Monitored anesthesia care in routine GI endoscopy has increased within the VHA, but remains low outside of it. This statistic was revealed in a research letter published in JAMA Internal Medicine.
In the letter, 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 his colleagues, stated: “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.”
The Ins and Outs of Monitored Anesthesia Care
MAC requires an anesthesiology professional and, typically, is done using propofol. Compared with endoscopist-directed sedation that uses short-acting opioids and benzodiazepines, propofol leads to deeper sedation.
According to previous research, more than 50 percent of MAC use occurs in low-risk patients who are having routine endoscopic procedures done, in spite of current guideline recommendations stating that MAC isn’t a cost-effective option for these patients. For that reason, Rubenstein and his colleagues examined MAC use within the VHA in order to have a fuller understanding of the motivation behind increased MAC use.
The Study
Together with his colleagues, Rubenstein conducted a retrospective cohort study of over 2 million veterans who had undergone more than 3.5 million outpatient esophagogastroduodenoscopies (EGD) or colonoscopies at a VHA facility. The time frame was from fiscal year 2000 through 2013, the mean age was 62.8 years, and 94.7% of the veterans were men.
MAC use more than doubled from 4% in fiscal year 2000 to 9.3% in 2013, and began a steady increase in 2008.
In fiscal year 2000, the median facility use of MAC was 0.11% vs. 3.52% in 2013. This varied widely from one facility to the next, especially once the study period was coming to an end.
Rubenstein and colleagues wrote that aside from financial incentives, this increase in MAC use may have been 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.”
They went on to say: “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.”
The Continuing Case for Bundled Care
The findings of this study support the utilization of bundled payments as a tool to reduce the use of low-value services. This conclusion comes from a related letter by Lee A. Fleisher, MD, of the Leonard Davis Institute of Healthcare Economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia.
In this letter, Fleisher states: “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.”
He went on to say that “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.”
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