Aetna, one of the nation's largest private health plan managers, is the latest insurer to clamp down on the use of a powerful anesthetic during an increasingly common form of colon cancer screening.
The company will send a letter to doctors today that says it plans to classify the drug as medically unnecessary for most such procedures. As of April 1, Aetna plans to stop paying for its use in those cases.
The change covers about 16.6 million members and comes on the heels of similar moves last year by WellPoint and six months ago by Humana. Other insurers say they have no plans to follow their lead, including UnitedHealthcare, which has 26 million members. Medicare leaves coverage up to local insurers that administer its plans, most of which cover the anesthetic, propofol, only in high-risk cases.
Critics say Aetna's decision would be a step backward in the battle against cancer of the colon and rectum, which trails only lung and prostate cancer as a cause of cancer death among Americans, according to the Centers for Disease Control.
The anesthetic eliminates the discomfort during a colonoscopy, a procedure in which doctors explore the lower intestine to identify - and remove - developing tumors before they become dangerous.
But all three major medical associations for specialists who perform colonoscopies have published guidance saying the anesthetic was not needed for routine procedures.
"This is like a lot of hard to explain geographical variations in medical practice in this country," said Aetna's chief medical officer, Dr. Troyen A. Brennan.
With millions of colonoscopies performed each year and specialists advising all Americans over 50 to get screened, the proper use of this anesthetic could become a multibillion-dollar point of contention.
"It's perfectly appropriate to say this doesn't look like a good place to spend healthcare dollars," said Dr. Douglas K. Rex, a colonoscopy specialist at the University of Indiana.
Propofol is relatively cheap because its patent has expired and a generic version is available. But it is tricky because it acts rapidly and no rescue drug is available to counteract its effects if a patient begins to have trouble breathing.
As a result, most doctors want an anesthesiologist to assist them when propofol is used, but an anesthesiologist can add $300 to $1,000 to the cost of a colonoscopy, according to insurers.
Aetna's policy is a slightly revised version of one it tried to introduce in 2006 but withdrew in the face of strong resistance. It includes an expanded list of exceptions where Aetna will pay for use of propofol and an anesthesiologist, including patients over 65, pregnant women, and patients with illnesses that make the use of other drugs more risky.
Brennan said Aetna believed the exceptions would cover 10 percent to 20 percent of colonoscopy screenings.
Many doctors say that the freedom to choose the treatments used is an important principle to preserve no matter what the cost to insurers because there is little agreement on what really amounts to a medical necessity.
Patients who fear the procedure often opt for less invasive screening techniques such as CT scans and other tests, which are less effective and do not allow doctors to immediately deal with any problems.
The propofol conflict is particularly challenging for gastroenterologists, the specialists who perform colonoscopies.
"There's no doubt patients prefer propofol," said Dr. Lawrence B. Cohen, a gastroenterologist in New York. Many doctors are fans because propofol can make procedures move more quickly and, because patients are usually stiller, which can lead to a more thorough exam.
Using an anesthesiologist also shifts a potentially distracting task normally handled by the doctor or a nurse at no extra cost - administering drugs that keep the patient comfortable - to a third party. In the traditional colonoscopy, patients are given a combination of a narcotic, like Versed, and a tranquilizer, like Valium.
