Doctors Successfully Repel Aetnas Unwarranted Intrusion Into How They Perform Colonoscopies

After coming under attack from doctors, Aetna has withdrawn its intention, announced late last year, that in New Jersey, effective April 1, 2008, it would drop its coverage of propofol, the anesthesia typically used during colonoscopies, calling the same medically unnecessary. In reality, it is not the propofol that Aetna minds paying for; what Aetna wants to cut-out is the $300 to $1,000 cost that Aetna pays for an anesthesiologist to be present at a colonoscopy.

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. Because of the powerful effects of the drug, good and accepted medical practice usually necessitates the presence of a qualified anesthesiologist during the procedure.

Aetnas plan caused much consternation amongst New Jersey doctors, who were so outraged that they threatened to sue Aetna if it didnt change its mind. Some doctors say that the drug sedates patients more completely during the procedure and allows them to recover more quickly afterward. The physicians thus argued that patients who fear colorectal screenings just would not get them.

Some doctors maintained that propofol helps them by keeping patients calmer than the traditional cocktails they administered of sedatives like Versed and tranquilizers like Valium. Aetna countered by contending that the moderate sedation–which doesn’t require anesthesiologist supervision–works just as well. Aetna said it would continue to cover moderate sedation, but limit coverage of monitored anesthesia care to patients at higher risk.

The doctors won, for now. Aetna has agreed to suspend its plan to stop paying for propofol. Aetna said it did not want to discourage anyone from having a colonoscopy.

According to an Aetna spokeswoman, the company was also concerned about complaints from doctors in the New York region, where many colonoscopies are performed in their offices instead of in hospitals or clinics. Some doctors told Aetna that they were no longer set up to do the procedure without the anesthesiologists.

Cancers of the colon and rectum trail only lung and prostate cancer in cancer deaths among Americans, according to the Centers for Disease Control and Prevention, but survival rates are high when they are caught early. A colonoscopy, in which a flexible tube is inserted into the lower intestine to search for potentially cancerous growths, is the most effective means of early detection. A good quality screening is important, especially in light of the recent study suggesting that flat growths are more common in Americans than once thought, and they appear to be more cancerous than polyps. Unfortunately, flat growths are more difficult to detect than polyps. Failure to timely diagnose colon cancer can, but not necessarily, serve as a basis for a medical malpractice case.

Health insurers are having more success in cutting off reimbursement for care resulting from serious errors. Aetna and WellPoint have begun to include provisions in some contracts that they won’t pay for (or let patients be billed for) care related to 28 “never events” compiled by the National Quality Forum, a coalition of physicians, employers and policy makers.

These never events include the death of a mother in a low-risk pregnancy, leaving instruments in patients after surgery, allowing a patient to develop bedsores and using contaminated devices. Other big insurers, including UnitedHealth Group and Cigna are considering similar moves, as are all 39 members of the Blue Cross Blue Shield Association.

If you believe that you or a loved one has been a victim of medical malpractice at a hospital, including suffering pressure ulcers, or bed sores, an object left in a patient during surgery, a fall, a blood transfusion error, an air embolism, an infection of the area between the lungs after heart bypass surgery, a urinary tract infection or vascular infection from using catheters, or other complication, please contact the medical malpractice lawyers at Levine & Slavit. We have offices in Manhattan and Long Island, handling cases in New York City, the Bronx, Brooklyn, Queens and surrounding areas. To learn more, watch our videos.

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