Dr. Gerson raises timely issues: there may be alternative bases on which to support the provision of a given healthcare service, and people may differ in how they value different services. Certainly, enhanced patient satisfaction, among a wider set of criteria, could be used to support an expansion of healthcare services, such as anesthesiologist involvement in colonoscopy sedation, as he suggests.

Although the demand for services is infinite, societal resources are finite, if not overstretched. Budgetary limitations in every country prompt difficult choices about which services to provide. Decisions principally reflect judgments about medical necessity, generally based on demonstrated benefit (e.g. , efficacy and effectiveness) and, increasingly, perceived value (i.e , cost effectiveness) in effecting population health. Dr. Gerson perhaps unwittingly acknowledges this critical point when he notes, “I think only those who pay for anesthesiologists' services [for colonoscopy sedation] might be less satisfied.”

Underlying the urgency of U.S. healthcare reform is the need to increase value in our feast-and-famine healthcare system; although first in per-capita healthcare spending, we have mediocre comparative population health rankings that have declined over three decades1: one-sixth of our population without health insurance, and uncontrolled healthcare costs that are an important factor in personal, corporate, and governmental bankruptcies. The lack of association between anesthesiologist involvement in colonoscopy sedation in the Canadian province of Ontario and patient acuity in the study by Alharbi et al.  2indicates that the service is not a medical necessity and, thus, has low value. As we noted in our editorial,3fragmentary evidence suggests that the same phenomenon prevails in the United States. Hence, we remain confident that anesthesiologist involvement in colonoscopy sedation in the absence of medical indication (e.g. , severe comorbidity) is a low-value service that is ripe for pruning as healthcare reform progresses.

*Yale University School of Medicine, New Haven, Connecticut. fred.orkin68@post.harvard.edu

Murray CJL, Frenk J: Ranking 37th—measuring the performance of the U.S. Health Care System. N Engl J Med 2010; 362:98–9
Alharbi O, Rabeneck L, Paszat LF, Wijeysundera DN, Sutradhar R, Yun L, Viden CM, Tinmouth J: A population-based analysis of outpatient colonoscopy in adults assisted by an anesthesiologist. Anesthesiology 2009; 111:734–40
Orkin FK, Duncan PG: Substrate for healthcare reform: Anesthesia's low-lying fruit. Anesthesiology 2009; 111:697–8