In 2011, the Medicare Imaging Demonstration from the Centers for Medicare & Medicaid Services began testing whether exposing ordering clinicians to appropriateness guidelines for advanced imaging would reduce ordering inappropriate images. Small changes in ordering patterns were noted, but decision support systems were unable to assign appropriateness ratings to many orders, limiting the potential effectiveness of decision support.
Special Feature: Discretionary Use of Anesthesia Providers
Endoscopies and colonoscopies are among the most common GI procedures in the U.S.—and thus important to consider when investigating how to curb health spending without compromising patient care or outcomes. Demand for screening colonoscopies is likely to grow in coming years, as the U.S. population ages and as the Patient Protection and Affordable Care Act expands preventive care coverage, making cost controls more urgent. RAND Health physicians and other experts have identified anesthesia services in GI procedures as one source of rising health spending—and a potential target for cost savings.
Why is this study significant?Click to Enlarge
The study is the first attempt to quantify and evaluate U.S. spending on anesthesia services for common outpatient gastroenterology (GI) procedures. Using a nationally representative patient sample, it analyzed health insurance claims from 2003–2009 to determine what kind of anesthesia care was provided to 6.6 million adults who had endoscopies and colonoscopies. These GI procedures are increasingly common—growing 25% in volume over the six-year study period, and totaling 12.5 million annually in 2009.
How is anesthesia provided during GI procedures?
For endoscopies and colonoscopies, sedation can be administered either by “anesthesia providers”—anesthesiologists or nurse anesthetists—or by physicians on the GI team. Over the six-year study period, anesthesia providers were involved in many more of these procedures. In 2003, for example, they administered sedation in 14% of cases. That figure more than doubled, to 30%, by 2009.
Why do costs increase when anesthesia providers are involved?Click to Enlarge
When the GI team administers intravenous (IV) sedation, anesthesia costs are included in the overall GI procedure fee. An additional payment is required, however, if an anesthesia provider delivers and monitors IV sedation. As anesthesia providers participated more often in GI procedures, anesthesia spending tripled—rising from an estimated $400 million to $1.3 billion nationally between 2003–2009. The amounts charged per procedure by anesthesia providers did not increase; the increased use of their services drove the spending growth.
Are anesthesia providers used consistently in GI procedures?Click to Enlarge
No, anesthesia provider use varies significantly by region. In the northeastern U.S., for example, anesthesia providers were involved in nearly half of all GI procedures, or 48%. In the western states, however, anesthesiologists and nurse anesthetists participated in only 14% of GI procedures. These disparities suggest that anesthesia provider use often is potentially discretionary rather than medically necessary, since patients’ clinical needs are unlikely to vary so dramatically from region to region.
Do patients benefit from anesthesia provider care?
Some do, but among the key findings was that only high-risk patients undergoing GI procedures—such as people with chronic heart or lung disease—warranted the intensive monitoring that anesthesia providers deliver. Yet high-risk patients accounted for only about $0.2 billion of the $1.3 billion spent on anesthesia provider care during the study period. For people at low risk of complications from routine GI tests (the majority of the patient cases examined in the study) there was no medical justification for having sedation administered by higher-cost anesthesia providers rather than by the GI procedure team.
How can the study’s findings help to reduce unnecessary health spending?Click to Enlarge
Avoiding the use of anesthesia providers during low-risk GI procedures could save the U.S. health care system more than $1.1 billion each year. In turn, better identifying the higher-risk patients who can benefit most from anesthesia provider care will improve the system’s efficiency and quality. This situation is only one of the many examples of potentially low-value care that should be a major target of cost containment efforts.
More Research on Health Care Costs
The U.S. Food and Drug Administration is expected to release final regulations outlining lower-cost approval pathway requirements for so-called biosimilar drugs. The introduction of biosimilars is expected to reduce prices. This Perspective combines prior research and recent data to estimate cost savings in the U.S. market. We predict that biosimilars will lead to a $44.2 billion reduction in direct spending on biologic drugs from 2014 to 2024.
CT screening reduced death from lung cancer by 20 % during a 6 year trial among heavy smokers age 50-74; the cost was about $81,000/ QALY gained. If screening is extended to not-so-heavy smokers, its value falls dramatically, and radiation risks may outweigh screening gains.