Pain in the rear

From the Wall Street Journal (Making Colonoscopies More Comfortable):

An increasingly popular approach to colonoscopies is making the test more comfortable for patients. But the method, which involves a potent and fast-acting anesthetic, is sharply boosting the cost of the procedures — and some insurers are taking action to curb its use.

Colonoscopies are critical for detecting colon cancer, a leading, preventable cause of death.

Anything to encourage people to get colonoscopies done is worthwhile from my standpoint, even if it’s not “medically necessary.”

By refusing to cover the use of Propofol, insurers raise doubts about how committed they are to prevention. After all, why not avoid the expense of colonoscopy and let the patient’s next insurer pick up the colon cancer tab?

——

PS – Blogger’s spellchecker, always wanting to get in on the action, suggests replacing “colonoscopies” with “saloonkeeper.”

December 27, 2005

12 thoughts on “Pain in the rear”

  1. What most people find uncomfortable about the colonoscopy experience is not the procedure itself but rather the preparation, involving drinking disgusting liquids and feeling for hours that you are about to vomit (or actually vomiting).

    Spending a lot of money perfecting the lesser bother of the procedure itself and ignoring the bigger bother of the preparation is an example of the classic management error of focusing on what is easy to measure and ignoring the more important part that is more difficult to document.

  2. An article in today’s New York Times:

    http://www.nytimes.com/2005/12/27/health/27cons.html?ex=1293339600&en=b4c863f4211b0698&ei=5090&partner=rssuserland&emc=rss

    details another downside of the preparation for colonoscopies – renal failure produced by the phosphate in the liquids that patients some patients drink to prepare fot the colonoscopies.

    Other non-phosphate approaches are available, but the one described in the article involves drinking a gallon of a polyethylene glycol solution.

  3. Dear Mickey,
    You state: “What most people find uncomfortable about the colonoscopy experience is not the procedure itself but rather the preparation, involving drinking disgusting liquids and feeling for hours that you are about to vomit”. Yes, but remember that most people are adequately sedated for the procedure itself, therefore finding the procedure itself comfortable. And, if you compare traditional “conscious sedation” for colonoscopy versus anesthesiologist administered propofol sedation for colonoscopy, you will find without a doubt a strong patient preference for the latter. I shoud know…I administer about 30 propofol anesthetics for colonoscopy a week!

  4. thats the whole point–DEPTH. Did you read what one of these endo centers that trains nurses does for training? Read the article below by Daniel Cook . MAN- i wish I knew I only had to do 10 cases and insert 3 LMAs to be qualified to give near-general anesthesia (’cause it aint conscious sedation!) What was I doing for 2 years!? If its that easy to design your own QUALIFIED training program, then I want to start one! I’ll train people for a week and 10 cases and charge what CRNA schools charge for the whole curriculum! Id make a fortune!Even dentists who do deep IV sedation/general do a YEAR to get the Dental Anesthesia Board Certfication.
    Really – read this article below. The ridiculousness that you can handle an emergency airway by a week of training, and a once a year refresher. Oh, but Dr Rex’$ study said they rarely need to place an emergency airway, so we really dont need someone around that can place one well. Its all about the money. The cost prohibitivesness he really is concerned aboout is that gastroenterologists would not make $300-700k per year if an anesthesia provider was paid to administer the sedation. Thats what its about- nothing else.

    A Training Program That Works

    Since 1998, the Surgery Center of Southern Oregon in Medford has trained 40 nurses to administer propofol – and the ASC has done so with a perfect safety record over about 36,000 cases. The keys, says Val Charley, RN, the endoscopy manager, are ensuring that RNs who administer propofol are ACLS and PALS certified, and that RNs pass the following eight-step training program.

    Complete a sedation clinical competency program consisting of nine written exams.

    Complete a 10-case rotation in the OR to learn about anesthesia gases, carts, and induction and emergence techniques. They must also demonstrate knowledge of the physiological effects of anesthesia, the phases of anesthesia (in both children and adults), the effects of paralytics and reversal agents, and emergency-call protocol.

    Perform three successful LMA insertions under an anesthesiologist’s supervision.

    Perform heart, lung and airway assessments, as well as show knowledge of vital signs.

    Attend an annual, five-hour airway class that involves circulating to competency stations and a written exam.

    Observe a competent RN administer propofol during a week’s worth of cases. The nurse-in-training demonstrates the location and knowledge of emergency drugs and monitoring equipment.

    Administer propofol under the direct supervision of the surgeon and a competent RN.

    Remain qualified to administer propofol by annually completing airway modules of the sedation clinical competency program; the OR rotation with the medical director; the airway management class; and performance in a case observed by the medical director.

    – Daniel Cook

  5. Yes…it is all about the money…unfortunately, the Wall Street Journal article stated: “administration of the drug often adds between $250 and $400 to the cost of colonoscopies, which typically run from $300 to $1,000 by themselves.” This is very misleading! The patient charge for a colonoscopy is NOT $300 to $1,000 by themselves…this would be the typical fee of the gastroenterologist alone!…this does not include the facility fee which can be as high as $6,000 alone!…so, administration of propofol by an anesthesiologist would add only up to $400 on a total bill of up to $7,000!

  6. I am a colon cancer survivor and ave had colonoscopies annually for three years and semiannaully till next month which will be 5th anniversary. I live in northeast Wisconsin, and the cost through an insurance plan has been between $1,000 and 1,500 dollars, excepting the first one. This includrd removing several polyps, and lab tests. The bill on that was $1700 or 1800 dollars.
    I know insurance companies negotiate a lower rate than a private individual, but I felt the costs are reasonable. Especially considering the colon resection was around $20,000 dollars, and would not have been necessary if I had a timely screening colonoscopy.

  7. Colonoscopy sedation may be good for marketing, but it increases the risk of perforation. Unsedated colonoscopy isn’t bad, I have had 3. If the endoscopist takes a little time, it’s not painful. Sedated patients get perforated because they can’t feel the pain of the scope getting looped. Deeply sedated patients (propofol) are at highest risk. Propofol should have little or no role in colonoscopy. Neither should sedation in most cases.

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