Changes To Insurance Coverage For Colonoscopies: What You Need To Know

WORCESTER - The next time you need a colonoscopy, be sure to read the fine print if your health insurance is covered by Massachusetts Blue Cross Blue Shield.

In the year Effective Jan. 1, the insurer changed its policies for endoscopy procedures, including colonoscopies, and some in the medical community worry that this is not only a bad decision for patients, but a way for Blue Cross to cut costs.

According to the American Cancer Society, medical professionals recommend that men and women ages 45 to 75 have regular colonoscopies to detect colon cancer, the second leading cause of cancer death in the United States.

What has changed this year is that Blue Cross will cover the full cost of sedation in a procedure called supervised anesthesia if the doctor deems it medically necessary.

To be medically necessary, a patient must have pre-existing conditions. According to Blue Cross, causes include serious illness, a history of sedation side effects, diabetes, high blood pressure, failure to follow instructions, drug or alcohol abuse, patients between the ages of 18 and 70, and pregnant women. .

If these and other risk factors are absent, Blue Cross will only cover the cost of moderate sedation, also known as conscious sedation. This means that the patient is not completely cured during the colonoscopy.

The insurance change could affect thousands of patients in Massachusetts who are used to fully-sedated colonoscopies. Currently, more than half of Blue Cross Blue Shield of Massachusetts patients who undergo colonoscopies are fully colonized.

Blue Cross processes approximately 74,000 colonoscopy patient applications each year in Massachusetts. About 47,000 are performed in hospitals, 56% of which are under general anesthesia. Another 26,000 are performed in endoscopy centers alone, and 75% involve full sedation. The new law could prevent thousands of patients from having insurance coverage for complete peace of mind because colonoscopies are deemed not to be medically necessary.

A concern in some medical circles

That fact worries some of the state's top health officials. The Massachusetts Health and Hospital Association believes this policy limits access to colonoscopy and may jeopardize patient safety.

The association pointed out several problems. The first is to limit general anesthesia after colonoscopies were banned during the Covid-19 pandemic and colorectal cancer rates and deaths in the under-55s have risen. According to the association, these two events caused a significant backlog of patients waiting for colonoscopy. .

In addition, the association stated that there is a shortage of nurses trained to provide moderate palliative care. Additionally, recovery times are longer with moderate sedation, so there is a backlog in the colonoscopy pipeline, meaning it takes longer to see patients.

"The bottom line is that physicians, not insurance companies, should be able to decide what type of sedation is best for their endoscopy patients based on the patient's condition and other clinical variables," said Karen Granoff, the association's executive director. Services. Careful. "Major medical groups have made it clear that the Blue Cross policy is leading to delays, inefficiency and a poor patient experience and staffing problem because many nurses are not trained to practice sedation."

Why is this cover change necessary?

Blue Cross said the change is consistent with updated guidelines from the American College of Gastrointestinal Endoscopy.

The guidelines highlight the health risks associated with general anesthesia, Dr. Sandhya Rao, chief medical officer and senior vice president of Blue Cross Blue Shield of Massachusetts. Therefore, the insurer follows the guidelines to ensure that its members receive quality, reliable and affordable care.

"Our goal is to enforce this policy," he said, adding that after hearing concerns from gastroenterologists, Blue Cross expanded the list of clinical conditions that qualify patients for general sedation.

According to the American Society of Gastrointestinal Endoscopy, risks associated with general sedation include aspiration, cardiopulmonary abnormalities, and intestinal perforation.

Cruz Azul: "Trying to Save Money on Stabilization Costs"

Blue Cross's financial health could be at risk, and to keep it healthy, some suggest the insurer could cut costs by limiting full sedation for more expensive colonoscopes.

"I think Blue Cross is trying to save money on palliative care costs. There's no doubt about that," said Dr. Christopher Marshall, chief of gastroenterology at UMass Memorial Health.

Paul Hattis, a senior fellow at the Lown Institute, believes that general sedation has "increased the cost of colonoscopy significantly".

