Is propofol for colonoscopy sedation worth the cost? Insurance company says no.

October 29, 2019

Last year, Independent Health, the second-largest insurer in the Buffalo Niagara region discovered that Gastroenterology Associates, a private practice with endoscopy centers in Amherst and Niagara Falls, was using an anesthesia group to administer propofol to their patients instead of using what had been their traditional conscious sedation methods. This discovery resulted in Independent Health ceasing payments for the use of propofol for colonoscopies and endoscopies on August 1. The story is discussed in an article in the Buffalo News. 

Propofol sedation for colonoscopy continues to increase in popularity across the country with more gastroenterologists preferring this method. Properly administered, propofol sedates and wakes patients faster, reduces complications during and after the procedure and allows for better visibility of precancerous polyps. Although, all these factors seem positive, the anesthesia bill adds $300 to $500 more per patient, adding cost for insurance companies like Independent Health and for their patients. Administering propofol is more complicated than conscious sedation and requires an anesthesiologist or CRNA for administration and ongoing management. 

Despite the insurance company refusing to pay the additional costs, Gastroenterology Associates are so supportive of the use of propofol that they are willing to take on the extra cost while they gather more evidence in favor of this method of sedation to share with insurers. 

EHC Note: EHC has witnessed the increasing use of propofol for endoscopy across the country where the technique is used in well over half of the cases. More and more hospitals and gastroenterologists are supporting this form of sedation for their patients.  A number of insurers have attempted to resist paying for this coverage over the years, but push back from patients and providers have overturned the vast majority of these attempts.  

As the article points out, there are some clear clinical and patient comfort advantages to using propofol but it also presents part of an escalating predicament for both hospitals and anesthesia groups. Endoscopy is only one example of the rapidly escalating requests for anesthesia providers to cover a variety of Non-Operating Room Anesthesia (NORA) locations.  These locations are often represent an expansion of the original coverage model, are often not on a coordinated schedule with the Main OR and they may be geographically spread about the hospital, making supervision of Anesthetists in a care team model challenging. 

Staffing for these unique NORA locations can present significant challenges for both the hospital and anesthesia group, leading to delays in cases due to “sharing” of anesthesia resources and increased anesthesia subsidies if locations are poorly utilized.  However, if run efficiently (quick room turnover, adequate utilization of staffed locations and enough available equipment) NORA can present a great revenue opportunity……that is if insurance will cover it.