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Letter to the editor

Insurers drop colonoscopy drug

A popular anesthetic costs more than a method of moderate sedation.

By Kris Hundley, Times Staff Writer
Published February 13, 2008

Over 50 and due for a routine colonoscopy? You might want to check your insurance.

Several major insurers have stopped paying for propofol, the popular drug that renders patients unconscious during the procedure to screen for colon cancer. These companies maintain that the alternative of moderate sedation, in which the patient remains awake but drowsy, works just as well and is less costly.

But many doctors insist patients are more comfortable and recover more quickly after using propofol, a quick-acting anesthetic with few side effects. They fear patients will avoid having the routine screening, which involves inserting a tube into the digestive tract, if their options for anesthesia are limited.

"Everyone who can afford it, and has had it done before, is going to pay the extra money for propofol," said Dr. Charles Campbell, who runs Diagnostic Clinic in Largo where virtually all colonoscopies are performed under deep sedation. "But if you really have trouble making ends meet, you're going to postpone it."

Aetna Inc. said that as of April 1 it will discontinue coverage of propofol, also known as Diprivan, for routine cases. WellPoint, an Indiana insurer, has already eliminated coverage of the drug. So has Humana in many markets, although it still covers propofol in Florida.

Cigna, United Healthcare and Blue Cross and Blue Shield of Florida continue to cover propofol, leaving the choice of anesthesia up to the doctor and patient.

Propofol, a generic, is relatively inexpensive, but its use requires the presence of an anesthesiologist or nurse anesthetist, driving up the expense. Aetna's medical director, Dr. Troyen A. Brennan, said having the drug monitored by a specialist can add $700 to $1,000 to the cost of a procedure.

"Anesthesiologists themselves have said if this usage grows, it could be in the $2- to $5-billion range in costs," he said. "Those are costs we can't afford."

Brennan said about 70 percent of all colonoscopies are performed with milder sedation, using a combination of a sedative and a tranquilizer delivered intravenously.

"And the satisfaction levels of patients who have this is as high as with other forms of sedation," said Brennan, who said he had intravenous sedation for both of his colonoscopies.

Brennan said there are also differences geographically in the use of deep sedation, ranging from fewer than 10 percent of patients in Los Angeles to more than 50 percent in New York City.

"It shows people aren't paying attention to evidence-based medicine," he said.

Dr. David Heiman, a gastroenterologist in Tampa, first tried propofol on a difficult patient five years ago and now uses it in nearly all his cases.

"My favorite part is that 10 to 15 minutes after the procedure, I can talk to the patient and he's coherent, with no nausea," he said. "I had it for mine."

Though a group of New Jersey doctors is threatening to sue Aetna if it goes through with its restrictions on propofol, Heiman thinks the list of exceptions, which includes anyone over 65 or especially "combative," is sufficient to cover most of his patients.

"They just want to exclude the drug for the perfectly health person," he said.

Campbell, from Largo's Diagnostic Clinic, did not have propofol during his last colon cancer screening but intends to demand it the next time. He said moderate sedation left him feeling "snowed."

"It was much more uncomfortable and embarrassing, then you feel nauseated and drugged for the rest of the day," he said. "The great thing about propofol is that 30 minutes later, you're ready to go back to work."

Aetna's medical officer said new technology may make the controversy moot. Computer-assisted patient sedation devices that would eliminate the need for an anesthesiologist are being tested. If the devices are approved by the FDA for propofol, Brennan said, Aetna would probably cover the drug.

Times researcher Carolyn Edds contributed to this report. Kris Hundley can be reached at hundley@sptimes.com or (727) 892-2996.

Anesthetic vs. sedation

The issue: More than 1-million colonoscopies are performed in the United States each year as routine screening for colon cancer. In most cases, patients are given a combination of drugs that leaves them awake but drowsy during the procedure. But a growing number of doctors prefer to use a stronger anesthetic, propofol, which renders the patient unconscious.

The debate: Some insurers, including Aetna, are refusing to cover propofol, saying it adds unnecessary expense. Doctors who use propofol say it makes the procedure more comfortable for the patient and allows quicker recovery time.

In Florida: 342,244 colonoscopies were performed in 2006, according to the Florida Agency for Health Care Administration.

[Last modified February 12, 2008, 23:40:49]