Full sedation is expensive because the gastroenterologist and the anesthesiologist must administer propofol to completely sedate the patient. The average cost of a colonoscopy in the United States is about $3,000. This can be compared to more expensive moderate sedation, a nurse sedation such as midazolam with a pain reliever such as fentanyl.

Rao emphasized that doctors, not Blue Cross, decide which procedure should be performed on a patient. He also reiterated the insurer's position that general sedation carries significant medical risks, according to the American Gastrointestinal Endoscopy Guidelines. Therefore, “the goal of the guideline is to ensure that members receive clinically appropriate and policy-compliant care.

Asked how the policy change would affect Blue Cross's financial results, Rao said, "It's too early to say what the financial impact will be."

Hospital profits are at risk

Hospital profits may decrease as general palliative procedures generate less revenue.

“The whole story has not been told. "I don't know how this will affect results at UMass or other institutions," Marshall said.

It's unclear how much revenue UMass Memorial Health makes from colonoscopies, as the company refuses to provide up-to-date information on patients, including revenue from endoscopic procedures performed, patient-specific numbers and revenue from colonoscopies.

"Unfortunately, we do not have this information," a UMass Memorial Health spokeswoman said in an email.

The state Department of Health did not release numbers for hospital colonoscopies in its latest report on colon cancer in Massachusetts. But Massachusetts offers colonoscopies: The American Cancer Society reports that 70 percent of citizens age 45 and older are screened for colon cancer. This is the highest rate in the United States, tied with the District of Columbia.

Another reason is that the Affordable Care Act requires private insurers and Medicare to cover the cost of routine colonoscopy exams. If additional procedures such as the removal of cancerous polyps are necessary, the patient will cover some of the cost.

When asked how the Affordable Care Act influenced Blue Cross' decision to change coverage, Rao confirmed that patients would not be out-of-pocket if doctors performed colonoscopies not covered by the Affordable Care Act. It is not related to the medical examination provided to the policy or insurance.

"Our contract prohibits physicians from paying their patients directly to the anesthesiologist unless it is covered by Blue Cross. If there is deep sedation and there is no clinical reason, the participant (patient) does not bear the cost under the terms of the contract," Rao said.

However, if a Blue Cross member agrees with the health care provider to assume financial responsibility for payments other than what the insurer charges, the member must pay the balance.

Cruz Azul's politics have their problems.

Marshall cited several issues about switching insurance from Blue Cross. He believes that private endoscopy clinics do not have nurses trained to administer sedation. Additionally, other insurance companies could follow Blue Cross's lead and encourage more patients to receive moderate sedation. Additionally, more staff are needed to identify cases and decide who should receive full or partial sedation.

"Throughput" is a term Marshall uses to describe how insurance switching affects the efficiency of endoscopy services and creates a backlog of patients with longer wait times.

"The problem is that the performance of endoscopic units decreases when there is less use of propolol. They reduce the ability to do business and make access (to colonoscopies) more difficult.

Conscious sedation has been a standard colonoscopy procedure for decades, according to Marshall. The "recent event" is deep sedation by the anesthesiologist with propopol.

According to Marshall, both procedures are safe, but total sedation offers advantages such as: b. For patients to fall asleep and wake up early. This allows an additional colonoscopy to be performed. Another reason is that older patients have complex medical problems and need an anesthesiologist to assist with sedation.

Talk to your doctor to determine the best option.

For Marshall, complete and moderate sedation has its place, and it's important to talk to your doctor to decide which procedure is best for you.

With changes in Blue Cross insurance now offering more patients the chance to use general anesthesia and avoid future exams, Marshall says the key is patient education.

He said the medical community has not done a good job in this area.

"Just because Blue Cross doesn't pay for deep sedation doesn't mean [sedation] won't be comfortable. You won't have a good experience," Marshall said.

"It's about managing expectations to understand what the experience will be, not just engaging the patient and saying 'let's do it'."

Contact Henry Schwan at henry.schwan@telegram.com. Follow him on X: @henrytelegram .

This article originally appeared in The Telegram & Gazette: Blue Cross Blue Shield of Massachusetts investigates colonoscopy coverage.

Abdominal polyp removal (endoscopy).