Changes to insurance coverage for colonoscopies: What you need to know
WORCESTER — The next time you need a colonoscopy, make sure you read the fine print if your health insurance coverage is with Blue Cross Blue Shield of Massachusetts.
The insurer changed its policy, effective Jan. 1, for endoscopy procedures including for colonoscopies and there is concern from some in the medical community that it's not only a bad move for patients but is a way for Blue Cross to cut costs.
Medical experts recommend men and women 45 to 75 get routine colonoscopies to screen for colorectal cancer, the second-leading cause of cancer-related deaths in the U.S., according to the American Cancer Society.
What has changed this year is that Blue Cross will cover the cost of being fully sedated during the procedure, known as monitored anesthesia care, if a doctor deems it medically necessary.
To be medically necessary, a patient must have preexisting risk factors. Some of the factors, according to Blue Cross, include severe morbidity, a history of adverse reaction to sedation, diabetes, hypertension, inability to follow commands, substance or alcohol use disorder, patients younger than 18 and older than 70 and those who are pregnant.
When those risk factors and others are absent, Blue Cross will only cover the cost of moderate sedation, also known as conscious sedation. That means the patient isn’t fully sedated while the colonoscopy is performed.
The insurance change could impact thousands of patients in Massachusetts who are used to full-sedation colonoscopies. Currently, more than half of Blue Cross Blue Shield of Massachusetts patients that get a colonoscopy have the procedure done through full sedation.
Blue Cross processes claims for about 74,000 colonoscopy patients yearly in Massachusetts. Roughly 47,000 are done at hospitals, where 56% fall under full sedation. Another 26,000 are done at free-standing endoscopy centers, where 75% involve full sedation. The new policy could mean thousands of patients whose colonoscopies are not considered a medical necessity will not get insurance coverage for full sedation.
Concern in some medical circles
The development troubles some of the state’s leading health care providers. The Massachusetts Health and Hospital Association believes the policy will limit access to colonoscopies and potentially compromise patient safety.
The association highlights several concerns. One is limiting full sedation comes after colonoscopies were halted during the COVID-19 pandemic and when colon cancer rates and deaths are climbing for people under 55. Both developments, according to the association, have created a significant backlog of patients waiting to get a colonoscopy.
In addition, the association said there is a shortage of nurses trained to give moderate sedation. Plus, there is a longer recovery time with moderate sedation, so there will be a backup in the colonoscopy assembly line, meaning it will take longer for patients to be seen.
“The main point is that physicians, not insurance companies, should be able to determine what type of sedation is best for their patients undergoing endoscopy procedures based on the patient’s condition and other clinical variables,” said Karen Granoff, the association’s senior director of managed care. “Leading medical groups have made it clear that Blue Cross’ policy will result in backlogs, reduced efficiency, a poorer patient experience and could worsen staffing issues because many nurses are not trained to do conscious sedation.”
Why the change in coverage?
Blue Cross says the change adheres to updated guidelines set by the American Society of Gastrointestinal Endoscopy.
The guidelines point to health risks associated with full sedation, said Dr. Sandhya Rao, chief medical officer and senior vice president at Blue Cross Blue Shield of Massachusetts. As a result, the insurer is following the guidelines, so its members have access to high-quality, safe and affordable care.
“That’s our goal of enforcing the policy,” said Rao, adding that Blue Cross expanded the list of clinical conditions that qualify patients for full sedation after hearing concerns from gastroenterologists.
Risk factors connected to full sedation, according to the American Society of Gastrointestinal Endoscopy, include aspiration, cardiopulmonary events and perforation of the intestine.
Blue Cross: 'Trying to save money on sedation costs'
The financial health of the Blue Cross balance sheet could also be in play, and to see that it remains healthy, some believe the insurer may be looking to cut costs by limiting access to the more expensive full-sedation colonoscopy.
“I think Blue Cross is trying to save money on sedation costs. Not a doubt,” said Dr. Christopher Marshall, clinical chief of gastroenterology at UMass Memorial Health.
Paul Hattis, a senior fellow at the Lown Institute, an independent think tank in the health care sphere, believes full sedation has “added huge costs to colonoscopy.”
Full sedation is more expensive because it requires a gastroenterologist plus an anesthesiologist to administer the drug propofol to fully sedate the patient. The average cost of colonoscopy in the U.S. is reportedly in the range of $3,000. That compares to less-costly moderate sedation when a nurse administers the sedative, like midazolam, with a painkiller, like fentanyl.
