Anthem policy on propofol for colonoscopies may be shortsighted

The health insurer limits the use of propofol to save money, which discourages patients from getting this important but uncomfortable preventive test.

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There is perhaps no better metaphor for the painful relationship between patients and our for-profit healthcare system than the fact that Anthem Blue Cross thinks you don't need anesthesia for a colonoscopy.

It's not "medically necessary," the insurer says.

Anyone who has experienced this most invasive of medical procedures might think otherwise.

I spoke the other day with a fellow named Michael, who works locally in the TV industry but didn't want me using his full name because he's terrified that Anthem will retaliate by messing with his coverage (and it says a lot about our system that this is even a consideration).

Michael is in his 50s, so he's at that age when men are supposed to bow before the gods of gastroenterology.

His doctor has scheduled a colonoscopy in coming weeks, and Michael faces the prospect of paying hundreds of dollars out of pocket for anesthesia if he doesn't want to be awake for every excruciating moment of the exam.

Michael already knows what he'll do. He'll pay.

"I can't imagine going through that procedure without anesthesia," he told me.

Many, if not most, people would agree. There are certain experiences in life that you just don't want to be conscious for.

So Anthem's policy raises a number of questions. How do you define "medical necessity"? Does it apply only to life-or-death situations? Or does it also apply to making a patient more comfortable, or to making a very important preventive treatment more accessible to those with, shall we say, squeamish sensibilities?

At the same time, should Anthem be commended for trying to keep health-insurance costs down by limiting the treatments it will cover? Should other insurers follow the company's example?

Dr. Karen Sibert, a Los Angeles anesthesiologist, said that when a strong sedative is going to be used for a colonoscopy these days, the drug of choice is propofol, the same drug that played a role in Michael Jackson's death.

"Propofol sedation is lovely in the sense that you go to sleep quickly, wake up quickly and there's very little nausea," she said.

The thing is, propofol requires the presence of an anesthesiologist or a nurse-anesthetist, as opposed to milder sedatives that can be administered by a doctor or nurse. This can add as much as $500 to the cost of the procedure, which is what Anthem is trying to avoid.

Sibert said she can see the insurer's point. While propofol might make for a kinder and gentler colonoscopy, it's not always a necessity.

"I think we can all agree that luxury cars are wonderful, but an economy car can get the job done," Sibert said.

Some smaller insurers have followed Anthem's example. In 2008, Aetna said it too would limit coverage of propofol. However, backlash from doctors prompted Aetna to indefinitely delay that decision.

Gastroenterologists I spoke with said there's no question that propofol is preferred for colonoscopies.

Dr. Eric Esrailian, co-chief of the Division of Digestive Diseases at UCLA's David Geffen School of Medicine, said he'd use propofol for almost all colonoscopies if there were no other factors involved (read: if an insurance company wasn't second-guessing his decisions).

"Colon cancer is a preventable cancer," he said. "Screenings are the key. We should do whatever is necessary for society to be screened."

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