Unnecessary Anesthesia Services for Gastrointestinal Endoscopies Increase Costs

During a 6-year period, utilization of anesthesia services for gastroenterology procedures increased significantly, particularly in low-risk patients who may have been candidates for less expensive intravenous sedation [JAMA. 2012;370(11):1178-1184].

To quantify temporal comparisons and regional variation in the use of anesthesia services in low-risk patients, the researchers conducted a retrospective analysis of insurance claims data for 1.1 million Medicare patients and 5.5 million commercially insured patients who had outpatient gastrointestinal (GI) endoscopy between 2003 and 2009. The investigators used 2 data sets: the Medicare Limited Data set, consisting of a nationally representative 5% sample of Medicare beneficiaries, and the Thomson Reuters MarketScan data set, with approximately 40 million individuals commercially insured through 150 plans at larger companies. The American Society of Anesthesiologists physical status classification was used to determine the need for anesthesia services. Patients labeled level 3 (severe systemic disease) or higher required anesthesia services. Patients labeled level 1 and 2 were considered low risk, and the use of anesthesia services was deemed potentially discretionary.

Main outcome measures included the number of upper GI endoscopies and colonoscopies, proportion of gastroenterology procedures that used anesthesia, payments for gastroenterology anesthesia services, and proportion of services and spending for gastroenterology anesthesia services administered to low-risk patients.

The results showed that the number of gastroenterology procedures per 1 million enrollees remained stable in Medicare patients (mean, 136,718) but increased >50% in the commercially insured patients, from 33,599 in 2003 to 50,816 in 2009. Also, there was significant regional variation in the proportion of procedures using anesthesia services in both populations, ranging from 13% in the West to 59% in the Northeast.

Overall, the proportion of anesthesia services used in low-risk patients was more than two thirds in the Medicare group, and more than three quarters in the commercially insured group. This proportion decreased over time from 78.6% (95% confidence interval [CI], 77.9%-79.2%) in 2003 to 64.1% (95% CI, 63.2%-64.6%) in 2009 in the Medicare group, whereas it remained stable in the commercially insured group (86.5%, 95% CI, 85.8%-86.9.6% in 2003 and 83.9%, 95% CI, 83.7%-84.0% in 2009).

Annual payments for anesthesia services in the Medicare sample almost doubled from $2.2 million in 2003 to $4.2 million in 2009 per 1 million enrollees. For the commercially insured patients, annual payments increased more than 4-fold from $1.9 million in 2003 to $8.4 million in 2009.

In Medicare patients, the number of procedures per 1 million enrollees that used anesthesia services for low-risk patients increased from 13,989 in 2003 to 25,069 in 2009. Annual payments per 1 million patients increased about 8% per year from $1.69 million in 2003 to $2.65 million in 2009. In commercially insured patients, the use of anesthesia services for low-risk patients increased from 3938 to 15,108 per 1 million enrollees. Annual payments for this group increased more than 4-fold from $1.69 million to $7.05 million.

The authors cited several study limitations including basing the determination of anesthesia use for low-risk patients on a statistical model and the inability to determine actual clinical need for anesthesia services in individual patients. The analysis did not include procedures performed in inpatient settings, or among patients <18 years of age, enrolled in Medicare managed care, eligible for Medicaid but not Medicare, or those who paid out of pocket.

“Our results suggest that the majority of gastroenterology-related anesthesia services are provided to low-risk patients and can be considered potentially discretionary based on current payment policies,” concluded the researchers.