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Increasing monitored anesthesia care in routine GI endoscopy may be driven by financial incentives
The use of monitored anesthesia care in routine gastrointestinal endoscopy increased over time within the Veterans Health Administration, but remains low compared with use outside the VHA, according to a research letter published in JAMA Internal Medicine.
“While our results demonstrate that [monitored anesthesia care (MAC)] use did indeed increase in the VHA over the study period, the overall rate of MAC use in the VHA is substantially lower than that observed in fee-for-service environments, further supporting the existence of prominent financial drivers in the growing use outside the VHA,” Joel H. Rubenstein, MD, MSc, of the department of Veterans Affairs, VA Ann Arbor Healthcare System, and the department of internal medicine at University of Michigan Health System, and colleagues wrote.
MAC requires an anesthesiology professional and is usually done with propofol, which leads to deeper sedation compared with endoscopist-directed sedation using short-acting opioids and benzodiazepines.
Previous research suggests more than half of MAC use appears to be in low-risk patients undergoing routine endoscopic procedures, despite current guideline recommendations that MAC use is not cost-effective for use in these patients.
Therefore, Rubenstein and colleagues evaluated MAC use within the VHA to better understand the influence of financial and other drivers of the trend toward increased MAC use.
They performed a retrospective cohort study of more than 2 million veterans who underwent more than 3.5 million outpatient esophagogastroduodenoscopies (EGD) or colonoscopies at a VHA facility from fiscal year 2000 through 2013 (mean age, 62.8 years; 94.7% men).
Overall, MAC was used in 5.2% of procedures, which increased by twofold from 4% in fiscal year 2000 to 9.3% in 2013, and increased steadily beginning in 2008.
The median facility use of MAC in fiscal year 2000 was 0.11% vs. 3.52% in 2013, and this varied widely across facilities, especially toward the end of the study period.
Aside from financial incentives, the observed increase in MAC use could be driven by “changes in patient characteristics, such as increased veteran comorbidities or use of prescription opioids (which may confer intolerance to standard sedatives), [and] organizational factors influencing health care delivery, including practice culture, patient preference for MAC, and increased availability of MAC in the VHA,” Rubenstein and colleagues wrote. “Understanding the presence and degree of inappropriate use of MAC inside and outside the VHA will help promote efficient use of resources and ensure delivery of high-value care.”
These findings support the use of bundled payments as an alternative payment mechanism to decrease the use of low-value services, according to a related editorial written by Lee A. Fleisher, MD, of the Leonard Davis Institute of Healthcare Economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia.
“Our first obligation to our veterans is to ensure that they are truly getting the best care and are satisfied with the care. Once that is ensured, and if the current findings simply reflect financial drivers on current practice, then the present article adds to the growing recommendations that bundled care for endoscopy has the potential to lead to delivering the best value: optimal care at the least cost,” Fleisher wrote. “If gastroenterologists, anesthesiologists, and facilities receive a set fee for the endoscopy procedure and the anesthesia and/or sedation services, then the incentive to provide anesthesia, in situations in which it is not needed, will be eliminated. However, to achieve the goal of getting the most value for our health care dollars, we need a better understanding of the value of anesthesiology vs. moderate sedation for performing endoscopy.” – by Adam Leitenberger
Disclosures: The researchers and Fleisher report no relevant financial disclosures.