Patients who undergo colonoscopy usually receive anesthesia of some sort in order to "sleep" through the procedure. But as one Long Island couple discovered recently, it can be a very expensive nap.
Both husband and wife selected gastroenterologists who participated in their insurance plan to perform their cancer screenings. But in both cases, the gastroenterologists chose full anesthesia with Propofol, a powerful drug that must be administered by an anesthesiologist, instead of moderate, or "conscious," sedation that often gastroenterologists can administer themselves.
And in both cases, the gastroenterologists were assisted in the procedure by anesthesiologists who were not covered by the couple's insurance. They billed the couple's insurance at rates far higher than any plan would reimburse — two to four times as high, experts say.
Now the couple, Lawrence LaRose and Susan LaMontagne, of Sag Harbor, N.Y., are fending off lawyers and a debt collection agency, and facing thousands of dollars in unresolved charges. All this for a cancer screening test that public health officials say every American should have by age 50, and repeat every 10 years, to save lives — and money.
"Doctors adopt practices that cost more, insurers pay less, and patients get stuck with a tab that in many cases is inflated and arbitrary," said Ms. LaMontagne, whose communications firm, Public Interest Media Group, is focused on health care. "I work on health care access issues every day, so if I'm having a hard time sorting this out, what does that say for other consumers?"
More than 20 million outpatient endoscopy procedures are performed in the United States each year, and the number is growing. A few hardy patients decide that they do not need anesthesia at all. Most receive conscious sedation, a combination of drugs that block pain and help patients relax while remaining conscious; three gastroenterology societies recommend this option as adequate in cases where there are no complications.
Still, a growing number of patients appear to be receiving full anesthesia. Some gastroenterologists say that patients recover more easily after full anesthesia and that the exam is better. But there is no clear scientific evidence to support this, and critics say that an extra pair of hands in the room simply allows the doctor to perform more procedures.
According to a study by the RAND Corporation, published this year in The Journal of the American Medical Association, use of anesthesia administered by an anesthesiologist or nurse anesthetist during outpatient gastroenterology procedures, mostly colonoscopies, has more than doubled in recent years, to more than 30 percent in 2009 from 14 percent in 2003. Most of the increase occurred among low-risk patients who could do without the expensive service. But the practice varies from region to region: Only 13 percent of gastrointestinal procedures in the West involved an anesthesiologist or nurse anesthetist, compared with 59 percent in the Northeast, the study found.
As much as $1.1 billion spent on anesthesia for gastrointestinal procedures each year may not be medically necessary, the researchers concluded. Insurers often foot the bill for full anesthesia, but not always.
Mr. LaRose, 48, said that he did not want to have full anesthesia in the first place. After his first consultation with the doctor, he said, he called his gastroenterologist's office and told a staff member of his preference.
But when he showed up for the colonoscopy on June 24, 2010, his doctor, Dr. Kristin Patrick Naso, told him the procedure is normally done with Propofol, which requires an anesthesiologist. By then Mr. LaRose had already spent 24 hours fasting and going through the unpleasant cleansing preparation, he said.
Mr. LaRose said he relented after the doctors assured him that anesthesiology would be covered. "You're starving and gaseous and you just want to get the whole thing over with," Mr. LaRose said.
In an interview, Dr. Naso said his office provided all patients with a notice saying that the anesthesiologist might not be covered by insurance and providing the anesthesiologist's phone number for more information.
Although Dr. Naso was in network and accepted payment from Mr. LaRose's insurer as payment in full, the anesthesiologist, Dr. Michael Rus, billed $1,600 for the procedure. He was reimbursed $588 by the plan and, after failing to collect the remainder from Mr. LaRose, sent the balance to bill collectors.
Dr. Rus did not respond to requests for comment.
It was a similar situation when Ms. LaMontagne went for her colonoscopy. She said she told Dr. Michael Krumholz in Manhattan about her husband's experience and her concerns about a lack of coverage for full anesthesia. She said she was not told about conscious sedation, which is not available at his practice. Instead, Ms. LaMontagne said, she was told that full anesthesia was standard practice. She went ahead with the procedure in February.
Dr. Krumholz accepted $192 from Ms. LaMontagne's insurance company, Freelancers Insurance Company, which is affiliated with the Freelancers Union. But the insurer rejected the bill from the anesthesiologist, Dr. Joanne Goldman, because she is out of network.
So Dr. Goldman's charge was sent to Ms. LaMontagne: $2,800. She called Dr. Krumholz's office to ask about this charge and any others of which she might be unaware. She said she was told there would also be an additional "facility fee" of $1,800 charged by the endoscopy clinic.
In an interview, Dr. Goldman said she did not do the billing herself and could not address questions about it.
In an e-mail, Dr. Krumholz said that he tells all of his patients about the risks and benefits of colonoscopy, as well as alternatives to the procedure, and of the benefits of and alternatives to anesthesia. He will perform the procedure without anesthesia if the patient so chooses, he said, but his practice does not offer conscious sedation, nor do "most modern endoscopy facilities in New York."
Jordan Fowler, chief executive of Frontier Healthcare and business manager of the endoscopy center where Dr. Krumholz practices, said Ms. LaMontagne "should not lose sleep" over the charges because the anesthesiologists in the group are about to become in-network providers.
Asked whether a $2,800 charge is reasonable for about 30 minutes of anesthesia, he said, "You bill a high fee to negotiate with an insurance company."
Sara Horowitz, founder and executive director of the Freelancers Union, said the trend toward using two doctors for a colonoscopy is "outrageous, when we have another perfectly good kind of anesthesia, twilight sleep, that the GI can do him- or herself."
But there's a bigger problem for consumers here, too. Many physicians who are not the primary contact with patients — like pathologists and radiologists as well as anesthesiologists — do not participate in health insurance plans. When they provide medical services at hospitals or outpatient centers, their charges may not be covered, or may be only partly covered, leaving even well-insured people with large, unexpected bills.
So, what to do if you need a colonoscopy?
CONSIDER ALTERNATIVES Other recommended colon cancer screening methods include the fecal occult blood test, which involves collecting stool samples at home, and sigmoidoscopy, in which a long, flexible tube with a tiny video camera is used to examine the lower colon. Indeed, a study published in The New England Journal of Medicine last week found that patients who underwent sigmoidoscopy had lower rates of colon cancer and lower cancer death rates.
PLAN AHEAD You know when you'll be turning 50, so estimate your costs in advance and put money away in a health savings account, so at least you're not paying taxes on it. (Remember, you may lose the money if you don't use it.)
ASK QUESTIONS When speaking with your gastroenterologist about the procedure, find out what kind of anesthesia will be used and who is going to administer it. If he or she insists on an anesthesiologist or a nurse anesthetist, you have two options: find a gastroenterologist who administers sedation on his or her own, or make sure the anesthesiologist is covered by your plan.
http://well.blogs.nytimes.com/2012/05/28/waking-up-to-major-colonoscopy-bills/
