Paul Liszewski, CRNA, DNP

A few months ago, Highmark Blue Shield (of Pennsylvania, Delaware, and West Virginia)
decided to limit the use of MAC with propofol for patients undergoing GI endoscopy,
bronchoscopy and interventional pain procedures to those who qualify from a specific list of
risk factors or significant medical conditions. This decision prompted a strong response from
patients, endoscopists, anesthesia providers, facilities and legislatures and Highmark has since
delayed implementation of their change in the anesthesia policy for colonscopies, etc to re-assess
the situation. The pro and con arguments on this topic would take many hours of discussion
to dissect completely, but some compelling thoughts come to mind when a standard of care is
challenged in this manner.

In my anesthesia practice I cover several endoscopy centers and my experience with propofol
MAC for colonoscopies and EGDs has led me to conclude that propofol is the ideal sedative
agent for these cases. The properties of quick onset, shorter 1⁄2 life, and the ability to titrate
levels of sedation promotes increased patient satisfaction, increased efficiency and improved
procedural tolerance. The antiemetic effect is valuable and I’ve been pleasantly surprised by
the amnestic properties of the drug. It is rare for me to work more than a day or two without a
patient recalling for me a bad experience with the previous sedation regimens of fentanyl and
midazolam and then a subsequent positive experience receiving propofol for the same procedure.
It seems to me the fear and anxiety of procedural pain and discomfort has been virtually
eliminated as a patient concern with the use of propofol sedation. And the safety margin of
propofol, when administered by an anesthesia provider, is such that it is recommended by all
experts for patients with co-morbidities that raise their risk of complications from procedural
sedation. And this general benefit of propofol over fentanyl/midazolam sedation naturally
extends to the low-risk patient as well.

In my opinion, it is a step backwards to limit propofol sedation for any patient undergoing
endoscopy. The published evidence regarding anesthesia-assisted endoscopies is limited
in design and bias, and is generally unremarkable as to recommending any change in the
current standard of practice. While the cost of an endoscopic procedure rises with anesthesia
involvement by approximately 20%, the cost of a single anesthetic has not increased over time.
Apparently, the increased financial responsibility to insurers has come from the increased use
of anesthesia providers for sedation which has allowed for more endoscopies to be efficiently
performed and more patients accommodated. It is difficult to place a price tag on the effect of a
satisfied patient on measures such as initial screenings, follow ups, or on return visits for patients
for high risk of GI cancers. Colorectal screening is a key tool in the prevention of colon cancers
and anesthesia assisted propofol sedation has become the industry standard for these procedures.
It is my hope that Highmark and other insurers will consider patient concerns and the expert
opinions of providers and facilities when determining the right course of action.

If you want to contact Highmark in regards to this issue:
HIGHMARK
Fifth Avenue Place
120 Fifth Avenue
Pittsburgh, PA 15222-3099
(412)-544-7000