A relief, albeit a temporary one

Implications: This potential issue has been of concern since we changed to Propofol based anesthesia for all of our patients approximately five years ago.  We made this decision because it made endoscopic procedures significantly more tolerable (essentially painless, except for the bowel prep) for just about all of our patients, as well as, frankly, safer.  While many patients did well with standard conscious sedation using agents such as Sublimaze and Versed, others did not do as well.  Using an anesthesiologist benefited not only high risk patients, but also patients who had rather high sedation tolerances, who often were difficult to identify prior to performing the procedure. 

Analysis: Propofol, at least in the state where I practice, can only be administered by anesthesiologists, so had third party payers limited their coverage, it would have made giving Propofol to many of our patients more challenging.  It is not just high risk medical patients (i.e. ASA-3 or higher) patients who need both anesthesiologists and this drug, but also patients who have higher sedation requirements, many of whom are not readily identifiable before the procedure.  Limiting access to Propofol (or at least safely administered Propofol) would have the effect of potentially creating some adverse outcomes, or at the least, bad patient experiences, which would limit patients' willingness to undergo endoscopic procedures, including screening colonoscopies. 

This issue will likely arise again when there are Propofol like drugs available that can be safely administered by non-anesthesiologists, and when guidelines are in place to adequately credential physicians and/or facilities to administer the drug (be it some new drug, or Propofol itself), monitor patients who get the drug, as well as manage potential side effects, be they hemodynamic or airway related.