping with my wife right after we left the facility. That is the entire difference."

And Dr. James Cottrell, chairman of anesthesiology at Downstate Medical Center in Brooklyn, N.Y., and past president of the American Society of Anesthesiologists, says that the move trespasses dangerously into the doctor-patient relationship.

"I don't think that the insurance companies can decide what is and isn't medically unnecessary," Cottrell says.

"This shouldn't be about whether an insurance company approves of or disapproves of a procedure. It really should be about the doctor and the patient."

'Medically Unnecessary'?

Aetna, the country's third-largest health care insurer, is not the first to yank coverage of propofol for most colonoscopies. WellPoint, the nation's largest insurer, instituted a similar move last year. And insurer Humana largely eliminated its coverage of the drug for colonoscopies about six months ago.

David notes that this change will likely have little effect on most patients getting a colonoscopy.

"Ninety percent or more of the colonoscopies are done with lighter sedation -- moderate or conscious sedation -- and only a small percentage actually need propofol," he says.

Dr. David Schoetz, chairman emeritus of the Tufts University School of Medicine's department of colon and rectal surgery, agrees.

"As a general rule, I agree that the use of propofol is medically unnecessary," he says. "The use of a general anesthetic may be necessary under specific circumstances, but these should be determined on an individual basis for each patient. If a patient were to ask, I would tell them it was not necessary."

But Dr. Steven Stryker, professor of clinical surgery at the Northwestern University Feinberg School of Medicine in Chicago, Ill., says that the move by Aetna will make it more difficult for patients who could benefit from the drug during a colonoscopy to have access to it.

"I would agree with the statement that not all patients require propofol for a routine colonoscopy but strongly disagree with the labeling of that option as 'medically unnecessary,'" he says.

The Cost Factor

Stryker adds that the move by Aetna and other insurers sets a dangerous precedent in which costs are accorded a higher priority than patient care.

"As with many recent moves by the insurance industry, this cessation of coverage for propofol is strictly about the money," he says. "There are no data to suggest that this move improves patient safety."

"The insurers are not doing this to provide better patient care," Posner agrees. "They are trying to save money, and that is all of the argument."

Indeed, considering the millions of patients who will likely be affected by the change, billions of dollars could hang in the balance.

Messages left with Aetna were not immediately returned.

Still, some doctors note that the move could be about more than just the bottom line. A more traditional combination of sedatives normally used for colonoscopies -- a mix of Fentanyl and Versed -- may be easier for doctors to control, and hence safer. And Weinberg says the tighter restrictions on coverage for the drug will not likely be the main factor that dissuades many from getting their recommended screenings.

"A small percentage may avoid it because of a perception about sedation, but there are many other more important barriers," he says. "In addition to fear, most people cite embarrassment, lack of access -- no or inadequate insurance -- and perhaps most importantly, the absence of a physician recommendation that they participate."

But Stryker says the move by Aetna could still have a detrimental impact.

"The fact that only about 40 percent of Americans who would benefit from potentially life-saving screening colonoscopy are actually undergoing the procedure is appalling," he says. "A major reason for failure to get screened is fear of discomfort during the procedure.

"We need to be focusing on ways to increase the level of participation in screening for colorectal cancer; failing to pay for the use of propofol will have the exact opposite effect."