Rao stressed that doctors, not Blue Cross, determine what procedure a patient gets. She also repeated the insurer’s position that it's following guidelines set by the American Society of Gastrointestinal Endoscopy that full sedation comes with increased medical risks. Therefore, the “goal of the policy is to ensure members receive care that is clinically appropriate and consistent with the guidelines.”
When asked how the policy change will affect the Blue Cross balance sheet, Rao said, “It’s too early to say what the financial impact will be.”
Hospital profits on the line
Hospital profits could also be affected because fewer full-sedation procedures translate to less revenue.
“The story is not told completely. I’m not sure what effect this will have on the bottom line at UMass or other institutions,” said Marshall.
It’s unclear how much revenue UMass Memorial Health makes from colonoscopies because it declined to provide its most recent patient and revenue numbers for endoscopy procedures performed including separate patient and revenue numbers for colonoscopy.
"Unfortunately, we do not have that information for you," said a UMass Memorial Health spokeswoman in an email.
The state Department of Public Health didn’t publish colonoscopy numbers at hospitals in its latest report on colorectal cancer in Massachusetts. But colonoscopy screenings are robust in Massachusetts, as the American Cancer Society reports 70% of state residents over 45 get colorectal cancer screening. That's the highest rate in the U.S. along with the District of Columbia.
Another factor is the Affordable Care Act requires private insurers and Medicare to cover the cost of routine colonoscopy screenings. If additional procedures are needed, like removing a cancerous polyp, the patient will pay a portion of the costs.
When asked how the Affordable Care Act played into the Blue Cross decision to change insurance coverage, Rao guaranteed that patients will not face out-of-pocket costs when doctors perform full-sedation colonoscopies that are not covered by Blue Cross policy or don’t match the medical diagnosis submitted to the insurer.
“The provisions in our contract prohibit doctors from billing patients directly for an anesthesiologist if it’s not covered by Blue Cross. If there is deep sedation and there is not a clinical reason for it, then the member (patient) will not bear the costs because of the provisions of the contract,” said Rao.
However, if the Blue Cross member signed a waiver with the medical provider to assume financial responsibility for any costs beyond what the insurer will pay, the member must pay the balance.
Blue Cross policy has its challenges
Marshall mentioned several challenges with the Blue Cross insurance change. He believes private endoscopy clinics don’t have enough trained nurses to perform conscious sedation. In addition, other insurance companies could follow Blue Cross’ lead and shift more patients to moderate sedation. Plus, more staff will be needed to triage cases to determine who should get full or partial sedation.
“Throughput” is a term Marshall used to explain how the insurance change will clog up the efficiency of endoscopy departments, causing backups that result in longer wait times for patients.
“The challenge is if you do less propofol, then you cut your throughput in endoscopy units," he said. "You cut the capacity to do cases and that hampers access (to colonoscopy).”
Marshall explained that conscious sedation has been the standard colonoscopy procedure for decades. The “more recent phenomenon” is using deeper sedation with propofol that is given by an anesthesiologist.
Both procedures are safe, according to Marshall, but full sedation has its benefits including patients going to sleep faster and waking up quicker. As a result, more colonoscopies can be done. Another driver is older patients face more complex medical challenges, so an anesthesiologist is needed to support sedation.
Talk to your doctor to determine best option
For Marshall, there’s a place for both full and moderate sedation, and it’s important for patients to talk to their primary care doctors to assess which procedure is best for them.
When presented with the scenario that many patients are accustomed to full sedation and may avoid future screenings because of the Blue Cross insurance change that could steer them to the unfamiliar moderate sedation, Marshall said educating patients is key.
The medical community hasn’t done a good job in this area, he said.
“Just because Blue Cross does not pay for deep sedation does not mean (conscious sedation) is uncomfortable; that you won’t have a good experience. It’s a different type of sedation," said Marshall. "People need education from their primary care doctor, talk to friends, so they’re not afraid of anything.
"It’s about managing expectation to understand what the experience will be, rather than just brining the patient in and saying, ‘Let's go.’”
Contact Henry Schwan at henry.schwan@telegram.com. Follow him on X: @henrytelegram.
This article originally appeared on Telegram & Gazette: Blue Cross Blue Shield of Massachusetts revises colonoscopy coverage
